Give low-income patients with hypertension access to the services of a trained health coach, ensure that the coaching includes frequent phone contact, and watch systolic blood pressure levels plummet by an average of 22 mm Hg. That's the result reported recently by family medicine researchers in the University of California-San Francisco's (UCSF's) Department of Family and Community Medicine. Their findings were highlighted in "Health Coaching to Improve Hypertension Treatment in a Low-Income, Minority Population(annfammed.org)," an article in the May/June issue of Annals of Family Medicine.
Corresponding author Thomas Bodenheimer, M.D., is the
co-director of the Center for Excellence in Primary Care at the UCSF School of Medicine. As such, he is no stranger to the topic of health coaching and patient self-management. Bodenheimer's work on the subject includes a series of videos(www.chcf.org) created for the California Healthcare Foundation.
But Bodenheimer told AAFP News Now that his past experience didn't prepare him for the positive results that were revealed at the conclusion of this study. "I was surprised by how much the blood pressures went down because most studies about trying different ways to improve hypertension will get a 5 or 6 millimeter drop in blood pressures -- we got a 22 millimeter (average) drop in blood pressure," said Bodenheimer.
"That's an enormous drop. I thought the coaches could really help, but I didn't think they could help that much," he added.
According to study authors, about 50 percent of U.S. patients with hypertension have poorly controlled blood pressure. Part of the problem, noted researchers, is that patients typically want multiple health concerns addressed in an all-too-short 15-minute office visit. "They often leave the visit without knowing their blood pressure level or goal," said the authors.
- Researchers in California trained college graduates without clinical health backgrounds to serve as health coaches for patients with hypertension.
- Coaches made weekly contact with patients and focused coaching efforts on medication adherence.
- Systolic blood pressure levels dropped an average of 22 mm Hg, and patients reduced the number of visits to their primary care physicians.
In addition, physicians -- typically primary care physicians, because their offices account for nearly 80 percent of patient visits for elevated blood pressure -- have so many competing demands on their time that they may not always be able to address a patient's hypertension.
Bodenheimer said the study's most important findings get at the heart of how to solve those issues. First, "You can actually affect blood pressure in a very profound way without involving physician time by training coaches in how to effect behavioral change in patients," he said.
Secondly, study results indicate more coaching is better. "The more telephone calls between a coach and a patient, the better the patient's blood pressure. It's almost like a medicine; if you increase the dose of coaching, you get a better result," said Bodenheimer.
The study was conducted between January 2009 and January 2010 in a family medicine residency clinic at a public hospital that serves low-income and largely minority patients. Eligible patients had blood pressure levels of at least 145 mm Hg systolic or at least 90 mm Hg diastolic.
A total of 237 patients were enrolled in the study, and they were divided into two groups. All patients had access to home blood pressure monitoring kits and health coaching by nonmedical professional coaches. Only one group had the option of physician-approved home titration of antihypertensive medications.
Coaches all had bachelor's degrees and received 16-20 hours of training that focused on hypertension and medications to treat hypertension, lifestyle behavior change, and medication adherence counseling.
Health coaches made weekly phone calls to patients and discussed patients' general well-being, their adherence to individual action plans and their blood pressure values.
During the course of the study, patients in the home-titration arm who reported blood pressure readings of greater than 140 mm Hg systolic or greater than 90 mm Hg diastolic could have their medications changed without scheduling a visit with their physicians.
In preparation for the study, physicians with patients in the home-titration arm completed a simple algorithm of antihypertensive medication adjustments.
Medication changes were facilitated by health coaches only after they were assured by patients of excellent medication adherence.
Researchers reported that patients participating in both arms of the study had nearly identical systolic blood pressure reductions. Furthermore, of the 166 medication changes among 68 patients in the home-titration arm, only 31 of those changes were made at home among 20 patients.
The other 135 medication adjustments were made by clinicians, leading study authors to conclude that "the feasibility of home titration remains uncertain, as less than one-fifth of patients in that arm actually undertook an adjustment of their antihypertensive medication at home."
However, study authors highlighted three take-home points for primary care physicians to consider when looking at improving their patients' blood pressure treatment:
- the more encounters between patients and their health coaches, the greater the reduction in patients' blood pressure readings;
- blood pressure can be improved without adding to existing demands on physician time; and
- unlicensed, nonprofessional caregivers can successfully serve as health coaches.
The authors reported a decrease in the number of primary care visits by patients in both arms of the study from 3.5 in the six months before the study, to 2.6 visits during the six-month study, and down to 2.4 visits in the six months after the study.
The researchers said that with the appropriate amount of training, coaches can improve patients' blood pressure by focusing coaching efforts on medication adherence.
Bodenheimer said family physicians would do well to embrace the team approach to care and welcome nonmedical personnel into the patient-care circle.
"I would say to my physician colleagues that nonprofessional team members in the primary care setting who have good training can really help you take care of patients with chronic diseases, such as diabetes and high blood pressure. You should welcome that help, because it makes your life easier and makes your patients healthier."