Collaboration between physicians and patients in the decision-making process has long correlated with improved health outcomes. Unfortunately, only 9% of patients participate in decisions regarding the management of their disease.

This regrettable state of affairs may be partly responsible for low levels of global adherence. In developed countries, adherence levels stand at around 50%, whilst rates in the developing world are lower.

One solution to this problem is the introduction of patient-centric health coaching as an integral part of the disease management program.

This innovative approach encourages individuals to actively participate in their own disease management. Advice and support from health coaches enables patients to take informed decisions about the life-style changes necessary to improve their overall health outcomes.

The health coach is in a position to establish a trusting relationship with patients, to help them follow instructions given by healthcare providers and to change lifestyle-related habits that may impact the outcome and progression of the disease.

Apart from functioning as a bridge between patients, physicians, pharmacists and other healthcare providers, health coaches also provide a useful point of contact for the distribution of evidence-based information, education and social support through appropriate referral systems.

Integrated disease management

It is possible to elicit a significant change by enabling, encouraging and empowering vulnerable patients to take better care of their own health, and by helping them navigate the complexities of healthcare systems. There may be a number of positive outcomes, such as fewer missed appointments, a reduction in emergency visits and in-patient admissions, improved adherence to lifestyle and overall self-care, and medication use.
An integrated health coaching approach to medical, behavioral and social health allows patients to address attitudes, barriers and beliefs that may be getting in the way of achieving better health.

A holistic approach addressing the needs of patients with multiple chronic conditions and related co-morbidities provides insight into the complexities of medical, behavioral and social health of this particular group to help them improve their overall health, wellness and lifestyle. Intervention should go beyond providing information, looking at the root causes that drive higher health risks, negative health outcomes and rising health expenditure.

This can be achieved through integrated and enabled care, with the health coach in partnership with the patients’ healthcare providers, and other social and community support groups.

Another area where health coaches may assist in integrated disease management is the transition from an acute in-patient hospital stay to homecare, decreasing the chance of re-admission due to poorly managed transitioning and helping patients to achieve greater independence and improved health outcomes.

With the complexities of modern healthcare systems, patients may be overwhelmed especially when combined with distraction, pain, fear and inconvenience. A well-trained health coach can assist in coordinating complex healthcare issues through the appropriate use of technology to monitor, track and communicate patient care and progress to all key stakeholders involved in the patient’s journey. This influences patient engagement and allows them to better connect with community, and other resources, and to improve collaboration with various healthcare providers.

For patients who can easily access healthcare providers or peer support, holistic health coaching is the process whereby individuals with chronic conditions (and often family/friends/caregivers) are able to share knowledge, responsibility and care plans with healthcare practitioners and/or peers. To be effective, it requires whole-system implementation with community social support networks, professionals willing to act as partners or coaches and online resources that are verified and relevant to the country, culture, language, and context of the disease. Knowledge-sharing, knowledge-building and a learning community are all integral to the concept of integrated disease management.

It does not really matter who serves as the coach. What is important is that a good coach understands that a collaborative approach is required, asking patients what changes they would like to make rather than being directive and telling them what they need to do.

Creating a successful program

Among the essential elements for a coaching program to be successful, a health coach needs to understand and practice the right engagement and ensure they achieve the desired outcomes.

Novel approaches to coaching

With a lack of appropriate healthcare resources and funding in many locations, health coaching often requires options other than face-to-face coaching, where the coach and patient need to be in close proximity and may be costlier.

Virtual and mobile coaching

This type of coaching may take more effort to establish initial rapport and trust between coach and patient. Examples of virtual coaching utilizing technology include the use of mobile phones and computer-based systems, such as Skype or FaceTime, that have the capability of using video to make it more personal. There is also the option of recording for follow-up. Such methods usually require a stable internet line and a good quality headset with a microphone. Other software and technology that can enhance the coaching process include Dropbox for file sharing, chat functions, SMS, email, goal-setting and weekly tracking. As with face-to-face coaching, it is important to plan ahead.

To achieve the best results, the option best suited to the patient needs to be chosen. From a coaching perspective, a number of technologies may be necessary. Training participants to use the platforms, technology and software, and having a trial run to sort out any potential issues, is important prior to program implementation. Back-up support and the use of administrators should form part of this training, particularly on the coaching side, to facilitate recording, utilization/drop-out rates, and feedback, among others. It is important when undertaking virtual coaching through mobile technology to have a back-up plan in case a method proves unsuccessful for a particular person. The coach may need to revert to simpler methods of coaching and recording, without losing focus on the overall process.

Laser or express coaching

Laser coaching is a technique that promotes speedy alignment between current daily activities and behaviors and future desired goals. It seeks to get to the source of a problem quickly and usually has a particular disease focus, for example, diabetes. Once the source has been identified, specific action is taken to overcome barriers and achieve goals.

