Prevention is critical to reducing rates of chronic disease, premature death and disability, and controlling health care costs. This point has been made many times over by health care and health policy experts both in the United States and abroad. Unfortunately, our current health care system is not set up to incentivize prevention efforts and our communities vary greatly in their ability to reduce barriers that stand in between individuals and healthy choices.
In January 2009, services began for the Healthy Howard Health Plan (HHHP) – a public-private health care access program for uninsured residents of Howard County, Maryland. HHHP was designed by the two authors of this blog post and Glenn Schneider, former Director of Health Policy and Planning for the Howard County Health Department While states and local jurisdictions have applied different access models to reduce the uninsured rolls, we believe HHHP is the first of its kind to couple health care services with compulsory health coaching. Although the program is young and the results of a formal evaluation will take time, several indicators suggest our coaching model to be a promising practice for health promotion.
In fact, the coaching component of HHHP recently was awarded the Department of Health and Human Services’ Healthy Living Innovation Award, and in the fall of 2010 HHHP was recognized with the “Bright Ideas” award from Harvard’s John F. Kennedy School of Government.
Access to Care – Necessary but not Sufficient
When setting out to develop HHHP, we knew that many of the negative of effects of being uninsured can be resolved or fixed by obtaining health care coverage. It was also clear, however, that behaviors like tobacco use, poor nutrition, excessive alcohol use and physical inactivity are the cause or main contributing factor for most chronic conditions, premature deaths and overall reduced quality of life. These behaviors are prevalent and embedded in the U.S. adult population, regardless of insurance status. Therefore, a program designed solely to expand access to care would get us only so far in terms of improving individual and community health outcomes. That led us to identify health coaching as a way to support individuals in making important and sustainable health-related behavior changes.
Health coaching is the “practice of health education and health promotion within a coaching context, to enhance the wellbeing of individuals and to facilitate the achievement of their health-related goals.” Coaching techniques have been used to improve performance in the business community (e.g. executive coaching) as well as at the individual level (personal “life” coaching). As a discipline, health coaching is rooted in psychology and addiction treatment in which the motivational interviewing process (or motivational enhancement therapy) was created to improve clients’ readiness and willingness to change behavior.
Evolution of the Health Coach Model
A review of health coaching interventions identified a range of approaches and methods. Of the existing studies, evidence is modest regarding coaching effectiveness. Programs labeled as “health coaching” are often comparable to traditional hospital or medical office-based case management and typically administered by a nurse or allied health professional. Many health coaching efforts are disease specific, focus on high-risk patients, and serve a short-term need (e.g. transition patient from acute event to prevent hospital readmission). Workplaces and health plans are known to contract with disease management vendors to provide a type of coaching delivered over the phone. It does appear that coaching done without any link to the patient’s medical home limits impact on both patient and provider behavior.
HHHP is part of a larger charge by our County Executive, Ken Ulman, to build a model public health community where county residents are surrounded by a range of clean, safe and healthy activities, products and environments. This vision recognizes the multiple influences on health and the critical role social determinants play in eliminating health disparities. The health coach approach needed to reflect this framework and HHHP’s overarching purpose and goals. This led us to set the following conditions on the model design: 1) coaching should take place outside the doctor’s office but within a health plan structure that emphasizes the medical home model and allows for communication between patient, provider and coach; 2) the majority of coaching interactions should take the form of face-to-face meetings; 3) coaches should be viewed as members of the community, with expertise in facilitating individual behavior change but not limited to nurses; 4) coaching should be ongoing and part of the member’s experience throughout his/her time in HHHP; and 5) coaching should be structured into cycles to allow for creation of time-bound goals and for members to realize multiple goal attainment.
