Implementing a Health Coaching Curriculum in Hawaii's Community Health Centers

Abstract

Chronic diseases impact 60% of Americans, with 42% reporting multiple chronic conditions, and account for $3.3 trillion in annual health care costs. In Hawai‘i, about 80% of adults report having at least 1 chronic condition, and more than half of those report having multiple chronic conditions. Health coaching is a technique of engaging patients to help them obtain the knowledge, skills, and confidence to become an active and engaged participant in their health care. Health coaching aims to assist patients with understanding their care plans, exploring their perceptions of their care plans, and working collaboratively with their health care team to implement these plans to improve their overall health. In 2016, the Hawai‘i Primary Care Association (HPCA) partnered with the University of California, San Francisco's Center for Excellence in Primary Care to train staff from HPCA and Hawaii's community health centers (CHCs) in health coaching. This 2-day training focused on using principles of adult learning theory to create interactive sessions aimed at building staff capacity to improve communication and empower patients to become active participants in their health care. The curriculum highlights 6 core elements of health coaching: ask-tell-ask, setting the agenda, closing the loop, know your numbers, behavior-change action plans, and medication adherence counseling. The aim of this case study is to present insights gained from the implementation of health coaching at 1 FQHC in Hawai‘i. Health coaching is found to be an effective approach to engaging patients and improving communication with patients and across clinic departments. Health coaching is a promising practice to address the growing chronic disease burden in Hawai‘i.

Introduction

Chronic diseases impact 60% of Americans, with 42% reporting multiple chronic conditions, and account for $3.3 trillion in annual health care costs.¹ In Hawai‘i, the most recent data estimate that about 80% of adults report having at least 1 chronic condition, and more than half report having multiple chronic conditions.² Diabetes impacts 96,000 residents of Hawai‘i.³ Further, hypertension impacts 31% of Hawai‘i residents.⁴ Obesity-related costs in Hawai‘i are estimated at $470 million annually, with an additional $770 million spent on diabetes-related care.⁵ Due to the prevalence and economic burden of chronic conditions, it is imperative to find effective solutions to address this public health concern.

Community health centers (CHCs) are community-based, non-profit health care organizations that provide primary and preventive care with a focus on serving low-income and medically underserved populations. CHCs provide services to all community residents regardless of their insurance status or ability to pay. In Hawai‘i, there are 15 CHCs that provide services to more than 155,000 patients annually. In 2017, 79% of CHC clients in Hawai‘i were ethnic minorities.⁶ About 26% of patients served had hypertension, 16% were diagnosed with diabetes, and 7% had asthma.⁶ Hawaii's CHCs are integral to reducing health disparities experienced by immigrants and underserved populations.⁷ Chronic disease management remains a challenge for patients served by Hawaii's CHCs, as 37% of these patients have poorly-controlled diabetes, and almost 40% have poorly-controlled blood pressure.⁶ One Healthy People 2020 goal is to reduce the rate of poorly-controlled diabetes to 16%.⁸

Team-based care is a health systems-level intervention that employs a multidisciplinary approach to caring for patients that offers a variety of supportive services more efficiently than the provider alone.⁹ The health care team works together to ensure the patient receives appropriate tests, medications, and support to self-manage their condition and make improved lifestyle choices.¹⁰ Research has shown that team-based care interventions are effective in improving blood pressure,¹¹ hemoglobin A1c (HbA1c), ¹⁰ and lipid levels.¹⁰ As a result, the US Preventive Services Task Force recommends team-based care as an effective means to improving diabetes and hypertension control.^10–11

Further, health coaching is a specific intervention aimed at promoting a team-based approach to caring for patients with chronic conditions. Health coaching engages patients by providing them with information, skills, and confidence to become an active member in their care.¹⁴ This patient-centered approach focuses on working with them to help them understand their care plans and work collaboratively with their health care teams to improve their health.¹² Researchers have identified this model as one of the building blocks of high-performing primary care settings.¹³

A series of studies has shown the effectiveness of health coaching across different diseases. In a recent systematic review, Kivela, et al, found 13 studies that explored health coaching with patients experiencing chronic conditions including type 2 diabetes, heart failure, dyslipidemia, obesity, chronic pain, and cancer.¹⁵ Health coaching improved physiological, behavioral, psychological, and social outcomes. Health coaching improved blood pressure,^14,16,17 cholesterol levels,¹⁸ and HbA1c levels,^19,20 and reduced rates of hospitalization among patients with chronic obstructive pulmonary disease.²¹ Linden and colleagues also noted that health coaching among those with chronic conditions improved their self-efficacy, patient activation, lifestyle change score, and perceived health status.²² A systematic review by Olsen and Nesbitt found that health coaching interventions that incorporate goal setting, motivational interviewing, and collaboration with health care providers improved chronic disease self-management and achievement of health behavioral goals.²³

