March 25, 2021
Patient outcomes matter! Whether you are a patient-centered medical home, part of an ACO, or engaged in alternative payment models, staff skilled in health coaching has become a proven success strategy. Drs. Bennet, Coleman, and Bodenheimer described the role and value of health coaching in 2010 (FPM journal, September/October 2010). Since then, and particularly with the arrival of CMS billing codes around chronic care management and care transitions, health coaching has found a “home” among key billable strategies included in care management and care coordination. The path to an effective coaching strategy: skilled coaching communications aligned with best practice care.
Healthcare organizations across the country are exploring innovative strategies to deliver better healthcare. The motivation – improved care management, care coordination, and patient navigation. However, achieving better health, improved patient experience, and reduced cost has been elusive. The reason – these outcomes hinge upon a high level of patient engagement and activation rarely observed.
A distinct change in form is required. Provider teams have long sought improved behaviors, better patient self-care skills, and inspired patient accountability. And now, more and more practices are partnering with patients to fulfill this dream. They are doing it with staff trained in health coaching. Listen to what one healthcare leader has to say.
Bodenheimer et al defined the health coaching role as 1) providing self-management support, 2) bridging the gap between clinician and patient, 3) helping patients navigate the healthcare system, 4) offering emotional support, and 5) serving as a continuity figure. More recently, health coaches have been utilized in many care team models, including innovative “whole person” approaches, such as Iora Health. They are also built into population health strategies, monitoring and supporting patients at high risk for health exacerbations.
Healthcare reform comes, in part, from changing the system – quality, delivery, and payment. True reform also arises from how individuals access the system and demonstrate health-promoting behaviors. Between 40-50 percent of healthcare outcomes are driven by personal behaviors. Opportunity springs from the capacity to engage and activate patients to build self-care skills, improve their health behaviors, and accept accountability for their health. For healthcare professionals, it is not about giving motivation for behavior change, but inspiring it.
Effective health coaching is built around 4 breakthrough ideas:
Most healthcare decisions take place in homes, grocery stores, restaurants, and gyms. The CDC reports that seniors spend an average of only 5 hours annually (out of 8,760 in a year) in the doctor’s office. This was reported even prior to the advent of COVID-19 and expanded telehealth. Wise providers recognize that they must reach into the setting of the patient, their personal culture, and social determinants of health, and align care with personal preferences and values for best practices to be sustained and influential.
The question is, “How can an already busy provider get to and serve all of these new interests of individuals and target vulnerable populations?” Most often it takes a healthcare team (care managers, care coordinators, dietitians, patient navigators, etc.) who, along with the physician, can effectively partner with patients to influence healthcare decisions occurring outside of the medical setting.
The Agency for Healthcare Research and Quality (AHRQ) has reported that 95% of diabetes care is self-care. Self-care impacts many other chronic conditions to a similar extent. Historically, chronic condition self-management has focused on patient education, encouraging health behavior change and compliance with prescribed medications. Patients not following through were labeled non-compliant or non-adherent. In truth, they required further engagement and activation toward better health.
There is a lot of talk and conversation about patient engagement. Technology may be one path to engagement, and frequent contact is another. Incentives prompt some to higher levels of engagement. These are not bad ideas. However, they miss a powerful point – engagement results most often from connecting individuals to their own expressed interests. It begins by changing the conversation from asking “What’s the matter?” to “What matters to you? As described by Dr. Stephen Rollnick, co-founder of Motivational Interviewing: “Instead of trying to persuade people why or how they should change, it’s far better to create a conversation in which they do it for themselves.”
Health coaching is finding a patient’s “star in the world” and “hitching their health behavior wagon to it.” Effective coaching helps patients uncover their own motivations and inspire meaningful self-care behaviors that take them there. Coaching helps connect the dots between the patient’s expressed long-term health interests and today’s behavior.
Telling individuals what to do, educating, or warning them about the consequences of their sub-optimal health behaviors has not worked. The New England Journal of Medicine has reported that 30-50% of patients leave their provider visits without understanding their treatment plan, hospitalized patients retain only 10% of their discharge teaching instructions, and chronically ill patients receive only 56% of clinically recommended healthcare. If this is true, it reflects reasons many patients remain a great underutilized resource.
Prior to his departure from his notable position as Director at the Office of the National Coordinator for Health Information Technology (ONC), Dr. Farzad Mostashari shared an illuminating observation, “We are in an era of looking at all of the underutilized resources in healthcare. The greatest underutilized resource in healthcare is the patient and their families.”
Tapping into patients and their families and utilizing them as a resource requires knowledge about a patient’s interests and rationality. This requires encounters that are collaborative, patient centered, and team executed.
Toby Cosgrove, longtime CEO of Cleveland Clinic, appearing on Meet the Press, was asked, “What is the one big breakthrough opportunity we have to change the nature of healthcare in this country?” He did not talk legislation and funding. Instead, he observed that the biggest challenge, and opportunity, for the future of healthcare is getting people to take greater personal responsibility for their own health.
Believing in health behavior change, inspiring it, and partnering with the patient represents a departure from, “how we have always done it.” Healthcare professionals must move from “do, teach, tell” to “ask, listen, inspire.” Rather than focusing service on the origin and treatment of disease, they focus upon the maintenance and development of health. In short, the effective healthcare team is a designer and builder of health – an architect for health.
To effectively partner with patients in the new design and build of health, healthcare professionals must be skilled in transforming the conversation between themselves and patients they serve. They must be “behavior change specialists,” not seeing the end of their work as teaching or telling a patient the best steps to care but growing the patient’s ability and confidence in long-lasting behavior change.
An analogy can be drawn between what therapists do in working with patients and what coaches do. Therapists often look back at the causes and background of individuals as a source of what causes the present situation – they act as an archeologist. In contrast, a coach picks up individuals where they are and acts to design or create a new or better future – they act as an architect.
Health coaching is a fundamental approach to delivering patient-centered care. There are practical coaching techniques that complement the care team’s clinical expertise to deliver a new level of patient engagement and activation. Enabling competent, confident, performance-oriented coaches to truly become architects for health! Who could ask for a higher calling?