Health Coaching – Your health, Your responsibility, Our care

Actions arising fromHealth Coaching Summit26th February 2013, London*

1.0Introduction

“As we move into an erathat calls for self-sufficiency over a lifespan (e.g. in managing health, finances or careers), professional coaches and health coaches will be the agents to facilitate this transition”.

On 26th February 2013fifty eight senior managers and clinicians attended a health coaching summit in London to consider the use of health coaching to transform clinician/patient relationships, support behaviour change and improve the experience and outcomes of patients with long term conditions (LTCs). The aims were to:

  • Explore the context and application of health coaching
  • Showcase innovation and international best practice
  • Consider ways to build clinician’s capabilities and embed skills
  • Inform the new national strategy and delivery model for LTCs (Domain 2)

Participants heard presentations and then participated in a workshop based on the NHS Change model to consider how to ensure health coaching skills become widely available to benefit people with LTCs. Appendix 1 outlines the design of the day with links to recorded videos of each speaker and slides.

This paper describes the key messages from the event and actions proposed at a national and local level as a resource for participants in addition to the slides and videos. It has been written by Penny Newman in collaboration with presenters Alf Collins, Andrew McDowell, Ed Mitchell, Margaret Moore, Sue Mortlock, Sue Robertsand Robert Varnam. Quotes from speakers and participants are given although are non attributable.

2.0Context

People with long term conditions account for 50% of all GP appointments, 70% of all inpatient bed days and 70% of overall NHS spend. The number of people with three or more long-term conditions is predicted to rise by a million to 2.9million by 2018.Multi-morbidity is more common among deprived populations, and together with a concurrent mental health problem,is a greater determinant of health service use than a single disease alone (Kings Fund).It is predicted that three quarters of all deaths by 2020 will be from chronic disease (WHO).

Given the growing and significant impact of long term conditionsnew approaches are required to

•Address the challenge associated with increasing patient confidence, self-management, medication compliance and lifestyle change while simultaneously reducing service utilisation and cost.

•Provide people with LTCs with the knowledge, skills and confidence to self-manage and thrive.

•Ensure all groups are equally enabled or “activated” to self-manage, especially those with few skills,low confidence,and poor quality of life who require more intensive support.

3.0A new strategy for long term conditions (Domain 2)

“Peoplewho live with long term conditions are themselves the ultimate delivery mechanism for high quality day to day care and management”.

Domain 2 has the primary goal of ensuring person-centred, coordinated care for people with long term conditions, along with parity of esteem for mental health. The domain will work within a ‘House of care model’ which recognises the importance of commissioning, the roles of individuals, their carersand healthcare professionals, and organisational processesworking together to achieve this

This new delivery system provides collaborative care planning asa starting point for local configuration, a unique personalised solution tailored to each individual, the potential to provide a template for workforce planning and environment for implementing health coaching.

The House of Care[1]consists of four interdependent and equally important components:

  1. Engaged, informed individuals and carers - enabling individuals to participate fully in the care planning process.
  2. Health and care professionals working in partnership with patients and colleagues in multidisciplinary teams– listening, supporting, and collaborating for continuity of care
  3. Organisational and clinical processes - ensuring that the clinic/practice processes (infrastructure) are designed and in place to support the care planning process.
  4. Commissioning - ensuring that the resources, processes and metrics are in place to enable care planning to occur and improve.

Figure 1: The House of Care

Currently LTC management is fragmented and often organised around the needs of institutions and clinicians rather than patients. At the heart of the chronic disease management model is the informed, empowered patient with access to self-management support as part of routine ongoing care : Central to the “house” is a process of personalised and collaborative care planning.

Professionals will work towards having a new type of conversation to understand the impact of the condition on a person’s lifeand to identify services to enable individuals achieve their goals. This new conversation will help identify the roles and responsibilities of both the individual and professional in their ongoing care.

Properly integrated self-management and support geared towards the individual’s goals will

  • Shift the emphasis of healthcare provision away from a biomedical approach towards a bio psycho social approach
  • Shiftthe focus of care and support onto preventative and wellbeing services in primary care and community settings
  • Assist people to avoid crises and episodes of deterioration, as well as manage such episodes with greater confidence.

To adopt the house of care model requires amongst other things, educational support for the workforce which, on the whole, has not been trained sufficiently to support patients to self-manage and predominantly employs the “diagnose and fix” or expert biomedical model that promotes further dependency.

“Through invoking a health coaching approach we can support people on their journey of activation… but we have never had a national initiative to train clinicians and our workforce to all enable activation. We say you have got to do more of this – use decision aides, employ health trainers, implement phone coaching - these are all important but they do not get to the core of the issue: We don’t train our workforce and we haven’t changed the system”.

4.0What is health coaching?