Among patients with diabetes, health coaching may reduce symptoms of diabetes at follow-up,²⁴ improve self-care behaviors related to diet and foot care,¹⁷ increase patient engagement,¹⁵ and reduce perceived barriers to medication adherence.¹⁷ Further, patients with diabetes may be more satisfied with their health care and have reduced levels of stress and perceived illness, and increased awareness of self-care goals and feelings of support from their health care team because of health coaching.¹⁸ Willard-Grace, et al, found that patients with diabetes were more likely to achieve their HbA1c goals when receiving health coaching.²⁵ Oksman and colleagues demonstrated that a telephone-based health coaching program was a cost-effective approach that increased quality-of-life scores for those with type 2 diabetes.²⁶

Research on health coaching within CHC settings and with diverse populations is limited. However, implementation of health coaching by clinical support staff has shown improvements in HbA1c levels among patients with diabetes compared to patients in the control group.^22,27–29 Ruggiero and colleagues²⁹ explored the use of medical assistant (MA) trained coaches to improve diabetes in one Chicago CHC. Participants with diabetes were randomized into health coaching by MAs or usual care. While the findings did not show statistically significant improvements, researchers noted that those receiving health coaching had a sustained reduction in their HbA1c levels, felt more empowered and decreased their negative perception of diabetes-related problems.²⁹ Van der Wees and colleagues compared health coaching implementation across 12 CHCs in California and found that health coaching implementation varied greatly and was contingent upon available time and competing responsibilities. The researchers underscored the importance of ensuring a flexible implementation that is responsive to the needs of the patient and the clinic practice.³⁰

Although health coaching has been shown to be effective in CHCs in the continental US, health coaching has not been widely tested and evaluated within Hawaii's CHCs. This article intends to provide insight on an innovative, evidence-based approach to promoting team-based care in Hawaii's CHCs, describe the core tenets of health coaching, and present a case study of health coach implementation at 1 CHC. Further, this manuscript highlights community-clinical linkages through the demonstration of health coaching as a means to conduct outreach to communities, educate them on chronic disease management, and facilitate follow-up with providers at the CHC.

Health Coach Training Curriculum

In 2016, the Hawai‘i Primary Care Association (HPCA) partnered with the University of California, San Francisco's (UCSF) Center for Excellence in Primary Care to train staff from HPCA and Hawaii's CHCs in health coaching. This 2-day training focused on using principles of adult learning theory to create interactive sessions aimed at building staff capacity to improve communication and empower patients to become active participants in their health care. The curriculum highlights 6 core elements of health coaching: ask-tell-ask, setting the agenda, closing the loop, know your numbers, behavior-change action plans, and medication adherence counseling.¹² “Ask-tell-ask” is a method of engaging patients by assessing their interests in learning about their conditions and willingness to follow through with treatment recommendations. For example, a health coach asks a patient, “What do you know about diabetes?” Based on the patient's responses, the health coach fills in gaps in knowledge or clarifies any misunderstandings about diabetes. Then, the health coach asks the patient if he or she have additional questions about diabetes. This process continues until the patient receives answers to all their questions about diabetes. “Setting the agenda” is a process by which the health coach gathers the concerns of both patients and health care providers and assists patients in prioritizing their concerns to maximize the medical visit. “Closing the loop” or “teach-back” enables the health coach to assess the patient's understanding of provider recommendations by asking the patient to repeat the recommendations in their own words. In practice, a health coach states, “Just to be clear, tell me what you know about your condition.” Then, the patient describes their understanding of diabetes in their own words. “Know your numbers” is a series of questions to help patients understand their baseline and treatment goals for their condition, and to seek clarification from their physician if they did not know. Action planning involves working with patients to create a detailed plan to help them achieve their goal(s). The last element is medication adherence counseling, in which health coaches ask patients a series of questions to reconcile medication and assess patients' knowledge and use of prescribed medications. These 6 core skill sets are reinforced through interactive group activities and role-playing scenarios to apply concepts into practice.

Building Champion Trainers in Hawai‘i CHCs

To ensure sustainability of health coaching training in Hawai‘i, HPCA staff received additional training and mentorship from UCSF to become “Champion Trainers.” Once a request for training was received, HPCA staff worked with CHC health coaches to plan the training for interested staff. CHC staff assisted with securing logistics and participant recruitment, while HPCA provided training materials and facilitated planning sessions with CHC health coaches. Utilizing the techniques learned from UCSF, HPCA worked with the CHC staff to tailor the content and determine appropriate training frequency to meet the unique training needs of each CHC. For example, one CHC wanted all staff to be trained in brief tobacco intervention counseling, and so that was integrated into the training curriculum. In some instances, HPCA facilitated most of the training and invited key staff (eg, pharmacists, behavioral health specialists) to facilitate portions of the training, relating the content back to the importance of health coaching in their CHC context. Further, HPCA provided training onsite to CHC staff to ensure maximum attendance of frontline staff.

