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Primary care clinicians - struggling to fit multiple agenda items into the 15-minute visit - cannot meet every need of their patients with chronic conditions.
In the face of these discouraging statistics, primary care must take on a new task: working with patients to ensure that they understand, agree with and participate in the management of their chronic conditions.
Health coaching can be defined as helping patients gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified health goals. Within the care team, everyone can integrate elements of coaching into their interactions with patients.
Registered nurses (RNs) are well poised to impart skills, build confidence and provide tools for patients, particularly patients discharged from the hospital or with multiple chronic conditions.
No matter who serves the coaching function, coaching presumes a collaborative paradigm (asking patients what changes they are willing to make) rather than a directive paradigm (telling patients what to do).
Health coaching encompasses five principal roles: 1) providing self-management support, 2) bridging the gap between clinician and patient, 3) helping patients navigate the health care system, 4) offering emotional support and 5) serving as a continuity figure.
The health coaching role can be added to a medical practice in a variety of ways, but two models have been particularly successful. Using a personal health record to record 30-day goals, health information and key questions to be shared with the physician at upcoming health care encounters. The Care Transitions coach (nurse or social worker) visits the patient once in the hospital and once at home, and communicates with the patient three times by phone. The low cost of this model allows for adoption in a wide variety of settings, and the investment in coaching pays dividends downstream in reduced health care costs. Health coaching has been shown to produce promising clinical benefits (see "A brief review of the health coaching literature"). Without payment reform, the only way practices can justify the added expense of health coaches is with the added clinician productivity that coaches can create.
These three case studies demonstrate that a business case can be made for hiring medical assistants to function as health coaches. Health coaching is both a conceptual framework and a concrete job category with the potential to improve patient care and assist clinicians struggling with insufficient time. Coaching involves a paradigm shift from a directive to a collaborative model so that care teams and patients pursue an active partnership, instead of patients being passive recipients of care. One of the best decisions I’ve ever made was to take a leap of faith and enroll in the health coaching program at the Institute for Integrative Nutrition (IIN). Call it coincidence, chance or destiny, but as I was trying to make this decision, I happened to meet people that had taken this course. I was a bit skeptical about the program before I started because I had been disappointed in other coaching programs I had completed.  Throughout the IIN health coach training program, I was consistently impressed with all of the content, tools and resources they provide.  The whole experience was much more than I expected!
If you are interested in health, nutrition and helping others live healthier, more fulfilling lives, this might just be perfect for you. Integrative Nutrition’s comprehensive curriculum covers over 100 dietary theories and combines counseling techniques with real-world business training. Learn from the world’s leading health, wellness and nutrition experts and begin a career that can change lives. Contact me with any questions you have and find out how I can help mentor you along the way. Teach a man to fish, and he eats for a lifetime," demonstrates the difference between rescuing a patient and coaching a patient. Olson's example, rescuing means telling him what to do about his current glucometer readings.