“The biomedical model has helped to generate problemsfor people withlong term conditions and so we cannot use the biomedical model to fix the problem it’s created - we need to look beyond this model into the 21st century. We shouldn’t ditch it but we need to augment it.”

Health coaching is an umbrella term for multiple applications of a coaching approach. There are numerous definitions of health coaching depending on its use, for example:

  1. In health improvement, it is “a behavioural intervention that facilitates participants in establishing and attaining health-promoting goals in order to change lifestyle-related behaviours, with the intent of reducing health risks, improving self-management of chronic conditions, and increasing health-quality of life” (Van Ryn & Heaney 1997)
  2. As an aid in decision making it “is based on strong provider communication and negotiation skills, informed, patient-defined goals, conscious patient choices, exploration of the consequences of decisions, and patient acceptance of accountability for decisions made”.
  3. In pilots in Midlands and East and NHS London to improve long term condition management it is the application of executive coaching skills by clinicians used in combination with specific psychological interventions and clinical skillsto “support patients to change their relationship with their health, through tapping into their potential for self-care, raising their awareness and responsibility, and increasing their confidence and motivation to act to achieve their goals” (Table 3, McDowell 2013).
  4. In wellness coaching the aim is the promotion of wellness or the optimal physical and mental health as defined by evidence and not an absence of disease i.e.ability to thrive in the presence of disease. Health and wellness coaches facilitate a partnership and change process that enables clients to change their mindsets, and develop and sustain behaviors proven to improve health and well-being, going beyond what they have been able to do alone, moving from where they are to where they want to be (Moore 2013).

In UK pilots health coaching is currently being used by doctors, nurses and allied health professionals in their consultations in primary, secondary and community care (table 1).

Table 1. Critical elements of health coaching in UK based pilots (McDowell).

Aims to / •Increase health-related quality of life and outcomes
•Improve patient experience of the health system
Supports a person to improve their relationship to their health / •Taps into their potential to self-manageand self-coach
•Raises their awareness of the value of good health and sense of responsibility
•Supports them to actively self-manage
•Increases their confidence and motivation to act
Requires a different kind of conversation / •Based on listening, trust, challenge and positive emotions
•Is collaborative and equal
•Tailored to the individual, his/her agenda and goals
•Requires transformation in the clinician/patient relationship
Useful in / •Improving lifestyle
•Chronic disease management
•Pain management
•Managing unexplained symptoms
•Medicines management and optimisation
•Decision support
•Recovery and rehabilitation
•Mental health (primary care)
Benefits / •Improved patient satisfaction, motivation and self-efficacy
•Evidence suggests reductions in service utilisation and improved outcomes
•Creates a mind-set shift and resilience amongst clinicians as they move from expert to enabler
•Creates clinical champions for spread.

5.0Experience in the USA

A health and wellness coaching industry in both corporate and clinical settings is rapidly growing in the USAand coaching skills used by broad variety of practitioners – nurses, fitness coaches, dieticians, doctors, rehabilitation professionals and mental health practitioners.

Its applications include professional health and wellness coaching delivering individual and group models, peer coaches, and as a skill set for clinicians. These applications all aim to be a catalyst for people to thrive and are applied across the whole continuum fromconsumer health and well-being to clinical application from birth (maternity care) to end of life and including obesity, diabetes, hypertension, rehabilitation, terminal and “catastrophic” care, for example, when used by social workers to enable the homeless to engage in treatment and reduce multiple attendances to the Emergency Room.

There is now evidence that health coaching can be effective as a key therapeutic agent in a variety of settings. Most coaching programmes are at least 3 months long, for example, the US government Medicare programme reimburses 20 obesity counselling sessions over 12 months.

6.0Health coaching skills

“There are a core set of fundamental principles (that help people thrive) and there will be varying levels of mastery from consumers coaching themselves to having access to the most experienced coach”.

Healthcoaching is a developing field and as such core competencies have not yet been widely defined and agreed. Coaching starts with the premise that problems can’t be solved with the same thinking that created them. To create new thinking and motivation to act, the relationship and conversation between the health coach and patient or client needs to:

  • Support and help people create a new world view and shift in thinking for them to prioritise their health and move to greater motivation and confidence -“I want to and I can”.
  • Aid the creation of an iterative cycle of change as new insights translate into new actions that wouldn’t have been tried otherwise. Clients become more open and curious, more willing to experiment on an ongoing basis. Over time this supports new habits and mind-set.
  • Generates rapport , connection and calm, and counters inner criticism and negativity with compassion e.g. people living with LTCs who work with clinicians with high empathy scores have better control of HbA1c and LDL.
  • Be collaborative by using open questions, listening and reflection as opposed to “telling” whichcan generate defiance rather than commitment and resistance in response to external motivation and “being told what to do”.
  • Create positive emotions in the client to build motivation and confidence through a focus on what’s good versus what’s wrong which in turn enables greater resilience and confidence to overcome setbacks. Positive emotions are becoming a vital sign given their important role in improving cognitive function and over time, physical health.
  • Provide timely and personalisedhealth education and information prioritised depending on how much is already known, what is most helpfuland how each individual likeslearn.