This sustainable training model has resulted in 62 trained health coaches at 9 CHCs. Those trained represent a variety of professions from frontline staff (eg, receptionists, medical assistants, community health workers [CHWs]) to licensed professionals (eg, behavioral health specialists, dietitians, nurse care coordinators). Many of these health coaches have continued to implement this training with new CHC staff. Although a formal evaluation has yet to be conducted on health coaching's impact on patient outcomes, a case study is presented below on health coach implementation at 1 CHC. The case study highlights the most valuable aspects of health coaching at this CHC and describes perceived benefits of health coaching in patient care.

Health Coach Implementation at Lāna‘i Community Health Center (LCHC)

Lāna‘i Community Health Center (LCHC) is an CHC located on the smallest inhabited Hawaiian island, Lāna‘i. LCHC provides comprehensive primary care services including medical, behavioral health, dental, and optometry services.³² LCHC provides a variety of services to prevent and manage chronic conditions, facilitate care transitions and referrals, and support telehealth to increase access to specialty services (eg, telepsychiatry and teledermatology, and telemedicine obstetrics). Additionally, enabling services, such as prescription assistance programs, transportation, and translation are provided to help address the social determinants of health. Although the center's services are available to all Lāna‘i residents, primary targeting is aimed at those whose incomes are at or below the 200% federal poverty level,³² who account for 54% of their patient population.³³

LCHC utilizes an integrative holistic health care approach, which involves looking at the whole health of a patient. In this model, staff within each department is expected to screen, provide brief interventions, and refer patients to other departments when a patient's health concerns require another department's expertise. Because of this integrated approach, LCHC decided to provide the health coaching training to medical assistants, dental assistants, behavioral health providers, and CHWs. Training in health coaching provides staff with an evidenced-based method of communicating with patients about their physical health while assisting to connect with other specialty services (eg, dental, behavioral health). It provides communication skills by teaching both motivational interviewing techniques and basic information about common chronic diseases, for CHWs. This training helps the CHWs understand their responsibilities to provide self-management support for individual patients with diabetes mellitus, hypertension, and other chronic conditions. When CHWs use appropriate communication techniques, patients progressively learn self-management skills, which can improve health outcomes. Staff are also equipped to assist in helping patients become active members in their treatment and care plans. LCHC staff members believe that if each department is providing the same messages about health, then a patient is more inclined to seek treatment and be more willing to look at treatment options. Health coaching aligns with LCHC's mission of providing patient-centered care with an integrative team approach. As a result, LCHC has required this training as part of onboarding of new clinical staff.

Since participating in the first cohort in 2016, LCHC staff members worked with HPCA to tailor subsequent trainings by removing irrelevant sections and incorporating a section on smoking cessation counseling facilitated by a behavioral health provider. Following the initial training, LCHC staff felt that the curriculum would provide them with a common language to discuss a patient's health concerns (eg, diabetes, hypertension, high cholesterol), medication reconciliation, and follow-up tests (eg, HbA1c levels). Anecdotal feedback from trained staff indicated that health coaching was beneficial in establishing and improving trusting relationships with patients and was a powerful strategy to empower patients to take an active role in reaching their health goals. CHWs confirmed in their monthly meetings the effectiveness of health coaching strategies in establishing great working relationships with patients. Motivational interviewing, medication reconciliation, and closing the loop were the most common strategies that enabled open communication and empowered LCHC patients.

Furthermore, warm hand-offs and follow-up dialogue occurs between CHWs and clinical providers after each patient visit. The meeting includes a debrief and discussion of patient's status. Medication reconciliation, current issues with hypertension and diabetes, and nutritional needs are common topics discussed with patients. Health coaching strategies have been so effective that previously non-adherent patients are now willing to take part in nutrition consultations and exercise classes (group or individual sessions).

HPCA surveyed trained LCHC staff to understand implementation of health coaching techniques and their perceived impact on patients and staff. Feedback from staff indicated that they have integrated health coaching components in their current roles at LCHC. Behavioral health providers noted that “ask-tell-ask” and “closing the loop” helped them assess their patients' understanding of their health, identify their level of motivation to make recommended lifestyle changes, and align treatment goals with their health needs. Trained staff also reported that the training provided non-medical staff with common medical terminology of chronic diseases, understanding goals of clinical metrics (eg, HbA1c levels, cholesterol levels, and blood pressure), and familiarity with the medications prescribed for chronic conditions. CHWs report that the curriculum has provided them with the skills to assist patients, offering a patient-centered, holistic approach to help patients reach their goals. Health coaching techniques motivate patients and promote a collaborative relationship, which ultimately leads to better health outcomes and improved quality of life.