However, to ensure that coaching takes place, at least one team member should be designated as a coach.
Social workers are also well equipped for this role as they receive significant exposure to coaching principles during their training and often apply them in their work to promote patient behavior change. A good health coach understands this, grasps the shift from rescuing to coaching, has a basic knowledge of common chronic conditions and medications, and reliably follows through to gain the trust of patients and clinicians. Self-management support is essential for patients to extend their health care outside the clinic walls and into their real lives. Throughout the care process, there are plenty of opportunities for disconnects between the clinician and the patient. Many patients, particularly the elderly, disabled and marginalized, need a navigator to help locate, negotiate and engage in services. Coaches connect with patients not only at office visits but also between visits, creating familiarity and continuity.
Piloted in 2006 at the San Francisco General Hospital Family Health Center (FHC), the "teamlet" (small team) model extends the 15-minute primary care visit by several minutes, depending on the patient, to include coaching.
Rojas to ask whether she has picked up her prescriptions from the pharmacy, to assess her understanding of how to take each medication and to encourage her to take the pills daily. Patients discharged from the hospital often feel confused about their new medications and the conditions that they must now learn to manage. Lumpkin was admitted to the hospital four times in the past three months because of heart failure exacerbations. Whether you’re interested in learning about nutrition, launching a meaningful new career, or even changing the world, Integrative Nutrition will empower you to transform your life and achieve your personal and professional goals.
Though shared decision-making is associated with improved outcomes, only 9 percent of patients participate in decisions.
In acute care, rescuing makes sense: surgery for acute appendicitis or antibiotics for pyelonephritis. Coaching means helping him understand and react to his glucose values, an enduring skill that he can use every day.
Health coaches can be nurses, social workers, medical assistants (MAs), community health workers (promotores, for example), health educators or even other patients if given appropriate training and support. However, since RNs and social workers are rare in primary care offices, MAs are often a good choice for filling the role. Coaches can help coordinate care and speak up for patients when their voices are not heard. This is particularly helpful in practices where clinicians work part-time or see one another's patients.
In a teamlet, a physician is paired with an MA or health worker who has received training in self-management support and specific chronic conditions and speaks the language of the patients assigned to him or her. Hilton Family Practice, a private family practice in Newport News, Va., implemented a care team with two clinical assistants (nurses or medical assistants) per physician, allowing the physician to delegate substantial work.
For example, one health coach (paid $15 per hour or $36,000 per year with benefits) could assist three physicians, since only a fraction of patients need coaching.
Yet, to ensure that coaching happens reliably, specific team members can be designated to be health coaches. Average adherence rates for prescribed medications are about 50 percent, and for lifestyle changes they are below 10 percent. For chronic care, patients need the knowledge, skills and confidence to participate in their own care.


While their scope of practice prevents them from making medical assessments, MAs are ideally suited to provide linguistically and culturally concordant coaching. A meta-analysis of 53 randomized controlled trials concluded that self-management support improves blood pressure and glucose control. It is a two-part endeavor: 1) writing prescriptions and 2) making sure patients obtain, understand and actually take the medications as prescribed. As trust and familiarity grow, coaches can offer emotional support and help patients cope with their illnesses.
Health coaches conduct a pre-visit for medication reconciliation and agenda setting, assist during the physician visit and, during a post-visit, assess whether patients understand and agree with the recommended care plan and engage patients in behavior-change action plans. Rojas to identify barriers and solutions that fit into her daily routines rather than doing this for her. This has increased visit volumes and collections by 60 percent.14 Their approach does not involve formal health coaching but does demonstrate the potential for increased productivity with the addition of an assistant. Each physician would need to see two extra patients per day at a reimbursement rate of $40 per visit to generate $57,600 in additional revenue, more than enough to pay for the health coach. When he gave up eating candy, he thought that would solve some of his problems, so he stopped taking several medications.
Working closely with clinicians or RNs, they can address medication adherence and lifestyle changes.
Because regular follow-up improves chronic disease outcomes, between-visit phone calls are used to check on action plans and medication adherence.
She admitted missing these games for fear that her urinary incontinence would embarrass her and her granddaughter. She helps him link his desire to avoid the amputation experienced by his brother to the importance of taking medications. Health coaches can bridge these gaps by following up with patients, asking about needs and obstacles, and addressing health literacy, cultural issues and social-class barriers. This has allowed the physicians to see two to three more patients per day, which pays for the additional medical assistants. She teaches him the skill of interpreting glucometer readings in relation to food, exercise and medications. Similarly, the University of Utah Hospitals and Clinics health system employs extra medical assistants to streamline physicians' work. As a result, productivity has increased and the health system's financial position has improved dramatically.
Lumpkin wrote down questions for her physician about incontinence treatments and practiced asking the questions through a role-playing exercise to build confidence. Lumpkin and Bernice reviewed signs and symptoms of worsening heart failure and how to respond. Rojas came to trust Lisabeth and, over time, became an active participant in her own care rather than simply a recipient of information.




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