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    Health coaching: Good for your patients and your practice

    How to cater to a growing segment of patients who want partners in their quest for health

    The patient fidgets nervously as she awaits her appointment with her physician. She has a number of questions she needs to ask and wonders whether she will remember everything once she enters the exam room. "I always seem to blank out," she says to herself. "Once I get in the exam room, I get tongue-tied because I know I am only going to have 5 or so minutes to get everything dealt with."

    Directly across the room sits another patient. She is on her cell phone, talking amiably with her daughter. She is not worried about getting enough "face time" during her appointment because she spoke with her health coach yesterday to prepare for her visit.

    "Her health what?" you may be asking, if you haven't yet heard about the emerging concept of a health coach as an integral part of a medical practice.

    It's been said that a physician takes an average of 18 seconds to determine a patient's course of action. With medical information available from multiple sources, consumers are more, rather than less, desirous of seeing caregivers who can help them sort out their options and answer their health questions.


    Roles of the medical practice health coach
    Today's patients are more technologically savvy than ever before. They want information to be delivered quickly and in a way that facilitates their encounters with the healthcare system. And many will willingly spend disposable income to pay for alternative treatment approaches or choose a retail healthcare clinic over going to the traditional doctor's office.

    Increasingly, consumers want more control over their healthcare choices, and a growing segment of health-conscious consumers prefers their caregivers to be genuine partners in their quest for better health.

    Thus, the new interest in health coaching.

    WHAT EXACTLY IS A HEALTH COACH?

    Health coaching has its roots in disease management. Although not a new concept—health coaching has been used by the insurance industry to screen for the inappropriate use of healthcare resources—it is a relatively new concept for medical practices.

    Physicians and medical practices have only started using health coaches more recently, primarily because many physicians have not been aware of the concept. In a medical practice, the health coach may act as an intermediary in the patient/provider relationship. In this role, the coach brings relevant information to the patient's medical team while also helping to motivate the patient in following appropriate medical protocols.

    A health coach also may instruct clients about diagnostic and therapeutic modalities and guide patients in making informed choices about when, how, and where to use community healthcare resources.

    Primary objectives of health coaching are to educate the patient regarding self health management and to encourage patients in taking a more proactive role in staying healthy. It is difficult these days to read a medical journal without encountering the topics of "consumer-driven healthcare," "patient empowerment," or "patient-centered care." The ubiquity of the World Wide Web (more than 80% of Web searches are for health-related topics1 ), combined with the pressure that employers are increasingly exerting on their employees to improve their health behaviors (such as smoking and obesity) are fostering a greater awareness among consumers of their personal accountability in the patient/provider relationship.

    A DIFFERENT FOCUS

    As a physician, you are trained to ask each patient his or her chief complaint, to take a history, and to focus on the information specifically relevant to your diagnosis of the complaint. Lifestyle issues such as stress, poor nutrition, substandard living conditions, and little or no exercise are factors contributing to the patient's overall health, but they usually are not the focus of an exam for a specific complaint. As a result of this narrowed focus, important clues to a patient's well-being may be missed. It may be an aside, an off-hand comment, or a casual observation that is key to learning the patient's real issue.

    Further, most patients want to please their physicians—they often will respond to a doctor's question in a way that they think he or she wants. If you are rushed, they may feel uncomfortable asking questions.

    If, on the other hand, patients can talk with a health coach in a more relaxed setting in which they do not feel the same time pressure, they often will feel much more confident discussing their health situation.

    The health-coaching model takes a different approach to information-gathering. It seeks to understand the social context underlying the physical issue. It probes the total well-being of the patient to learn what is happening in the patient's life that could be contributing to his or her physical illness.

    WHO CAN BE A HEALTH COACH?

    Although many health coaches typically are registered nurses or allied health professionals, prior clinical training is not a requirement for a coach to be effective. Mercy Clinics, a 150-physician multispecialty clinic in Des Moines, Iowa, uses 3 levels of health coaches to meet the needs of its different clinics.2 Duke University Medical Center in Durham, North Carolina, uses both registered nurses and allied health professionals, such as licensed professional counselors, health education specialists, exercise specialists, social workers, yoga therapists, and mind/body therapists. A smaller group practice may choose to use a nurse practitioner or a certified medical assistant as a health coach.

    The most important qualifications for coaches are that they have excellent listening and communication skills; good planning, organization, and follow-up techniques; and an ability to motivate people toward making positive changes in their lifestyles to achieve health-related goals. Ultimately, qualifications will vary, depending on the specific coaching model your office chooses to implement.

    VARIOUS ROLES OF THE HEALTH COACH

    Health coaches bring many benefits to your patients and to your practice:

    • helping patients navigate an increasingly complex healthcare system;
    • helping patients prepare for their medical visits, such as preparing questions and reviewing progress since the last visit with the patient and with the medical team;
    • answering questions regarding medical instructions and processes;
    • confirming that information is correct in the medical chart;
    • following up with the patient after a visit to your practice;
    • strengthening patient satisfaction;
    • motivating patients to change behaviors and to self-manage their health toward meeting mutually agreed-on goals.

    CAN HEALTH COACHING IMPROVE PATIENT OUTCOMES?