Laser coaching does not mean speaking faster, rather that the process is swift with a clear focus. It is not unusual for a coach to interrupt the patient in a laser coaching session because of time constraints and bring them back to the required topic. Laser or express coaching usually consists of three main phases:

• Initial: identifies, invites, and enrolls the patient, according to particular criteria and parameters.

• Discovery: establishes ground rules following enrollment and what will be discussed in forthcoming sessions.

• Maintenance: consists of any number of sessions depending on program design and length, or alternatively patient progress and ability to realize sustainable change.

If applied correctly, 10- to 20-minute sessions of laser health coaching can produce similar outcomes to lengthier conventional coaching sessions. With their coach’s support in these intense short sessions, patients can clarify specific health challenges and commit to action to resolve them. Laser coaching also means coaching is accessible to more patients per coach, making it more cost-effective.

Measurement

In addition to measuring the success of the patient in changing lifestyle and behavior, a health coaching program requires measurement and the capturing of data for key stakeholders. Objectives need to be clearly described when starting health coaching. The more concrete the goals, the easier they are to measure, track, and follow-up. And to recognize success, it is important to have clear and measurable outcomes in the plan at the outset. Such evaluation provides feedback and lets the patient and coach gauge how they are doing and the value in what has been achieved.

To understand whether interventions or a health coaching program have had a positive impact on a patient, it is important to have baseline data with which to compare:

Clear and measurable outcomes can be used to provide relevant information to all three groups involved in the coaching process:

• Patient The patient needs to have an idea of their progress and when they have reached their goals or targets. Outcomes reinforce how successful they have been and how they have done throughout the coaching period.

• Coach/service provider It is vital that the coach has some indication of how effective the coaching process has been, and the patient’s success and feedback can be reinforcing for the coach.

• Third party/payees Healthcare providers and other key stakeholders require access to aggregate data to determine the success of a health coaching program. This will help to determine what is working well and what aspects of the program may require refining or improving. Data reflecting success also serves as a marketing tool to indicate the value of health coaching.

Charting change

Health coaching can be an effective individual change methodology, one that is becoming more widely accepted as part of chronic disease management programs. A recent survey of Kaiser Permanente patients in a health coaching program indicated that most were satisfied with the program and believed that coaching had helped them to achieve their health-related goals. The levels of satisfaction and perceived success with health coaching were high and positively correlated with the number of sessions completed and patient activation.

In another cohort study, 6,129 employees, aged 21-88 years, were enrolled in telephonic health coaching during 2002-08. The individuals making changes in physical activity or nutrition had the highest body mass index (BMI), lowest levels of exercise, and poorest overall health. They were also more likely to continue with health coaching over 12 months.

Those not ready to make changes, or having maintained an appropriate level of physical activity or nutrition for more than six months (i.e. made sustainable changes already), were more likely to discontinue health coaching during the 12 months.

They also had the lowest BMI, highest levels of exercise and best overall health. The conclusion was that attrition in the telephonic health coaching program over 12 months was greatest among those least in need of behavior change. Of those who continued in the program, the greatest decrease in BMI occurred in those with the greatest need for behavior change.

There is therefore increasing evidence to suggest that health coaches may well be beneficial in assisting patients to improve overall health outcomes and reach sustainable lifestyle changes that impact their disease. However, health coaching needs to be appropriately planned and implemented.

Outlook

With the growing prevalence of chronic diseases, higher demands are being made on limited healthcare resources and services. Health coaching for people at risk, or who already have one or more chronic diseases, is seen as a means of supporting them to manage their health, thereby reducing the burden on the healthcare system. It involves moving from a directive “prescribe and treat” model to a more collaborative “advocate and inspire” model, allowing healthcare providers and patients to pursue a more active partnership, instead of patients being the passive recipients of care.

Integrating health coaching into disease management programs can start to improve patient outcomes as well as effectively change the behavior of healthcare providers and healthcare systems, reducing health costs (outpatient visits, hospitalizations, expensive tertiary care, among others) and unnecessary utilization of healthcare resources.

There is now sufficient proof that coaching alone is effective in improving health outcomes for a broad category of diseases, such as diabetes, cardiovascular disease, asthma, cancer pain, and others. If the principles of health coaching are applied correctly and effectively, the process can be applied to any disease, singular or multiple, at any time in the disease timeline. The ultimate goal is to change patient behavior, and to make it sustainable, with intervention if there are any relapses.

While there is clearly no “one-size-fits-all” solution to managing patients with chronic disease, health coaching that is appropriately planned and implemented may be effective for improving self- management skills and a means of supporting patients with chronic diseases to manage their own health.



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