The Transtheoretical Model (Prochaska and DiClemente, 1983; Prochaska and Velicer, 1997) forms the theoretical basis for our health coach model. In addition, our approach is informed by the Chronic Care Model (Wagner et al, 1996; Bodenheimer et al, 2002), Bandura’s work on the role of self-efficacy in health outcomes (Bandura A., 1991, Self efficacy mechanism in physiological activation and health-promoting behaviors, in Adaption, Learning and Affect, Madden J, Matthysse S, Barchas J editors, pp 226-269), and the patient activation construct formalized by Hibbard and colleagues (2004).
A Member-Driven Approach
Figure 1 displays the model designed for and implemented as part of the Healthy Howard Plan. In our approach, coaches help members identify the health-related changes they wish to make in their lives and work to empower members to take an active role in improving their health. We expect the coaching process to improve members’ self efficacy and quality of life and allow members to decrease their risk of future disease development. (By signing the member agreement, each HHHP member provides broad consent to allow de-identified information to be used for program improvement as well as any subsequent evaluations of the program.)
HHHP members are assigned a coach after the first primary care appointment. Due to coaching’s position within a health plan and the knowledge that the uninsured in general are most likely to have unmet health care needs, it was important for the member to first establish care with the medical home. The coaching cycle is six months in length and involves three in-person meetings and two-telephone check-ins. In-person meetings take place at a venue of the member’s choosing but not in a member’s home. Branches of the county’s library appear to be the most popular pick based on coaches’ charted notes; other frequent spots include the food court at the mall and Starbucks. Meetings take place before, during or after regular work hours. While the majority of meetings occur during the traditional work week, they can also be scheduled on a weekend day. (Note 1)
Similar to individual or group-based programs to improve self-management of chronic conditions, a Health Action Plan (HAP) serves as the cornerstone of the coach-member relationship. Utilizing motivational interviewing techniques and a SWOT–style analysis (Strengths, Weaknesses, Opportunities, and Threats), the coach and member work together in the first face -to-face meeting to develop the HAP. Members do not select from a list of pre-determined goals and action steps. Our process is member-driven and coaches guide members in goal setting and creating specific action steps to work on for a period of six months. Coaches emphasize the importance of developing a realistic and manageable HAP, as each goal is linked to a set of action steps. A main function of the check-in call is for the member and coach to assess HAP fit and consider the need for goal or action step revision at the next in-person meeting. There are two main reasons for HAP modification. Typically, according to coach feedback, a member either completes action steps sooner than expected or personal life events (e.g. change in hours at work, family member falls ill) render the overall goal too large to meet in the time frame.
Response to Health Coaching
An initial content analysis of HAPs found members setting goals to address key health-related behaviors. The most common goal, found in 33 percent of the HAPs reviewed, was exercise/physical activity. Goals related to weight or food/eating/diet appeared in 30 percent of plans while 21 percent of plans addressed social factors such as employment or managing finances.
Instead of telling a member what to do, our model of health coaching acknowledges the multiple layers of influence on health, and then builds from member-identified barriers to healthy living. Based on the initial categorization of HAP goals, members know what to do and are working within the health coach process to address the issues that put them at risk for future health problems.
While findings from the formal evaluation are forthcoming and examine health coaching in detail, preliminary analysis of one member assessment – the Member Perception Survey – highlights the promise of this approach. A pen and pencil survey, the “Member Perception Survey” is first administered at the three-month meeting and then at each subsequent in-person meeting. This survey was informed by the Patient Activation Measure.
The general purpose of the survey is to consider how members understand the health coaching process and perceptions regarding the role coaches and health action plans play in promoting a healthy lifestyle. As designed, our working hypothesis is that health coaching should increase an individual’s knowledge, skills and beliefs relevant to health-related behavior change, empower the individual to initiate change and support sustained change. Table 1 presents the results from a sample of 100 HHHP members who finished one full cycle of coaching (six months) and completed two perception surveys.
