A Physician Perspective on Health Coach Training
Over the span of two months this past winter I took the Iowa Chronic Care Consortium’s (ICCC) Clinical Health Coach training. I took it because the ICCC’s Executive Director promised me it would improve my communication with my difficult patients, and possibly, even with my husband. What I took away from it was a renewed sense of the potential for medicine to improve peoples’ lives, improve my job satisfaction and reduce healthcare costs all with one disarmingly simple solution—health coaching.
How can health coaching accomplish all of this?
80% of healthcare dollars are spent on chronic disease[i]. 80% of that is accounted for by inpatient stays and ER visits. At a minimum, 80% of chronic disease management is done by patients in their own home[ii]. Health care professionals equipped with health coaching skills have a special capacity to help patients motivate themselves to take control of their health. This results in improved health outcomes and reduction of high cost utilization. Clinical Health Coach training focuses upon the practice of proactive population health management, which also reduces rates of high cost utilization and improves patients’ satisfaction. The following are a few of the basic tenets that illustrate how all of this is attainable.
Behavioral change is possible[iii].
Clinical health coaching uses motivational interviewing to pick patients up wherever they are along the spectrum of health and disease and move them towards health. They also pick patients up wherever they are along the spectrum of change and move them towards positive changes. Motivational interviewing (MI) has been proven over and over again to work in the most recalcitrant of patients—addiction. If it works in addiction it’ll work with anyone[iv]. MI works because it respects a patient’s autonomy, affirms their worth as a person and elicits what is important to the patient as the motivation for change.
In using my MI skills with patients it was illuminating to see how they would open up when they realized I really wanted to know what was important to them, not what I thought should be important to them[v]. My patients know what they need to do to be healthier—they know because I have been telling them at their physical for years—“eat healthier, exercise more, take your medicine.” This approach has worked in very few of my patients. When I started asking open ended questions about why their health was important to them and where they thought they could start and how they would incorporate it into their life and what would make it worth it, the patient would come up with a plan that both myself and the patient thought there was a greater than 90% chance they would follow through with it.
Translation: Simply telling your patient to do something is not enough. You have to help them find their motivation to do it. Patient engagement is what makes that happen and MI skills are just one of the tools health coaches have to accomplish this.
For those of you who scoff about why motivation and not just education is important consider this study about physician behavior. In a study published in the American Journal of Infection Control (2014) [vi] about how often physicians practiced hand hygiene prior to placing central lines, it was done 62% of the time. Despite the fact that we have known for decades that hand washing is important to decrease the spread of disease and physicians are highly educated and physicians know that hand washing is cheap and effective–it was only done 62% of the time. Education is not enough for physicians and it is certainly not enough for patients[vii].
“FLEXCare®”Communication strategies are another tool health coaches utilize. During the training I learned my Myer-Briggs personality preferences, how to identify my patients’ preferences and how to “flex” my communication style to match my patients and therefore provide more effective care. I learned that those patients’ parents who I thought were testing me…were testing me, but not in a bad way. Their way of establishing trust was by making sure I knew what I was talking about and once I answered enough questions “correctly” (or was honest that I didn’t know the answer but I would find out) I would have earned their trust and they would be much more willing to follow through on my advice. Conversely, there were those patients that didn’t ask a lot of technical questions but wanted to know that I cared about their child and needed me to demonstrate that either verbally or nonverbally. Once I had done this they would be much more willing to follow my advice. The program did indeed improve my communication with my “difficult” patients because I realized they weren’t being difficult, rather they just had a different preference for how they needed to obtain and process information. Now, I could provide that for them without feeling defensive about the barrage of questions or awkward about demonstrating that their child’s health was important to me personally.
Behavioral change translates into improved health outcomes and healthcare savings[viii] and increased patient satisfaction. In a study done by the ICCC[ix] in a rural Medicaid population, a health coach/care coordinator was assigned 250 diabetic patients. After clinical variances were identified the health coach contacted the patient and provided a number of resources, not the least of which was health coaching to motivate change. This program reduced total diabetes events by 6% (improved health outcome—check!) and resulted in overall savings mainly through decreased inpatient stays, even when the cost of the program was taken into account (healthcare savings—check!). In addition, 93% of patient participants felt the program improved their quality of life (improved patient satisfaction—check!).