    A review of the clinical literature, although sparse, demonstrates that motivational lifestyle coaching can have a salutary effect on adherence with evidence-based approaches for disease management.

    To determine the clinical efficacy of health coaching, medical practices can run a pilot program using a control group (uncoached group of patients) and a group of patients who are coached. Population-based quality measures, such as blood pressure, LDL-C levels, and HbA1c levels can be measured over a set period of time to see whether coached patients are able to achieve and sustain pre-established goals.


    Roles of the medical practice health coach
    In one such study, Duke University Medical Center conducted a randomized, controlled trial among 154 outpatients aged at least 45 years, all of whom had 1 or more known cardiovascular risk factors, to assess whether personalized health planning (applying integrative medicine principles) could reduce 10-year risk of coronary heart disease. The study focused on diet and exercise and teamed each participant with an integrative health coach. Although the study acknowledged several limitations with respect to the relevance of its findings to the general population (most of the subjects were female, educated, and had family incomes well above median), it found that personal health planning using integrative medicine principles improved cardiovascular risk compared with usual care.3

    Although the clinical research still is being amassed, it is safe to say that motivated patients are much more likely to maintain and sustain improvements in key lifestyle behaviors. According to David Grossman, MD, medical director for preventive care with Group Health Cooperative, Seattle, Washington: "Health coaching has been proven in randomized trials to make a difference....People can be helped using motivational techniques."4

    ANSWERING CONCERNS ABOUT HEALTH COACHING

    Not everything about health coaching is self-evident. Some physicians may have deep concerns regarding health coaching. Answers to some of the more frequent questions physicians ask include:

    • Will having a health coach cost me more than it will benefit my practice?
    It all depends on the model that is pursued and on the arrangement that the practice has with its coaches. Some practices already employ healthcare professionals who can be trained in health-coaching techniques, so there is no additional salary to pay (although the way in which their time is allocated will be a financial consideration for the practice, of course).

    Practices that are successfully using health coaches tend to see the health coaches as full-time members of the medical team and find that the business they are able to generate through better use of their time more than pays for the cost to support the cost of the coaches. Mercy Clinics in Des Moines, Iowa, states that it is bringing in "at least $4 in revenue for every dollar spent on health coach salary and benefits" and that, due to the success of its coaching program, it has negotiated a payment for coaching services with its largest insurer.2

    Other practices may offer health coaching through arrangements with independent coaches who contract directly with clients.

    • Could a health coach result in fewer patient visits to my practice?
    Because health coaches are an "added value" to your practice, this is highly unlikely. In fact, it is possible that employing a health coach could increase patient visits because of the amount of time that is saved in reducing no-shows, inappropriate follow-up, and miscommunications between the practice and its patients.

    • Could I lose some of the patients' respect and the practice autonomy I now have?
    Health coaches are not a substitute for the patient's physician. If anything, health coaching can boost patient respect and perceptions of your practice and increase the practice autonomy. Also, a health coach can follow up on issues with a patient that a physician cannot spend as much time on, and this ability can help keep patients from leaving a practice due to dissatisfaction.

    • Is personal health coaching just a fad?
    Not according to the increasing number of employers and insurers who are using health coaches to reduce inappropriate utilization of healthcare resources. Many academic medical centers now employ health coaches in their medical clinics—something that was essentially unheard of just a few years ago.

    • Isn't health coaching something that only large medical clinics can afford?
    Again, affordability all depends on the model that you employ. Although a large group practice has certain benefits with health coaching, even a smaller practice group can benefit from the increased emphasis on patient accountability and self-health management.

    GAIN A COMPETITIVE ADVANTAGE

    Employing a health coach or multiple health coaches in your medical practice can not only improve patient satisfaction; it also can help differentiate your practice from your competitors. It can improve patient flow and lead to a more successful practice. But most important, it's just good patient care.

    REFERENCES

    1. "Cyberchondriacs" on the rise? Harris Interactive: Harris Polls Web site. http://www.harrisinteractive.com/NewsRoom/HarrisPolls/tabid/447/mid/1508/articleId/448/ctl/ReadCustom%20Default/Default.aspx|~http://www.harrisinteractive.com/NewsRoom/HarrisPolls/tabid/447/mid/1508/articleId/448/ctl/ReadCustom%20Default/Default.aspx . Published August 4, 2010. Accessed November 10, 2010.

    2. Swieskowski D. Office-based health coaches: creating healthier communities. Group Pract J. 2008; 57:41–45.

    3. Edelman D, Oddone EZ, Liebowitz RS, et al. A multidimensional integrative medicine intervention to improve cardiovascular risk. J Gen Intern Med. 2006; 21:728–734.

    4. Jay Greene. Guiding the way to wellness. America's Health Insurance Plans Web site. http://www.ahip.org/content/default.aspx?bc=31%7C130%7C136%7C20588%7C20589|~http://www.ahip.org/content/default.aspx?bc=31%7C130%7C136%7C20588%7C20589 . Published July/August 2007. Accessed November 10, 2010.

    The author is president and CEO of PB Healthcare Business Solutions (www.pbhealthbiz.com), a consulting firm that specializes in medical practice management and marketing. Send your feedback to

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