Table 1: Member Perception Survey — Preliminary Analysis of Results
The overwhelming majority from this sample of 100 members agreed or strongly agreed with the statements over time. Members appear to understand the goals of their Health Action Plans as well as how reaching HAP goals will improve their health. In addition, members indicate positive perceptions regarding the health coach role and the member-coach relationship. Perceived ability to keep up with HAP action steps and to maintain behavior changes over time is high. This high level of positive response was achieved within one coaching cycle or the equivalent of six months of member exposure to the coaching intervention.
What does the information in Table 1 mean in terms of people and their behaviors? The following local newspaper summary of public testimony by a HHHP member describes how the support of health coaching translates to pounds lost and much more.
Pamela Spong of Ellicott City choked with emotion throughout her testimony, telling council members her husband had put off needed medical testing for six years because the family did not have insurance. But she said the program’s benefit to her family goes beyond that, to the encouragement and help she got to improve her own health through better living practices. “I lost 85 pounds recently,” she said, adding that her health coach helped her get two months of free gym membership, which put her on a path to better living. “Just having someone to help me be responsible for my health helped me,” she said, along with losing the stress of worrying about her husband. (Carson L. , April 27, 2010, “Advocates seek more money for Healthy Howard,” Baltimore Sun)
Obviously, displaying results from a small subset analysis is not enough to secure “buy-in” for our health coaching intervention. Decision makers will needs answers to questions regarding program cost and effectiveness as well as scalability. In addition, it will be important to consider the context of the health plan itself as factors such as the public/private funding structure and county-based service network may indeed influence the effect of the coaching program. In other settings, the overall concept and approach to our coaching intervention won’t change but the mode of delivery may need to be refined to fit with resource or geographical constraints or the composition of the target population. As mentioned earlier, a formal evaluation of the health plan and the coaching program is forthcoming, and more information on early results from the overall HHHP is available here and here.
Promising Practice for Comprehensive Prevention Strategy
The uninsured are truly a population “at risk”. The members of the Healthy Howard Health Plan offer a snapshot of the U.S. uninsured population or who will be served come 2014, if not before. According to an analysis of baseline demographic and health behavior data from members enrolled in HHHP during 2009, these previously uninsured adults did not have higher rates of chronic disease but did have significantly higher rates of unhealthy behaviors such as physical inactivity, tobacco use and poor diet.
Due to the role our behaviors play in chronic disease, premature death and escalating health care costs, this status will endure long after access to care is achieved if substantial changes are not made within our health care and public health systems. A change is needed in how we think about prevention and behavior change as well as how we prioritize such efforts in medical and community settings.
The need for a change was underscored during the development of our health coaching model. In explaining the coaching process (especially member-driven goal setting and the ability to modify Health Action Plans) to community partners, providers and potential funders, some expressed a preference for a more directed approach to tackle member’s health issues. “An obese member should have a Health Action Plan focused on losing weight” – was a frequent comment. This type of response highlights how deeply entrenched we are in the traditional medical model and a limited working definition of “health”. An external party’s priority list for behavior change will remain as such, given what is known regarding health behavior change principles, the importance of an individual’s activation, self-efficacy and readiness to change in achieving sustainable behavior change, and how living and working conditions impact health status and health outcomes.
The Patient Protection and Affordable Care Act (PPACA) has the capacity to serve as a catalyst in our health care system to prioritize disease prevention and health promotion. On the path toward 2014, policymakers, health officials, advisory groups and councils at the federal, state and local levels will review and ultimately recommend a series of programs and policies. We need a real national prevention strategy and funding for effective prevention programs. The evidence base, HHHP member successes and preliminary data analysis suggest that a health coaching program such as the one designed and implemented in Howard County could be a valuable component of a comprehensive wellness strategy.
Note 1. This health coaching model is named for the individual who conceptualized and designed it – Elizabeth Edsall Kromm . It is also important to recognize the contribution of Maureen Pike, BSN, MPH, who was hired as the lead health coach after the model was developed. Pike determined the coach training protocol based on the model and is responsible for the implementation and practice-based oversight of the coaching program.