More than Enough Work to go Around: Adding a Health Coaching Program

into an Integrated Primary Care ClinicShandra M. Brown Levey, PhD, Department of Family Medicine , University of Colorado School of Medicine

Kaile Ross, MA, Clinical Health Psychology University of Colorado DenverLacey Clement, MA, Clinical Health Psychology University of Colorado Denver

Kevin S. Masters, PhD, Clinical Health Psychology Department of Psychology University of Colorado Denver Corey Lyon, DO, FAAFP, AF Williams Family Medicine University of Colorado School of Medicine

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # F2AFriday, October 16, 2015 – Period 2 –1:30 PM

Faculty Disclosure

The presenters of this session• have NOT had any relevant financial

relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Describe the complexities of integrating health coaches into an existing clinical team.

• Discuss the importance of a targeted intervention to assist patients who want to make health changes but lack the traditional support and resources to do so.

• Develop ideas for better integrating this form of support into other clinical settings.

Bibliography / Reference1. Leung, L. B., Busch, A. M., Nottage, S. L., Arellano, N., Glieberman, E., Busch, N. J., &

Smith, S. R. (2012). Approach to antihypertensive adherence: a feasibility study on the use of student health coaches for uninsured hypertensive adults. Behavioral Medicine (Washington, D.C.), 38, 19–27. doi:10.1080/08964289.2011.651174

2. Adams, S. R., Goler, N. C., Sanna, R. S., Boccio, M., Bellamy, D. J., Brown, S. D., … Schmittdiel, J. A. (2013). Patient satisfaction and perceived success with a telephonic health coaching program: the Natural Experiments for Translation in Diabetes (NEXT-D) Study, Northern California, 2011. Preventing Chronic Disease, 10, E179. doi:10.5888/pcd10.13011

3. Appel, L. J., Clark, J. M., Hsin-Chieh, Y., Wang, N.-Y., Coughlin, J. W., Daumit, G., … Brancati, F. L. (2011). Comparative Effectiveness of Weight-Loss Interventions in Clinical Practice. New England Journal of Medicne, 365(21), 1959–1968.

4. Frosch, D. L., Uy, V., Ochoa, S., & Mangione, C. M. (2011). Evaluation of a behavior support intervention for patients with poorly controlled diabetes. Archives of Internal Medicine, 171(22), 2011–7. doi:10.1001/archinternmed.2011.497

5. Patja, K., Absetz, P., Auvinen, A., Tokola, K., Kytö, J., Oksman, E., … Talja, M. (2012). Health coaching by telephony to support self-care in chronic diseases: clinical outcomes from The TERVA randomized controlled trial. BMC Health Services Research, 12, 147. doi:10.1186/1472-6963-12-147

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

OverviewEvery clinic is challenged to help patients who

struggle to make needed behavioral health changes.

Even in a level 3 PCMH residency clinic with behavioral health integration, our reach was limited.

In this presentation, we will describe the implementation and early findings related to a health coaching program which provides an extra layer of support to both patients and clinic staff.

Understanding and addressing these complexities can help medical homes manage and treat patients in a more holistic manner.

What is health coaching? A behavioral health intervention that helps pts.

establish and attain health-related goals to increase quality of life and improve self-management of chronic diseases.

Aid pts. in making and progressing toward health-related goals.

improved medication adherence weight loss healthful eating increasing physical activity smoking cessation stress reduction.

Many health coaching programs report helping pts. identify appropriate health behavior goals and develop an action plan to reach the goal(s).

Lit Review: What is health coaching?

Variable education and training Utilization varies by siteMethod of health coachingInterventions

What does health coaching look like? Due to the variety of educational backgrounds of health

coaches, the variety of patient contact schedules, and the differences in contact modality reported, it is difficult to compare one health coaching program to another.

Some components appear repeatedly in effective health coaching programs: 1) multiple structured contacts with the patient, 2) patient education, 3) goal setting, 4) health coach follow-up on goal progress, and 5) utilization of motivational interviewing techniques and

patient empowerment.

ImplementationMultiple modalities of introducing new

program into a complex clinical systemEmail intro to clinicWord of mouthPrecepting room (Visibility/Constant reminders)

Listening in when residents precept pts/inquire about health coaching needs

Calling patients in front of providers Difficulties and benefits

Clinic online surveyClinic presentation during implementationFlyers in clinic with tear off information for patients to self refer

“I understand what health coaching is.”

N=24

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

0% 10% 20% 30% 40% 50% 60% 70%

“The patients I work with could benefit from health coaching services.”

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

0% 10% 20% 30% 40% 50% 60% 70%

N=24

“Please rate your confidence in your ability to describe health coaching to patients.”

Completely Unsure

Somewhat Unsure

Neutral

Somewhat Confident

Completely Confident

0% 5% 10% 15% 20% 25% 30% 35%

N=24

Provider Responses Pre-Implementation

“I know we need them (health coaches) for sure.”

“I think this would be a great resource to be able to offer patients.”

“Patient needs more teaching than I can provide in the context of a visit.”

