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What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers
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Patient Education and Counseling xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers Christopher Johnson* , George Saba, Jessica Wolf, Heather Gardner, David H. Thom Department of Family and Community Medicine, University of California, San Francisco School of Medicine, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 July 2017 Received in revised form 15 November 2017 Accepted 24 November 2017
Objective: To examine activities of health coaches during patient medical visits and when meeting oneon-one with patients at 3 urban federally qualified health centers. Methods: Encounters were videotaped and transcribed. Data was analyzed using a matrix analysis approach that allowed a priori identification of expected categories of activity, based on the health coach training model and previously developed conceptual framework, which were modified based on activities observed. Results: A total of 10 medical visits (patient, clinician and health coach), and 8 patient-coach visits were recorded. We identified 9 categories common to both medical and patient-coach visits and 2 categories unique to the medical visit. While observed activities were generally consistent with expected categories, some activities were observed infrequently or not at all. We also observed additional activity categories, including information gathering and personal conversation. The average amount of time spent on some categories of coaching activities differed substantially between medical visits and patient-coach visits. Conclusions: Health coaching activities observed differed in several respects to those expected, and differed between medical visits and coaching only visits. Practice implications: These results provide insights into health coaching behaviors that can be used to inform training and improve utilization of health coaches in practice. © 2017 Elsevier B.V. All rights reserved.
1. Introduction Health coaching is a patient-centered one-to-one process which assists patients in identifying and achieving their healthrelated goals through education and personal support [1–3]. In the U.S., health coaching has developed from or been incorporated into existing several existing support models, including the personal trainer model (typically paid for by individuals) [4–6]; the care or case management model using nurses or other licensed medical care professionals employed by health delivery systems to managing care of complex patients [7,8]; and the model of community health workers [9] (or ‘promotoras’ in Latino communities [10]) who usually work within the public health system to provide community-based care for low-income and vulnerable populations. [11–14] Health coaching by unlicensed
* Corresponding author at: 1001 Potrero Avenue Building 80/83, San Francisco, CA 94110, United States. E-mail address: [email protected] (C. Johnson).
health workers has also been incorporated into team care models to improve primary care for patients with chronic conditions in primary care [2,14–17]. As a member of the patient care team, health coaches assist patients to set goals and follow through on mutually agreed upon ‘action plans’ for behavioral changes [14,17]. While there have been efforts to establish certification and/or licensing requirements for independent, professional health coaches [18], there is no widely accepted certification program for health coaching by unlicensed health workers [13]. Health coaches also may provide patients with health-related information, help them navigate the health care system and make connections to community resources. Health coaching has been shown effective in improving management of diabetes and pulmonary disease and risk factors for cardiovascular disease [2,14,19–22]. Coaches may be particularly valuable in resource poor settings, where low-income communities bear a disproportionate burden of chronic disease and its complications, and are less likely to engage in effective self-management of their conditions [23]. Despite the increasing use of health coaching, there has been little if any direct observation of what coaches do in practice. In the
https://doi.org/10.1016/j.pec.2017.11.017 0738-3991/© 2017 Elsevier B.V. All rights reserved.
