Family physicians know that their most vulnerable patients -- those with chronic diseases in resource-poor communities -- need more hands-on attention than a single physician can provide in an office visit.
That's why the health coaching phenomenon -- a model that designates another person on the care team to support patients in making decisions about their health care -- is catching on around the country.
The Department of Family and Community Medicine at the University of California, San Francisco (UCSF), has taken a particular interest in health coaching, as evidenced by ongoing research on the topic.
In their latest effort -- led by corresponding author David Thom, M.D., Ph.D., vice-chair of research for the department -- researchers conducted a qualitative study designed to learn exactly how health coaches support and work with patients.
In an interview with AAFP News, Thom said previous studies showed that health coaching improved some patient outcomes, such as glycemic control for patients with diabetes. "This study, funded by PCORI (Patient-Centered Outcomes Research Institute), offered the opportunity to really delve into understanding how health coaches and patients work together."
- An article in the latest issue of Annals of Family Medicine details findings from a qualitative study designed to learn how health coaches support and work with patients.
- Authors identified seven themes from which they constructed a conceptual model to show how health coaches and patients work together.
- Those themes are shared characteristics between coach and patient, availability, trust, education, personal support, decision-making support, and patient/clinician bridging.
Thom, a practicing family physician for 30 years and a researcher for more than 25 years, noted his longstanding passion for understanding the patient-physician relationship, and, in particular, patient trust.
"I think that the health coaching model pioneered at the UCSF Center for Excellence in Primary Care offers many of the same benefits to the patient I saw with the patient-physician relationship, particularly for the complex patients we see in the safety-net system with poorly controlled chronic disease," he added.
The research findings were published in the November/December issue of Annals of Family Medicine in an article(www.annfammed.org) titled "A Qualitative Study of How Health Coaches Support Patients in Making Health-Related Decisions and Behavioral Changes."
Authors noted that health coaches in primary care typically help patients with everyday decisions that include taking medications, incorporating dietary changes and undertaking physical activity.
For this study, Thom and his research team relied on focus groups and individual interviews with patients and their family and friends, health coaches, and clinicians at six urban public health primary care clinics that had ongoing experience with health coaches.
Health coaches were medical assistants or other nonlicensed health care workers with previous or current experience in coaching roles. All received 40 hours of instruction that included active listening, nonjudgmental communication, self-management support, and social and emotional support.
They also received basic education about patients' chronic diseases, the importance of medication adherence and how to access community resources. Interview data were obtained from 20 clinician participants; of those, 17 were physicians, two were nurse practitioners and one was a physician assistant.
Researchers identified seven themes from which they constructed a conceptual model to show how health coaches and patients work together. Those themes are described here:
- Shared characteristics include language, culture, sex, social status, and similar experiences and values. According to the study authors, these shared traits help the patient feel comfortable with and understood by the coach "and therefore more likely to work with the coach to make health decisions." One coach reported that patients saw her more as a peer. "I could understand them or relate to them better … It was comforting for them."
- Availability includes the frequency and duration of a health coach's contact with the patient, continuity of that contact over time, and patient accessibility to the coach. "We have the luxury of having an hour visit," said one coach. "We talk and talk" and ask a lot of questions. "And then little by little, the patients feel comfortable."
- Trust involves building a strong and positive relationship. According to the authors, "A trusting relationship enabled patients to be honest, ask questions, and express doubts or disagreements, which allowed the health coach to be more effective."
- Education includes health coaches sharing basic information with patients about their health condition and explaining how behaviors affect that condition. Coaches help patients choose their goals, determine patients' readiness for change and assess their understanding of the information presented to them.
- Personal support "includes valuing the patient, which helps the patient value himself or herself enough to make decisions and take actions to improve (his or her) health," wrote the authors. Personal support is all about listening to the patient and allaying fears, and providing hope, confidence, encouragement and motivation.
- Decision-making support means helping patients identify goals and create action plans. Coach and patient work together to overcome barriers and locate resources. One coach said she tells patients, "I'm not here to tell you what to do. I'm here to offer you options."
- Bridging between the patient and clinician occurs when the health coach acts a liaison between the patient and the physician or other clinician. One clinician told researchers, "If I haven't explained something well or can't do follow-up or can't reinforce a message, I'm hoping the health coach can do that."
Thom had additional comments about the research team's findings; those thoughts are captured in the following Q&A:
Q. Why is this topic important at this point in time?
A. Health coaching and similar models are spreading rapidly beyond research studies and into practice in many forms. While our model has used practice-based health coaches who have sustained individual contact with patients, other places are using models that include off-site health coaching or even Internet-based coaching. At the same time, there are models such as patient navigators or care managers that can have many of the same features as our model of health coaching, but under a different name.
We felt it was important to get a better understanding about the mechanisms by which health coaching works to help decide which models make sense and which are less likely to be effective.
Q. Can you pinpoint your most important finding?
A. All the groups from whom we collected data -- patients, health coaches, clinicians, patients and families -- recognized the importance of the relationship in the effectiveness of health coaching. In addition, clinicians and health coaches, for the most part, perceived the health coach as a bridge between the patient and their primary care provider rather than as a barrier.
Q. Were you surprised by any of your results?
A. Health coaches develop relationships with patients, but also are part of the clinical team. We were surprised that health coaches could sometimes be conflicted about their role when a patient confided in them about information the patient did not want to share with the primary care provider.
In that instance, the health coach is put in a difficult position -- not wanting to betray the patient's trust, but at the same time understanding the potential danger to the patient's health by withholding information from the doctor that could affect clinical care. It's clearly an issue that needs to be addressed during health coach training.
Q. What's the most important takeaway for family physicians?
A. Our results support a model of health coaching where the health coach is part of the care team -- accompanying the patient to doctor visits whenever possible and then communicating with the patient and the physician between visits. This can be an asset to both the patient and the physician when it's done well.
Q. Can you translate what you've learned to practical use in family physicians' practices?
A. Like many other aspects of primary care that are not seen as essential to the business function of the office visit or as a reimbursable additional service, many of the activities of health coaching are expected to be done by the primary care physician if they are done at all.
In creating a team-based model for primary care, it is possible to include a role for health coaching, either combined with other duties such as those of a medical assistant or, in larger practices, as a principal role. The specifics of how to do this best will vary between practice settings and reimbursement environments.
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