True healthcare reform springs from the capacity of individuals in a population to build self-care skills, improve their health behaviors and accept accountability for health. It is not about giving motivation but inspiring it.
This inspiration comes more easily for some than others. Lifting health status and reducing the risks in a population can be dramatically influenced by the culture of health. However, inspiring those at most risk is the nut of achieving real clinical and cost reduction outcomes. Some of individuals at higher risk will be motivated by knowledge of their condition and interest in better well-being; others will be the “drinkin, smokin, carrying-on types.” Each must be reached.
The Clinical Health Coach training was developed several years ago by the Iowa Chronic Care Consortium specifically to drive better outcomes in population health–clinical, quality of life, patient experience and cost. It is a highly performance oriented program that develops a very particular set of skills that builds self-care skills, prompts improved health behaviors and inspires accountability in individuals. It was designed to address the needs of individuals requiring active care management; it serves well those benefiting from health promotion and maintenance.
This innovative training strategy was created to address three gems of evidence based knowledge: 1) 98% of healthcare takes place outside of a provider office or clinic; 2) most care is self-care, from health promotion to chronic condition management; and, 3) individuals and their families are the greatest underutilized resource in healthcare. This knowledge is the foundation for three breakthrough ideas for capable of reforming healthcare.
#1. Reaching 98% of Healthcare.
Increasingly, healthcare has become serious about outcomes. The Triple Aim of better health, better healthcare and lower cost is more than a mere mantra for change. It is shifting our approach to healthcare. Payors, health plans and patients are becoming more savvy regarding outcomes. Patients who have long exhibited priority interest in being “fixed” are grasping the value of reducing risk and maintaining health status. Attention to health risk and health status are longer term goals supported by improved access, prevention, timely care, management of chronic conditions and improved health behaviors.
The question is, “How can an already busy provider get to and serve all of these new interests of individuals?” And, “How can appropriate attention be given to those with the highest risk and lower health status that will experience condition exacerbations and cost?” Quite frankly, if delivered in traditional ways, they cannot. Most often it takes a team, who along with the physician can effectively partner with patients to reach into and influence what occurs in the 98% of healthcare that happens outside of the office, clinic or hospital.
Most healthcare takes place in the bedrooms, bathrooms and kitchens of an individual’s home. Competent providers recognize that they must reach into that setting of the patient and their personal culture for best practices to be sustained and influential. Knowledgeable providers believe that they can partner with patients influencing their health behaviors and their accountability for improved outcomes. Wise providers know that reducing risk and improving health status for their population of patients can only be achieved by reaching into and inspiring behaviors in the 98% of healthcare.
#2. Recognizing the Power of Self-Care.
The Agency for Healthcare Quality and Research (AHRQ) recently reported that 95% of diabetes care is self-care. Even the best of physicians and healthcare providers cannot get to results by themselves. Historically, we have encouraged, sought and preferred patients who were compliant with and adherent to education, prescriptions and recommended behaviors. Those that were not were described as non-compliant or non-adherent. In truth, there were likely not engaged or activated.
There is a lot of talk and conversation about patient engagement. Technology is often touted as a path to engagement. Frequent contact is often recommended means to an engagement end. And, selected health plans and employers report that incentives prompt higher levels of engagement. These are not bad ideas. However, they miss a powerful point – engagement results most often from connecting an individual to their own expressed interests.
By coaching an individual to identify and claim their highest health interests – better quality of life, staying out of the hospital, remaining independent, thriving in life – the value of building self-care skills, improving health behaviors and living accountably comes alive. A patient’s stated interest or goal to be around for grandchildren or travel confidently for the next several years provides powerful self-motivation for changed behavior or the practice of evidence founded self-care skills. Building self-care skills, motivation to use them and accountability to sustain health is a new high calling for all of healthcare professionals.
#3. Tapping the Great Underutilized Resource.
Prior to his recent departure from the Office of the National Coordinator for Health Information Technology (ONC), Dr. Farsad Mostashari shared an interesting quote at the HIMMS National Conference and Exhibition, “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. The next big healthcare application will be behavioral informatics—how do we understand behavioral change, not just give people knowledge, but helping people tap into their rationality.”
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 health care. If this is true, it reflects reasons many patients remain a great underutilized resource.
Tapping into patients and their families utilizing them as a resource requires knowledge about a patient’s interests and rationality. In the 1960s, a traditional healthcare encounter was physician centered and self-executed. The elements were: gather information; perform examination; offer diagnosis; and, give instructions. Today, effective encounters are collaborative, patient centered and team executed. The elements include: open discussion; build relationship; gather information; understand patient perspective; perform examination; share information; determine patient interest in change; agree on problem and plan; and, provide closure.
Reaching effectively into the 98% of care, believing in health behavior change and practicing it, and partnering with the patient to tap this great underutilized resource 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 provider 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 the 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. The labeled “non-compliant” patient is often someone who needs further exploration in discovering their own motivation for change. These healthcare professionals must also be attentive to population health processes, acting as care management facilitators who align best practice care with patient centered resources.
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. A coach picks individuals up where they are and acts to design or creating a new or better future –they act as an architect.
Health coaching is a fundamental approach to delivering patient-centered care. While this can be challenging for a care team, there are powerful health coach strategies that will complement the care team’s clinical expertise delivering a new level of patient engagement and activation. Health coaching strategies improve the entire team. Coaching skills enable physicians, care coordinators, community health workers, ANPs, PAs, dietitians, social workers and other healthcare professionals to move behaviors. Our mission in the Clinical Health Coach training is building highly competent, performance oriented individuals who can truly become architects for health! Few could ask for a higher calling.
William K. Appelgate, PhD