Please cite this article in press as: C. Johnson, et al., What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.11.017
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current paper, we look into the ‘black box’ of health coaching activities, using direct observations of health coaches during both medical visits and one-on-one patient-coach visits outside of the context of the medical visit. 2. Methods 2.1. Study design The current study analyzed data from: 1) medical visits that included the patient, clinician and health coach; 2) patient-coach visits–individual meetings between health coaches and patients between medical visits; and 3) stimulated recall sessions–review of the videotapes of each of these types of visits by each participant (patient, health coach, clinician). Data were collected between December 3, 2012 and May 16, 2013. The study was approved by the University of California San Francisco Committee on Human Research (#12-09132). 2.2. Participants and setting The study was conducted at 3 urban public health primary care clinics (federally qualified health centers) serving low-income patients. Health coaches were medical assistants (allied, nonlicensed health workers who perform routine administrative and clinical tasks) who received approximately 40 h of training at the UCSF-CEPC [24]. While the content of the training was based on existing models (Chronic Care Model [25], Motivational Interviewing [26,27], Self-Efficacy [28], and Patient Activation [29], no single theoretical framework determined the content or processes of training. Training included instruction in active listening and nonjudgmental communication; harm reduction, navigating healthcare systems, creating self-management goals, and interactive communication including the use of ‘teach-back’ to assess patient understanding of new information and ‘close the loop’ in communication [30,31]. Health coaches were not trained to interpret clinical results or offer medical advice. 2.3. Recruitment and enrollment Health coaches, identified by clinic managers or other coaches, were contacted via email by a member of the study team. Those interested met with a member of the study team and provided informed consent. Participating coaches identified and made initial contact with patients that they coached. Members of the study team contacted patients expressing an interest in participating, and obtained informed consent prior to data collection. Primary care clinicians (physician, nurse practitioner, or physician assistant) of the participating patients were contacted by the study Principal Investigator (DT). Patients received $10 for the direct observation and $20 for their stimulated recall session. Health coaches and clinicians were paid $50 for participating in stimulated recall sessions. All patients, health coaches and research assistants were bilingual in English and Spanish. 2.4. Data collection Encounters between patients, health coaches and clinicians were videotaped. Videotapes were reviewed during stimulated recall sessions with each of the participants separately, generally within 2 weeks following the encounter. The purpose of the stimulated recall sessions was to allow participants to reflect and elaborate on parts of the encounter. Audio portions of the videotapes of the visits and audio tapes of the stimulated recall sessions were transcribed and personal identifying information was removed. In addition, participants completed a short survey
about demographics and other characteristics, including length of the relationship between the patient and primary care clinician. 2.5. Data analysis Our analytic goal for this paper was to categorize and describe coaching activities observed, informed by our previous study of how health coaches work with patients and our knowledge of the content of the training received by health coaches. We therefore chose an approach known as matrix analysis that allowed us to test the categories of activities we expected against the activities observed and to identify new categories. Matrix analysis [32] has been used in the analysis of qualitative data derived from structured or semi-structured interviews [32–34]. We initially identified categories of health coaching activities based on our knowledge of the health coach training and our previously reported model of how health coaches work with patients [35]. Using neutral descriptive labels for these a priori categories we then created a matrix of categories by visit and ‘mapped’ the content of each of the observed visits into the resulting cells. We created additional categories and modified existing categories as needed to best capture the activities observed. Final categories were chosen by consensus of the primary reviewers and tested for fidelity across all 3 reviewers (CJ, GS, DT). In addition to assessing categories of activities, we also looked for the use of ‘teach-back’ (asking patients to repeat new information in their own words) to close the communication loop. Data was analyzed by 3 members of our study team, a family physician (DT), a clinical psychologist (GS) and a post-baccalaureate pre-medical student (CJ). All transcripts were read by at least 2 study team members. Data from transcripts was entered into individual matrix cells in the form of paraphrased or quoted passages identified by line number to allow us to check back to the original passage. Transcripts for the stimulated recall sessions were reviewed to check our understanding of the content from the direct observations and help resolve any ambiguities from the direct observations, which were rare. Any disagreement in categorization of data was resolved by discussion. We also coded the time spent in each category of health coaching activity by listening to and timing the audio recordings for each encounter. 3. Results We recorded a total of 10 direct observations of medical visits (patient, clinician and health coach), three of which were with the same clinician. In 7 of the medical visits, the health coach met with the patient in a pre-visit, prior to the clinical visit with the doctor or other clinician. In 3 of the medical visits, the health coach also continued to meet after the clinical visit (post-visit). We also recorded 8 patient-coach visits, five of which were with the same health coach. All visits occurred in the context of an established relationship between the patient and health coach or clinician. These 18 visits involved 17 patients, 5 health coaches and 6 clinicians. Stimulated recall sessions were not conducted with clinicians for 4 of the 10 medical visits, due to scheduling conflicts. Patients and health coaches each completed stimulated recall sessions for 17 of 18 visits. Characteristics of participants are shown in Table 1. Nearly 60% of patients spoke Spanish as their primary language, and over 70% had been seeing their primary care clinician for more than 5 years. Health coaches were predominately female. All were bilingual in English and Spanish, as were half of the clinicians. Table 2 compares the final categories of activities arrived at after analysis of all transcripts to the initial categories. For example, we noted that in addition to the expected activity of medication review, health coaches often gathered additional information (e.g.,
Please cite this article in press as: C. Johnson, et al., What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.11.017
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C. Johnson et al. / Patient Education and Counseling xxx (2017) xxx–xxx Table 1 Participant Characteristics. Characteristic
N or range
% or mean
11 38 to 84 10
65% 60 59%
5 10 2
29% 59% 12%
7 4 6 12
41% 24% 35% 71%
Health Coaches (n = 5) Female Age (years) Bilingual Spanish/English (n, %)
4 24 to 38 5
80% 29 100%
Clinicians (n = 6) Female Age (years) Bilingual Spanish/English M.D. degree
2 39 to 61 3 4
33% 50 50% 67%
Patients (n = 17) Female Age (years) Spanish speaking Race/ethnicity Black/African-American Latino/Hispanic Asian Education < High school High school Some college Length of relationship with PCP 5 years
taking a blood pressure, reviewing results of laboratory tests, taking an ‘interval history’ of patient activities or changes since the last visit). Thus we created a new category of “gathering additional information” to capture these activities. We divided our original category of ‘patient support’ into ‘emotional support’ and ‘providing practical support” as these appeared to be distinctly
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different activities. We also noted an additional category we termed ‘personal conversation’ to capture talking about shared interests or sharing of personal information. The original category label ‘closing the loop’ refers to a communication model rather than a category of behaviors and was therefore changed to ‘reviewing clinician recommendations.’ Closing the loop is addressed separately below. In total, we identified 9 health coaching activity categories common to both medical visits and patient-coach visits and 2 additional categories unique to the medical visit (identifying goals for the visit and reviewing clinician recommendations). Time spent on activity by category during the 10 medical visits and 8 patient-coach visits are presented in Tables 3a and 3b, respectively. Pre-visits had a median length of almost 13 min, while the clinical portion of the medical visit were approximately twice as long on average. Health coaches participated in 9 of 10 clinical visit, albeit usually briefly. Patient-coach visits were nearly twice as long as pre-visits, on average. Activity categories are described below and sample quotations are in Table 4. Often activities in different categories were interleaved during the visit. For examples, medication review could segue into patient education or review of action plans before returning to medication review. Setting the agenda for the visit with health coach usually lasted less than a minute and was typically initiated by the health coach with patients asked to add items. Agenda setting was seen in 6 of 8 patient-coach visits but was done for only a single medical previsit. Identifying goals for the visit with clinician could be initiated by either the patient or the health coach. Items to be addressed during the visit were generally provided to the clinician and addressed
Table 2 Initial and final categories of health coaching activities. Context Medical Medical Medical Medical Medical Medical Medical Medical Medical Medical Medical
and patient-coach visits visit only (during pre-visit) and patient-coach visits and patient-coach visits and patient-coach visits and patient-coach visits and patient-coach visits and patient-coach visits and patient-coach visits and patient-coach visits visit only (during post-visit)
Final Categories
Initial Categories
Setting agenda with health coach Identifying goals for visit with clinician Medication review and reconciliation Gathering additional information Providing information and education Goal setting and action planning Providing emotional support Providing practical support Personal conversation Bridging between patient and clinician Reviewing clinician recommendations
Same Creating agenda for visit with clinician Same None Same Same Patient Support Patient Support None Same Closing the loop
Table 3a Patient-coach-clinician visit. Time (minutes:seconds) spent by category of health coaching activities. Darker shading indicates activities with longer mean durations. Study number
Duration of pre-visit Duration of medical visit Duration of post-visit Setting agenda with health coach Identifying goals for clinical visit Medication review and reconciliation Gathering additional information Providing information and education Goal setting and action planning Providing emotional support Providing practical support Personal conversation Bridging between patient and clinician Reviewing clinician recommendations *
6
13
14
22
30
31
33
34
36
37
Mean
Median
Range
None 19:19 None
24:13 13:02 None 0:00 2:45 2:11 1:42 4:37 3:26 0:10 1:35 6:48 0:00
25:51 22:46 None 0:20 1:09 8:35 0:00 0:00 8:49 0:15 0:55 4:11 1:27
7:30 16:20 12:10 0:00 3:30 0:00 0:45 0:50 1:05 0:14 3:50 1:15 2:07 3:11
12:48 21:47 None 0:00 1:15 0:00 3:34 1:05 0:00 0:05 0:00 1:24 1:23
3:33 16:25 3:40 0:00 0:04 0:00 0:30 0:12 0:22 0:10 0:10 0:00 1:05 1:01
11:05 34.16 2:10 0:00 0:10 0:43 1:34 1:15 6:35 0:25 1:35 2:55 0:40 0:00
None 40:29 None
None 32:17 None
16:18 46:44 None 0:00 4:39 2:40 0:19 0:34 0:15 0:00 0:12 2:35 2:37
14.49 28:14 1:48 0.03 1:56 2:01 1:38 1:13 2:56 0:11 1:11 2:35 1:13 0:27
12.48 25:38 2:10 0.00 1:15 0:43 1:33 0:50 1:05 0:10 0:55 2:44 1:16 0:00
3:35 25:51 13:02 46:44 0:00–12:10 0:00 0:20 0:04 3:30 0:00 8:35 0:00 4:37 0:00 4:37 0:00 8:49 0:00 0:25 0:00 3:50 0:00 6:48 0:00 2:37 0:00 3:11
0:20
4:37*
1:20
1:12
diabetic foot exam performed during the medical visit.
Please cite this article in press as: C. Johnson, et al., What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.11.017
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Table 3b Patient-coach visit. Time (minutes:seconds) spent by category of health coaching activities. Darker shading indicates activities with longer mean durations. Study number
Patient-coach visit Setting agenda with health coach Medication review and reconciliation Gathering additional information Providing information and education Goal setting and action plans Providing emotional support Providing practical support Personal conversation Bridging patient and clinician
10
16
21
26
27
28
30
35
Mean
Median
Range
38:20 0:35 3:19 2:39 1:16 15:02 1:05 5:40 6:32 1:09
30:16 1:34 1:29 3:42 2:29 14:47 0:49 2:36 0:50 0:00
32:03 0:15 7:02 7:40 2:18 0:43 0:30 6:05 0:00 3:00
21:41 0:00 0:00 1:18 4:12 13:36 1:27 0:52 0:10 0:00
22:42 0:15 1:02 4:49 1:41 5:45 0:55 0:00 0:06 0:42
24:48 0:35 0:00 1:10 4:44 14:01 1:50 0:38 0:52 0:25
27:55 0:00 5:01 1:07 0:28 0:00 0:00 14:35 0:46 5:02
25:04 0:34 1:35 7:45 1:00 2:20 2:39 0:15 2:15 0:00
27:51 2:26 2:26 3:46 2:42 4:47 1:09 3:50 1:26 1:22
26:29 0:25 1:32 3:11 2:24 6:41 1:00 1:44 0:48 0:34
21:41 0:00 0:00 0:37 0:28 0:00 0:00 0:00 0:00 0:00