Table 2 below illustrates the skills taught in the UK pilot health coaching programmes. Different skills are needed depending on the level of competency requiredin different contexts.

Table 2. Health coaching competencies (McDowell)

7.0Next steps

Fig 2: Application of the change model: Outputs for creating a strategy for health coaching

“We have a clear sense of purpose around helping growing numbers of people in this country living with multiple medical problems that medicine can’t cure. The current paradigm doesn’t serve them well enough and it’s not sustainable for the NHS.

We’ve heard that it’s time for a paradigm shift and for us to share knowledge, decisions and power with people living with long term conditions. How can we make this a reality? In health coaching we have a useful and accessible approach that can help us move into that new paradigm. It’s not the only way, but it offers significant potential and possibility. To implement coaching at scale is going to take commitment, skills and changes in the system”.

Health coaching is integral to the “house of care” and

•Is consistent in philosophy with the approach

•Aims to engage and inform individuals and their carers through a different type of conversation

•Can provide clinicians with supplementary consultation skills and a mind-set that enables them

  • To move away from a paternalistic and dependent model to one that is empowering and shared based around the aspirations and goals of people who live with long term conditions
  • Act as champions for shared decision making

•By being integral to a consultation with their usual clinician, coaching can support lifestyleschange and self-management without always requiring onward referral

•Can be adopted within a care planning consultation to augment clinical skills at a basic level

•May require referral of patients with more complex problems to more specialist health coaches and services.

Evidence suggests that training in health coaching skills alone may not be sustainable unless developed within a supportive commissioning and delivery system. Equally, change cannot be achieved without activating patients to self-care as well as activating clinicians to support them to do so. The focus of the summit was on the latter, acknowledging it is only one aspect of the “house of care”.

“We have conditioned our population into the medical dependency model and placed doctors and other professionals in the role of hero. If taking control of your life and managing your own condition in partnership with professionals is what we are looking for somehow we need to encourage the public to come with us on that journey”.

The following actions, generated in applying the change model, were identified given this caveat (Figure 2):

  • Our Shared Purpose: A shared purpose, compelling narrative and call to action should be created for health coaching. A health coaching approach should be establishes as “core business” and used in all consultations to significantly improve patient satisfaction and self-efficacy.
  • Leadership for Change: Leadership for health coaching requires national and clinical “champions” as well as patient “pull”, for example, from National Voices.
  • Engagement to mobilise: In the call to action national, regional and local stakeholders should be engaged and would include organisations system wide (Health Education England, NHS England, Local Authorities, Public Health), patients and patient groups, and the NHS Leadership Academy. Primary care and engaging GP practices is paramount.
  • System Drivers:
  • A workforce strategy should be developed to establish and develop core competencies, levels of training, stages of training, national standards and identify which patients benefit most and cultural fit.
  • New levers in the system need to be appliedto promote health coaching, for example, ensure it is embedded in new pathways, linked to QOF standards, and usedin the adoption of new technologies e.g. telehealth and telecare.
  • A model service specification should be developed for commissioners.
  • Spread of Innovation:
  • A glossary of terms including “health coaching”, “shared decision making”, “personalisation” and “no decision about me without me” should be developed to create shared understanding of key concepts.
  • A health coaching Foundation should be established to scale up the field and bridge the evidence emerging from pilots into health care reform.
  • More evidence is required on the skills clinicians need to support self-manage, and on health coaching practice and outcomes from UK and international studies.
  • A communications strategy should be created that uses new technologies such as tweeting, videos etc.
  • Transparent measurement:
  • A measurement system and KPIs are required to align training the workforce with a coherent measurement system to benchmark geographical areas and identify movement towards the shared purpose.
  • New projects (including the roll of in the East of England) should be evaluated to establish return on investment and outcomes e.g. % teams trained, and changes in readmissions and A&E visits, smoking cessation, and GP appointments. Evaluation should include patient stories, assessment of quality of care, and impact on patient experience.
  • Rigorous delivery:
  • Health coaching training should be aligned with other initiatives when adopting “the house of care” including patient activation, commissioning and system change.
  • A national programme for delivery would require rigorous project management.
  • Improvement methodology should be applied to implementing a health coaching approach e.g. adoption of the change model and knowledge of large scale change in addition to continuous improvement, learning from doing as in PDSA cycles.

Appendix 1. Design of the day and speaker films