With Ruth Wolever, PhD, Mark Dreusicke, MD, and Clare Liddy, MD
A 6-month integrative health coaching intervention significantly improved medication adherence in adults with type 2 diabetes, and a significant decrease in hemoglobin A1C levels (from 8.0% to 7.7%). Patients also reported less perceived stress, better mood, greater perceived social support, improved engagement, and a more positive assessment of their chronic illness. The prospective observational trial was published in the BMJ Open Diabetes Research & Care.
To learn more about applying the principles of integrative health coaching to diabetes management, EndocrineWeb spoke with authors Ruth Wolever, PhD and Mark Dreusicke, MD.
Q: What are the key clinical implications of these findings?
Dr. Wolever: Medication adherence is a well-documented problem. Non-adherence is associated with worse clinical outcomes and increased risk factors, increased hospitalization and healthcare service utilization, and elevated healthcare costs.
A strength of this study was using objective pharmacy records to calculate medication adherence, rather than patients' subjective self-report. The medication possession ratio (MPR) is the ratio of medication obtained/medication that should be used; while we don't know if people actually swallow the medicine obtained, MPR does give an account of medications obtained using pharmacy benefits. MPR was greater during the health coaching intervention (Figure 1; P=0.001) and after the intervention (P=0.011) compared with before the intervention, suggesting medication adherence improved and was sustained after the intervention. The improved medication adherence also was correlated with a significant decrease in A1C.
Figure 1. Medication adherence calculated by pharmacy claims data. IHC, integrative health coaching; MPR, medication possession ratio; n.s., not significant. Source: Wolever RQ, Dreusicke MH. BMJ Open Diab Res Care. 2016;4:e000201.
After the intervention, participants reported decreased perceived barriers to medication adherence (P=0.001), increased patient activation and engagement (P<0.001), improved mood (P=0.010), decreased perceived stress (P=0.013), improved overall morale regarding having diabetes (P<0.001), greater social support (P=0.001), and perceived benefits from living with diabetes (P=0.006).
Q: What are the principles of health coaching?
Dr. Wolever: Healthcare providers may find the principles of health coaching helpful in their practice. In health coaching, patients are considered the most knowledgeable, capable, and reliable resource of information regarding personal strategies for behavior change that will fit well in their daily lives. This differs somewhat from traditional models, where the provider or diabetes educator, by definition, is the expert who provides information.
In coaching, education is provided at the patient's pace—ie, when information is meaningful in the context of the patient's goals and purpose. Coaches elicit ideas and resources from patients, encouraging them to learn about their disease in the framework of their own lives. A coach may ask, "What aspects of controlling your blood sugar are most confusing to you? What have you heard? Where would you normally go to find this information?" The coach always asks permission before offering education, reinforcing that the patient is in control.
Q: How can primary care clinicians and endocrinologists implement this type of health coaching into their practice?
Dr. Wolever: We anticipate that primary care practices in the future will have credentialed health coaches as an integral part of their teams. Finding a credentialed health coach is critical to ensure the expertise and quality of coaches. Historically, health coaches have not required credentialing, but after six years of a best-practices process, the National Consortium for Credentialing Health & Wellness Coaches (NCCHWC) has established national standards for individual health coaches, as well as education standards for the programs that train them. In May 2016, the NCCHWC and the National Board of Medical Examiners (NBME) announced the formation of a partnership to implement these standards.
Vanderbilt's Health Coaching Certificate Program is one of 45+ institutions that have received program accreditation by NCCHWC. Vanderbilt's niche is training licensed health and allied health professionals who want to add coaching skills to their toolbox. Vanderbilt's program also offers a unique opportunity for individuals who may be interested in receiving health coaching, but do not have resources to pay. These patients can volunteer to work with Vanderbilt program health coach trainees.
Q: What impact do you hope your study will have on the diabetes community?
Dr. Wolever:Improved lifestyle behaviors are a recurring theme in the diabetes community, and mounting evidence makes it clear that knowledge alone does not lead to improved self-management behaviors. Health coaching has emerged as a promising intervention to target behavior skills. In health coaching, individuals are empowered to achieve self-determined goals through a deliberate and individually tailored learning process. Coaches have a wide knowledge base of health issues and distinct healthcare resources, but their area of expertise is not medicine; their expertise is specifically in helping clients build motivation and personalize strategies for behavior change.
We have noticed that accountability in conventional medicine is confusing when providers believe their role is to "fix" the patient. Providers feel pressure and are even offered incentives for having their patients achieve certain A1C levels; however, an A1C of 7% may seem arbitrary and meaningless to the patient in the scope of his or her life priorities and values. Health coaches provide a missing link in current medical models, since coaches are trained to clarify accountability as part of the coaching process. For example, coaches are trained to discuss with patients how they prefer situations be handled when they do not follow through on a commitment to themselves. Some patients prefer to be asked direct questions to figure out what went wrong, some want support, while others want to be reminded of a particularly relevant personal story.
We welcome the opportunity to study health coaching in larger populations of patients with chronic disease, particularly diabetes. I encourage researchers or providers who are interested in collaborating to contact me (firstname.lastname@example.org).
Bio: Dr. Wolever is a clinical health psychologist and Director of Vanderbilt Health Coaching at the Osher Center for Integrative Medicine at Vanderbilt Schools of Medicine & Nursing in Nashville, Tennessee. She also is an Associate Professor in the Department of Physical Medicine and Rehabilitation at Vanderbilt Schools of Medicine & Nursing. Dr. Dreusicke is conducting postdoctoral research at Duke University School of Medicine, Durham, North Carolina.
Clare Liddy, MD
Department of Family Medicine
University of Ottawa, Canada
This is an interesting study about integrative health coaching for people with type 2 diabetes. The findings of improved medication adherence and, importantly, improvements in glycemic control (reduction in A1C from 8.0% to 7.7%) are clinically relevant and support the positive impact of health coaching. The ability of the patient to set their own agenda and then work with a coach to support their goals is a key component of this approach. It was quite an intense study, with 14 individual phone sessions being offered over 6 months; however, most patients were able to schedule and "attend" the sessions, indicating a high level of acceptability for motivated patients. The challenge is to be able to direct this type of support to those who are "ready" and most likely to benefit, whilst not abandoning other patients who are earlier on in the continuum of learning to engage in positive health behaviors.
We recently conducted a study to examine the feasibility of implementing health coaching in primary care practices.1 We offered training in a much more limited manner (11 hours of training based on Peers for Progress2) to existing clinical staff and supporting them in implementing the program in their respective clinical settings. All three clinics were able to implement and offer health coaching using existing resources. Overall, the approach was considered acceptable, although the importance of physician buy-in was cited as a key facilitator.
There is a need, as Wolever and colleagues identified, to describe the role of the health coach, as a variety of definitions exist. Expanding the role of existing clinical staff, to adopt a health coach approach needs to be explicitly communicated to the healthcare team to promote a system-level change in supporting patients with the challenges of living with chronic diseases such as diabetes.
1. Liddy C, Johnston S, Nash K, Ward N, Irving H. Health coaching in primary care: a feasibility model for diabetes care. BMC Fam Pract. 2014;15:60.
2. Boothroyd RI, Fisher EB. Peers for progress: promoting peer support for health around the world. Fam Pract. 2010;27(Suppl 1):i62–i68.
May 27, 2016
Wolever RQ, Dreusicke MH. Integrative health coaching: a behavior skills approach that improves HbA1c and pharmacy claims-derived medication adherence. BMJ Open Diab Res Care. 2016;4:e000201.