during the visit. This activity, unique to medical visits, and was observed in all 7 pre-visits, though for 2 pre-visits only a single item was noted. Medication review and reconciliation included coaches asking patients the specific name of medications and confirming the dosage consumed by the patient. In some cases, coaches also asked patients about the purpose of the medication as well. This process revealed if a patient had stopped taking a certain medication without alerting the coach or the clinician or had trouble filling a prescription. Patients also signaled to the health coach if they wanted to alter medication usage. Activities related to patient education and review of health goals often occurred during the medication review. Medication review usually occurred during the beginning of a visit but was sometimes dispersed throughout the visit. This activity occurred in 4 of the 7 pre-visits and 6 of 8 patient-coach visits. Time spent doing medication review was highly variable, ranging from less than a minute to over 8 min. Gathering additional information occurred when coaches asked patients questions and gained information. Common areas were dietary patterns, living situation, significant life events that might cause stress, exercise habits, specific health goals, recent health history, any specific pain or symptoms, and current psychological and emotional health. Taking blood pressure, conducting a foot exam and checking test results were also included in this category. Information gathering was seen in all but 1 visit, ranging in duration from less than a minute to over 7 min. On average, coaches spent more time gathering information during the patient-coach visit (median of over 3 min) than the pre-visit (median of one and a half minutes). Providing information and education was seen in response to patients’ questions and when topics arose during the visit. Examples of information were providing patients with resources to community exercise classes, sharing a recipe for healthy food, directing patients to psychological counseling services and directing patients to medical waste services. Education included explaining the purpose of medications, teaching patients about interpreting vital signs or test results and identifying healthy foods. In providing education, health coaches generally first assessed the patient’s level of understanding as they were trained to do. This activity occurred in all but 1 visit and was substantially longer, on average, in patient-coach visits than in pre-visits. While coaches often assessed patient knowledge before providing new information, we did not observe any examples ‘closing the loop’ in communication by using ‘teach-back’ to reassess the retention and comprehension of new information. Goals and action planning was noted when health coaches and patients talked about patients’ efforts to make changes in behavior such as increasing exercise, decreasing meal sizes, altering their diet, and decreasing stress levels. Health coaches suggested or reinforced concrete health goals including setting a target weight,
38:04 1:34 7:02 7:45 4:44 14:47 2:39 14:35 6:32 5:02
exercising a determined number of hours a week, altering dietary patterns by increasing and decreasing intake of specific food groups, and providing patients with precise vital numbers to work towards achieving. Though often not explicitly referred to as ‘action planning’, this activity was the most common activity during the patient-coach visit, with a median of nearly 7 min, compared to approximately a minute during the pre-visit. Emotional support refers to praise and encouragement for making changes or improving measures of blood pressure or diabetes control. Typically this occurred in the form of brief comments throughout the visit, (e.g., “that’s great!”) but could also be more detailed and extended during the coach-patient visit. Providing practical support included reviewing upcoming appointments, calling a pharmacy to check on a medication, faxing forms or connecting patient with community resources. Examples of practical support were observed during all but 2 visits, generally occupying less than 3 min, though requiring substantially more time (over 14 min) during one patient-coach visit. Personal conversation refers to talking about topics such as shared interests, family, and recent experiences. Nearly twice as much time was spent in personal conversation during the pre-visit, usually while waiting for the clinician to arrive. Bridging between patient and clinician, while not explicitly part of health coach training, was noted to be an important activity in previous analysis of interviews with patients, patient family members, health coaches and clinicians. Bridging during the medical visit refers to coach activities that improved communication and understanding between patient and the clinician, including correcting misunderstandings, providing additional information, advocating for the patient, or supporting a clinician’s recommendation. In the context of the patient-coach visit, bridging refers to the coach stating they would communicate with the clinician on the patient’s behalf. Reviewing clinician recommendations following the clinical visit was observed in only 3 of 10 medical visits. Topics reviewed included medication changes, exercise instructions, new appointments and lab tests. In 2 visits the health coach assessed the patient’s understanding of the clinician’s recommendation (see example in Table 4), though without using teach-back test for patient understanding. 