Health Coaching

1. Health Coaching Thad Schilling, MD Medical Director, Patient-Centered Medical Home Harvard Vanguard Medical Associates Heidi Duskey, ACC, CHFS Health Coach, Harvard Vanguard Medical Associates Medford and Chelmsford Practices March 27, 2012

2. Overview of Today’s Presentation • How did Harvard Vanguard get into the business of Health Coaching? • What is Health Coaching? • What is the impact of Health Coaching on patient clinical outcomes(Cost/Benefit ratio)? • What lessons have we learned? • Future direction of Health Coaching

3. Current State : America’s Health Report Card *34.1% are overweight while 32.2% are obese. JAMA 2006;295:1549-1555

4. Determinants of Health and Their Contribution to Premature Death Schroeder S. N Engl J Med 2007;357:1221-1228

5. Daily choices impact health + = = + + = + + = + = + + =

6. Primary Care Physician competence and capacity to change patient behavior • Current practice • 42% of obese patients receive advice to lose weight • 23% to 42% PCPs counsel about diet • 34% PCPs counsel about physical activity • Educational deficiency • 72% feel “ill-prepared” to counsel about diet • 5% PCPs are confident that counseling will improve cholesterol • Operational barriers • 72% lack time • 47% lack educational materials McInnis KJ,Franklin BA,Rippe JM Counseling for Physical Activity in Overweight and Obese Patients. Am Fam Physician. 2003; 67:1249-56,1266-8; Prev Med. 1993 Jan;22(1):96-109. Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising obese patients to lose weight? JAMA. 1999;282:1576–1578

7. Where the traditional Medical Model falls short Sometimes information is not enough • On January 11, 1964, Luther L. Terry, M.D., Surgeon General of the U.S. Public Health Service, released the first report of the Surgeon General's Advisory Committee on Smoking and Health. • On the basis of more than 7,000 articles relating to smoking and disease already available at that time in the biomedical literature, the Advisory Committee concluded that cigarette • smoking is: • A cause of lung cancer and laryngeal cancer in men • A probable cause of lung cancer in women • The most important cause of chronic bronchitis

8. Where the traditional Medical Model falls short

9. What is Coaching? A powerful alliance designed to forward and enhance the lifelong process of human learning, effectiveness, and fulfillment. Co-Active Coaching, Whitworth, Kimsey-House, Sandahl

10. Coaching promotes behavior change How? Its foundation is a partnership that is client- or patient-centered and non-judgmental. Its context is experimentation and exploration. Its methods foster self-discovery, personal growth, and resilience. Its orientation is one of process. Coaching links desired outcomes to behaviors and choices.

11. What’s in a coach’s tool box? Transactional Tools • Factual learning – aspects of physiology, fitness, nutrition, stress • Skills – selecting reminders, identifying antecedents, crafting SMART action plans, brainstorming Transactional tools are all about what we are doing and what we know

12. What’s in a coach’s tool box? Transformational Tools Visioning – envisioning what’s possible Values – aligning our behaviors to what fulfills us Perspectives – those that empower, those that do not Speech Acts – how our language creates reality Our Inner Critic – a truth rather than “The Truth” Mindfulness– developing focus, being present Neuroscience – changing our minds to change our brains, our body’s chemistry, genetic expression Transformational tools are all about who we are being and how we know what we know

13. Why is transformation important? • It supports transactional learning • It informs intrinsic motivation, resiliency, and self esteem. • It fosters patient engagement: “a process in which a patient takes ownership of his or her health by choosing to take action to achieve a specific goal.” Advance Medical Home Rapid Improvement Experiment on Patient Engagement • It generates positivity, making it easier to sustain change through greater self awareness

14. Harvard Vanguard’s coaching program • Supports the patient/clinician relationship • Offers eight 40-minute sessions scheduled every 2-4 weeks at no cost to the patient • Provides secure, on-line support between visits • Is available to any Harvard Vanguard patient, 16 years of age and older, with a clinician (PCP or specialist) at either the Medford or Chelmsford practice • Offers an opportunity to evaluate the effectiveness of less traditional interventions like telephone consultations and group classes

15. Timeline of Health Coaching Intervention • 2008 – Lead BCBS Innovative Opportunity • Fall 2008 – Health Coach hired at Chelmsford Practice – total patients coached thru year end 2011 : 1200 • August 2011 – Health Coach shared with Medford Practice in Pilot for Patient Centered Medical Home - total patients coached thru year end 2011 : 96 • Currently at capacity at both sites and exploring ways to see more patients in groups.

16. Patient Engagement: Action Plan

17. Patient Engagement : SMART Plan Goal #1: Wear pedometer every day • Percentage Accomplished: 100% Goal #2: Fill ½ of my dinner plate with vegetables OR limit my starch to ¼ of the plate. • Percentage Accomplished: 80% New Weekly Action Plan: 1) Purchase a blood pressure monitor by the end of month 2) Begin to take FBS on a daily basis 3) Check weight every Monday morning 4) Write health coach with results • Importance of weekly action plan to patient on a 1-10 scale: 10 • Confidence that patient has what they need to follow through with the plan on a 1-10 scale: 8

18. Measuring effectiveness – the client’s perspective How 187 coaching graduates rated themselves on a 1-10 scale for the goals they choose, with “10” being goal accomplishment.

19. Clinical Outcomes:Diabetic Improvement in Weight

20. Clinical Outcomes:Diabetic Glycemic Improvement Average drop in A1c = .7 Average drop in A1c = .9 Average drop in A1c = 1.2 Average drop in A1c = .8

21. Clinical Outcomes:Impaired Fasting Glucose Improvement in Weight

22. Benefits to Clinicians of Health Coaching • Creates capacity for MDs and APCs to see their panel of patients with medical needs and be available to accept new patients into their practice • Allows all Team members to practice at top of license; for MDs this means diagnosing and treating complex patients • Content expertise: Physicians are not trained in behavior change

23. Cost Comparison • Health Coaching : 40 minute visits (series of 8 for a total of 320 minutes) • Salary Cost for Health Coach- $189.63 • Salary Cost for RN- $230.61 • Salary Cost for APC - $311.13 • Salary Cost for Physician - $607.86

24. Lessons Learned and Future Challenges • Physicians have embraced the idea of health coaching, even those that have been practicing traditional medicine for 30+ years with many varied practice styles. • Recognized need to build a model for sustainment • Better understand how to motivate patients not ready for coaching. • The current model is built by a single coach. Our future may include a community of coaches which may further improve the interactions. • Group visits need to be explored to increase capacity without diminishing the intervention

25. Contact Info Thad Schilling : Thad_ Schilling @vmed.org Heidi Duskey : Heidi_ Duskey @vmed.org Thank You!