Physicians should be managing the health of their entire panel of patients, not just the ones who walk through their door.
Yet according to Yarnell et al. (2009) in order for physicians to take care of their entire panel of patients including acute care, chronic care and prevention using standard guidelines, it would take 21.7 hours a day[x]. Health coaches can help with this burden. Clinical Health Coach training highlights the value of disease registry management and health risk assessments (HRAs)—two essential and reasonably priced tools in population health management.
For me as a pediatrician there are obvious benefits; a registry can identify my asthmatic patients and when our flu shots arrive my staff can call the list and encourage the patients to come in. Since depression has an adverse affect on chronic disease management, the registry can keep track of which of my teenagers who suffer from chronic disease (e.g. type I diabetes, inflammatory bowel disease, juvenile arthritis, cancer) has been screened for depression. These teenagers tend to use their specialist as a primary care provider but there is a lot to be gained for them by seeing a general pediatrician and talking about all aspects of their health. It can also keep track of health measures for obesity—most recent height, weight and BMI and whether they have they been screened for comorbidities—when was their last blood pressure check, lipid check, fasting glucose, do they smoke, and their family history. I see a majority of my teenagers for sports physicals every year. However, I don’t see all of them and unfortunately my obese teenagers make up a large portion of those that I don’t see. Equally unfortunate is that these are the teenagers I should be seeing more regularly.
In adult medicine disease registries play an even larger roll. There are good evidence based guidelines that can be embedded into disease registries — congestive heart failure, hypertension, type II diabetes, COPD and asthma. Are these patients getting the screening tests they need? Are they coming in for their appointments? Is their health improving or worsening? A properly maintained disease registry can answer all of these questions and is a foundational tool for the Clinical Health Coach. If a type II diabetic comes in for sore throat, the receptionist can check the disease registry and see if anything else needs to be done. The health coach can then order tests (think hemoglobin A1C, urine albumin/creatinine, cholesterol) based on evidence-based guidelines and the physicians’ preferred protocol. When the patient comes in to see the physician it will all be ready and laid out for her. This shifts significant time burden away from the physician. The physician can then efficiently treat the sore throat and also make recommendations for chronic disease management that can then be reinforced and followed up on by the health coach.
In order for Clinical Health Coaches to make the maximum impact on a physician’s panel of patients it makes sense to start with the sickest patients, those who need the most help managing their chronic disease. Disease registries and HRAs help offices track these patients and their progress. A well-circulated and true story at my training went like this: a clinical health coach earned a huge return on the investment of paying for her clinical health coach training by establishing a disease registry. Simply calling all the new Medicare enrollees to come in for their Welcome to Medicare Physicals paid not just for her training but also her salary for the year. This is just one of the many metrics that can be included in a disease registry.
I am still learning and honing my health coaching skills and exploring how a health coach can help in my office. I am certain I communicate better with my patients and feel my guidance is followed through on more often. This has increased my satisfaction AND my patients’ and their parents’ satisfaction. I appreciate the impact a disease registry has on not just the efficiency but the quality of the care I provide. There is hope in medicine that costs can be curbed and quality can be improved. Clinical health coaching can and should be a part of that. And yes, in case you are wondering, communication with my husband has also improved!
Heidi Shreck, M.D., FAAP
[v] “People are generally better persuaded by the reasons which they have themselves discovered, than by those which have come into the mind of others.” Blaise Pascal, Pascal’s Pensees (17th Century)
[vi] State of infection prevention in US hospitals enrolled in the National Health and Safety Network Patricia W. Stone, PhD, FAAN, Monika Pogorzelska-Maziarz, PhD, MPH, Carolyn T.A. Herzig, MS, Lindsey M. Weiner, MPH, E. Yoko Furuya, MD, MS, Andrew Dick, PhD, Elaine Larson, PhD, FAAN
[vii] Discussion with Alan Morris, July 2014 and viewing of Grand Rounds at the University of Utah May 29th, 2014 http://medicine.utah.edu/internalmedicine/grand-rounds-archive/2014.php
[x] Yarnall KSH, Østbye T, Krause KM, Pollak KI, Gradison M, Michener JL. Family physicians as team leaders: “time” to share the care. Prev Chronic Dis 2009; 6(2):A59. http://www.cdc.gov/pcd/issues/2009/apr/08_0023.htm. Accessed [August 15, 2014].