Although a formal evaluation of health coaching on patient outcomes at Hawaii's CHCs has yet to be conducted, trained CHWs report that health coaching allows patients to be more willing to adopt new behaviors. CHWs can use health coaching strategies to help patients overcome any hesitance to adopt new behaviors by building trust and allowing them to discover approaches that work for them. Patients feel empowered and in control of their own health journey. As trusted health care team members, CHWs help bridge communication gaps between patients and providers by regularly sharing information learned from the patient that could impact treatment outcomes. Because they may see patients more often than primary care provider, they can relay patient concerns back to medical provider, promoting quality team-based care. Additionally, CHWs and behavioral health providers reported that health coaching has improved patient communication. Among CHWs, the “closing the loop” technique helps patients verbalize understanding of their patient care plans. Behavioral health providers note that health coaching has helped ease patient ambivalence, build trust between patient and provider, and increase patients' willingness to be more involved in their care and open to treatment options.

Discussion

Through partnerships with UCSF, HPCA has built the internal capacity to continue the spread of health coaching within Hawaii's CHCs. Health coaching curriculum has enabled HPCA to build the capacity of CHC staff to implement an evidence-based intervention. Although research has demonstrated that health coaching is an effective approach in engaging patients, evaluation of its impact in Hawaii's CHCs patients is still unknown. This case study of Lāna‘i Community Health Center's implementation is the first step in understanding the impact of health coaching within CHCs in Hawai‘i.

Although not a formal evaluation of health coaching effectiveness within CHCs, the case study of implementation mirrors findings found in the literature. The information gathered from the LCHC staff demonstrates that health coaching is a method of creating quality team-based care, which is vital to promoting high functioning primary care in the current health care environment. Researchers have observed that a provider with about 2,500 patients would have to work almost 18 hours a day to address all aspects of the recommended chronic disease management and preventative care.³⁴ Research also has shown that only half of patients leave their office visit understanding their treatment plans.¹² LCHC's approach of training all staff who interface with patients ensures consistent messaging, as well as multiple opportunities for care plan discussion, and creates the environment for more effective and efficient office visits.

The LCHC staff also shared that the training and techniques enhanced their ability to communicate with and motivate patients. For patients, staff shared that the skills helped to promote a collaborative relationship with patients and providers, allowing them to be active participants in their care. Unfortunately, it is estimated that for 90% of office visits, patients are not involved in the decision-making process, leading to a lack of adherence to treatment plans.³⁵ Providing patients with the opportunity to collaborate in the development of their care plan will lead to improved adherence to treatment recommendations, resulting in enhanced health outcomes.¹²

Community health workers are important members of the health care team, particularly in rural and underserved areas. CHWs are trusted members of the community, provide culturally-competent care, and act as a bridge between the diverse population and professional staff. CHWs, whether fortunate enough to have received a formal CHW certificate or on the job training, may have limited knowledge of complex medical conditions or limited experience in effective communication skills. The health coaching training is an effective curriculum that offered practical tools for effectively developing patient self-management skills. At LCHC, trained staff, particularly the CHWs, confirmed that the health coaching techniques and tools were effective in supporting their ability to help patients. As is frequently the case in health services research, health coach training and implementation is a component of the evolving team-based care at LCHC. While its impact on the clinical metrics of HbA1c levels and blood pressure control remains to be seen, health coaching's impact on the CHWs' ability to assist patients validates the value of this training curriculum.

Practical Implications

Assessments of health coaching implementation at 1 CHC support that it is an effective method of transforming health care systems to provide high-quality team-based care and empower patients to become active members in their health care. CHWs are essential members of the health care team and are ideal staff to receive health coaching training to support their ability to assist the communities they serve. Health coaching skills can also support and enhance other health care team members' abilities to communicate and engage patients in their treatment care planning. Health coaching is not only effective, but it is efficient in leading to better managment of patients with chronic and often complex medical conditions. Demonstration of the value of health coaching requires continued case studies and model refinement to develop an affordable high-quality health care system. Therefore, it is vital to evaluate the effectiveness of health coaching on improving patient outcomes, identify effective health coaching models, and sustain health coaching efforts through health insurance coverage. Health coaching is a promising practice to address the growing chronic disease burden in Hawai‘i.

Conflict of Interest

None of the authors identify a conflict of interest.

Highlights

• Health coaching helps patients become informed, active participants in their care.

• Health coaching promotes high quality team-based care in primary care settings.

• Health coaches can bridge communication gaps between patients and providers.

• Community health workers and other staff may benefit from health coach training.