Empowering Patients to Make Healthy Changes Virtually
Leveraging health coaching and integrative primary care.
Posted Sep 10, 2020
Patients with chronic diseases—6 out of 10 adults in the United States[i]—need help to adopt and sustain healthy behaviors.
“Most clinicians have a really hard time talking to patients about healthy behavior change. We either beg or threaten them to make changes. This doesn’t work very well,” says Thomas Bodenheimer, M.D., MPH, a professor in the department of family and community medicine and founding director of the Center for Excellence in Primary Care at the University of California, San Francisco. He is also a nationally recognized expert in health coaching who had developed health coaching curriculums for the University of California, San Francisco, and the AMA.
Instead of telling patients what to do, which doesn’t work well, health coaching engages patients in decisions about their health and supports them in making changes to live healthier lives. Health coaching helps these patients understand their chronic disease(s) and actively participate in their care. It can be done using telemedicine (video or telephone) or in person.
Making Healthy Behaviors Easier
“Behavior change is a big component of chronic disease management,” says Dr. Bodenheimer. As a primary care physician, Dr. Bodenheimer realized that he hadn’t been doing a very good job helping his patients, especially those with chronic diseases, adopt healthier behaviors. Neither were other primary care providers.
When Dr. Bodenheimer joined the University of California, San Francisco, he developed a model for health coaching in primary care and studied it in two randomized controlled trials. “Health coaching is finding out what patients are willing and able to do and meeting them halfway,” he says. Health coaches are trained medical assistants, laypeople, nurses, or other staff members who:
- Provide patient education and support
- Assess patients’ understanding
- Engage patients in developing and following action plans for healthier behaviors
Health coaching can be done virtually or by telephone (telemedicine) or in person. While telemedicine is a safer way to provide health coaching during the COVID-19 pandemic, it also has other benefits. It is part of integrative primary care, the coordinated delivery of evidence-based conventional medical care, complementary medicine, and lifestyle medicine within a primary care practice. It facilitates patient engagement in care decisions and gives the physician more time to provide integrative health care.
A Four-Step Process for Implementing Health Coaching
The AMA STEPS Forward Health Coaching Implementation module uses a four-step process:
1. Commit to health coaching.
2. Build a health coaching model.
3. Recruit, train, and mentor the coaches.
4. Start coaching and track progress.
Once practice leadership and the care team have a commitment to health coaching, staff members are trained, the program is developed, and workflows to incorporate health coaching in the practice are created. The Center for Excellence in Primary Care health coaching curriculum includes free training for health coaches. Building the health coaching model begins with assigning someone who understands health coaching and is available to lead the health coaching program. The health coaching leader works with practice leaders to develop a feasible workflow for health coaching within the practice and to identify goals. This includes identifying patients who can benefit from health coaching.
The role of health coaches in the practice can help determine which staff to train as health coaches. A nurse or social worker is appropriate if health coaching will provide clinical education. If the health coach will call patients to remind them to follow their action plan, a medical assistant could make a good health coach. Peer health coaches, patients who have met their health goals, are a good choice for non-clinical health coaching once the health coaching program is well established. Pre-medical or pre-nursing students also make good volunteer health coaches.
The health coach or provider should introduce patients to health coaching with an explanation of the goals and what to expect. Along with training, new health coaches should be mentored. The practice should evaluate the health coaching program at least annually. Indicators of success include:
- Patient outcomes related to better health
- Referral of the right patients to the health coach
- Successful recruitment and retention of patients
- Higher patient satisfaction and engagement
- Less provider stress
Health Coaching Works
“This is not touchy-feely health coaching. There’s evidence behind everything we do,” says Dr. Bodenheimer. Evidence from two randomized clinical trials conducted by Dr. Bodenheimer shows clinical benefits for primary care providers and patients and operational benefits for primary care practices.[ii], [iii]
- Better health outcomes
- Better medication adherence
- Higher patient satisfaction
- Increased trust in and satisfaction with primary care providers
- More provider time
- Reduced provider burnout
- Higher provider satisfaction
Also, evidence supports the use of telemedicine for counseling patients with chronic conditions. The Agency for Healthcare Research and Quality (AHRQ) reported evidence of benefit from telehealth (another name for telemedicine) in communicating and counseling patients with chronic conditions based on its meta-analysis of 58 systematic reviews published between 2007 and 2015. More than 950 of the studies included in the systematic reviews covered telehealth.[iv] Other studies have shown marked improvements in clinical outcomes for patients with arthritis, diabetes, and heart disease who received coaching via telehealth or mobile health tools.[v]
[i] Centers for Disease Control and Prevention. Chronic Diseases in America. Accessed 7/23/20.
[ii] Willard-Grace R, Chen EH, Hessler D, et al. Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial. Ann Fam Med. March/April 2015;13(2):130-138. Accessed 7/23/20.
[iii] Thom DH, Ghorob A, Hessler D, De Vore D, Chen E, Bodenehimer TA. Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial. Ann Fam Med. March/April 2013;11(2):137-144. Accessed 7/23/20.
[iv] Agency for Healthcare Research and Quality. The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During the COVID-19 Pandemic. May 2020. Accessed 7/22/20.
[v] Eric Wiklund. Telehealth Gains Favor as a Coaching Platform for Chronic Care. mHealth Intelligence. Accessed 7/22/20.