Main Preliminary Concerns of ProvidersConcern: How to communicate with the health coaches

Response 1: Behavioral Health and Health Coaching in-baskets Response 2:Precepting room Response 3:“Grab us in the hallway or whenever you see us”

Concern: Knowing when the health coaches are available Response 1: White board in precepting room with team

availability and in main hallway Response 2: Behavioral health monthly schedule in pods and

precepting room Response 3: Composite with team members pictures and roles

in pods and precepting room Response 4: Walkie Talkie

How is health coaching integrated into the team?

Graduate students in clinical health psychology PhD programhealth-focused clinical and behavioral strategies

Health coaching provided under the supervision of a licensed psychologist without the need for additional health coach specific trainingmotivational interviewinghealth behavioral change counseling

Health Coaches are part of the Integrated Health team.Team: Social Work, Pharmacy, Care Management,

Psychologists, Psychiatrists

How do patients participate in health coaching?

Warm hand offFollow-ups by telephone or in person as

a one-on-one appointment or a co-consult

In-basket messages

Targeted InterventionIdentify top 1-2 goals with patient15-30 minutes max for most contactsAverage 2 follow ups

Brief interventionGoal setting, MI, problem solvingValue-based interventions

Importance of the “why”

Evidence Based Action Plans and ResourcesActions plans were created to aid health coaches in

the educational piece of their intervention. included brief educational points regarding the

respective topic and a place to write down short-term goals, along with importance and confidence ratings of those goals. Sleeping Well Weight Loss (diet and exercise) Smoking Cessation Chronic Disease Management

Resource List – to identify and contact various resources such as mental health referrals, emergency housing and shelters, support groups, and crisis lines.

Sleep Action Plan Example

Sleep Action Plan Example

Referral Source Number who made ≥ 1 referral

% of total referrals

Medical Provider 44 95.3

Behavioral Health Provider

5 3.6

Patient – self-referral

3 1.1

• 279 health coaching referrals to date

• Where did referrals come from?

Referrals primarily came from the patients’ primary care providers.

Health Coaching in Action

Referral Reason N

% of referral

s

Weight loss139 49.8

Smoking cessation 52 18.6Exercise and physical activity 40 14.3Nutrition and healthy eating 38 13.6Sleep issues 33 11.8Disease management 11 3.9Stress management 4 1.4Depression- behavior activation 3 1.1Emotional eating 2 0.7Alcohol reduction 2 0.7Medication adherence 2 0.7Anxiety 1 0.4Pain management 1 0.4

Total279

What was the reason for health coaching referral?

Depression, anxiety, and stress management - paired with a health behavior need (e.g., insomnia, diet, smoking)

Mental Health Diagnoses amongst Health Coaching Patients

7.6%

25.5%66.9%

Initial contact with patient Providers seemed to prefer the ease of referring

patients via in-basket referralLeading to more phone contacts as initial contact

with patient

Patients also preferred phone visits- easier to schedule & no co-pay

Type N %co-consult 2 0.7warm hand-off 16 5.7In-person visit 7 2.5Phone visit 254 91

Patient PerspectivePatient qualitative outcomes

“I haven’t changed my diet yet, but I have met with a trainer and I’m working out 5-6 times per week a the gym.”

“I’ve completely quit drinking soda and I’ve lost 3 pounds.”

“I’ve been getting off one bus stop early so that I can get extra steps in my day.”

Provider/staff post surveyI understand what health coaching is –

82% agree/strongly agree17% neutral/disagree

I see a clear use for health coaching in the clinic – 81% agree/strongly agree14% neutral5% disagree

The patients I work with benefit from health coaching services – 67% agree/strongly agree; 24% neutral10% disagree

Provider/staff post surveyMy interactions with my patient are enhanced

by the addition of health coaches to the staff – 50% agree/strongly agree45% neutral5% disagree

Health coaches have added to the effectiveness of patient care – 57% agree/strongly agree38% neutral5% disagree

Provider/staff post survey• Provider impact

• Positive: “Saves me time in trying to motivate patients” “They have helped my patients meet dietary goals.” “I referred a patient who raved about their experience.”

Neutral “I haven’t heard of any of my patients that have seen

them.” “I worry that sometimes patients get lost. Referral is

made, phone call made but no contact.”

Provider/staff post surveySuggestions for improvements

Ability to call patients after hoursMore availability/ visibility of coachesMore warm hand offsMore training for providers on what health coaching

is and how to explain it to pts“We should keep health coaching, it’s a great idea,

we need to figure out how to get them involved with our patients.”

Preliminary ConclusionsHealth coaching helps facilitate patient

accountability for change in health behaviorsDemand continues for health coaching and is

increasing based on patient volumeContinued education about relatively new

initiatives Continued workflow refinementCreative ways to allow for program sustainabilityLots of communication is needed on a continual

basisResidency clinic norm

Next StepsContinuation of health coaching programContinuing education for providers and staff

regarding health coaching servicesSustainability (graduate students, grants,

billing, etc.)Tracking longitudinal data in clinic to

determine impact (QOL, clinical outcomes, claims outcomes, provider outcomes, etc.- Quadruple+ Aim)

No such thing as overcommunication!

Implementing Health Coaching into Other Clinics/Health Settings

Connect with PCMH effortsSupport CIC Initiatives (Diabetes, HTN,

Depression, Smoking, Obesity…)

Expand reach of existing providersBehavioral health- bringing in grad students

for practicum placements Psychology, social work, masters-level

clinical/counseling programs

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!