4. Discussion and conclusions 4.1. Discussion Health coaching is emerging as a valuable way to engage patients in their care and improve their health. A growing body of literature now includes conceptual models of health coaching, delineates roles and responsibilities of health coaches, and demonstrates how they can improve patient satisfaction and
Please cite this article in press as: C. Johnson, et al., What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.11.017
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C. Johnson et al. / Patient Education and Counseling xxx (2017) xxx–xxx Table 4 Sample quotes for selected health coaching activities with study identification number. Setting agenda with health coach (#10)
Health coach: Alright. So, today I want to talk about, I’m gonna follow-up on your action plan. Patient: Hmm-hmm. Health coach: Remember we set up an action plan? Patient: Hmm-hmm. Health coach: I also want to talk about your medications. Patient: Yeah. Health coach: So, I took your blood pressure. We’ll talk about that. Patient: Hmm-hmm. Health coach: And your blood sugar. Patient: Hmm-hmm. Health coach: And is there anything you want to talk about? Patient: Oh, [Chuckling] maybe my blood pressure because why it’s like that. Health coach: Okay. Alright, we can talk about that.
Identifying goals for the clinical visit (#22)
Health coach: What are the reasons why you want to see the doctor today? Patient: I want to see the doctor today because I’m always in pain, so much pain. Health coach: Okay, so you want pain meds. Patient: Um hmm. Health coach: Anything else? Patient: No, I have a little knee trouble on the right side. Health coach: Anything else that you want to talk to her about? Patient: Oh, cough medicine. I need some cough medicine bad. Health coach: Anything else you want to talk to her about? Patient: No, that’s about it. Everything else is going pretty good. Health coach: Do you need any refills on any medications? Patient: Blood pressure, high blood pressure. Health coach: Let’s see, do you have any papers or forms or letters that you need her to fill out or sign for you? Patient: No.
Medication review and reconciliation (#21)
Patient: . . . but I can’t find it. So, I haven’t had no blood pressure medicine in about two days . . . I might have a refill, I don’t know. It starts with an L. Health coach: (Lisinopril?) Patient: Uh-huh. Health coach: And hydrochlorothiazide? Patient: That’s the cholesterol? Health coach: That’s for your blood pressure too. Patient: It is? . . . I thought it was for my cholesterol. Health coach: Here, let me write that out for you. Patient: So, they’re both for the blood pressure? Health coach: These are the two medications that you need for your blood pressure. Patient: Okay. So, this one might . . . it must be for the cholesterol? Health coach: Yes. Patient: Okay, that’s the one I take at bed time. But I thought . . . I had it mixed up; I thought that one was for the cholesterol.
Gathering additional information (#27)
Patient: And I feel like a shiver when I inject [insulin] in the morning. I tried it twice, I injected but it gave me shivers . . . . So, I decided I wouldn’t inject, I would just take the pill. Health coach: Okay. Well, yeah, right? And how many times has . . . your sugar came out low? Patient: It happened twice. Health coach: What time did it come down? What time was it when your sugar dropped? Patient: Oh, twelve-forty. Health coach: And what time did you eat that morning? Patient: I had breakfast at nine. Health coach: Okay, very well. Yeah, I’m going to write all this down for the doctor because she also wants to see what . . . what are your numbers and what you are doing and all of that, to see what is . . . if the insulin is working
Providing information and education (#35)
Health coach: Do you remember where the number for your cholesterol should be at? What number? Patient: 130. Health coach: Very good. 130. What is cholesterol? Patient: Well it’s accumulated fat . . . Health coach: What would happen if all of this had fat here [pointing to a picture of the heart]. What would happen? Patient: Well there is a cardiac arrest. Health coach: Why? What happens? Is it [the artery] closed or is it open? Patient: It is closed . . . Health coach: What type of food do you eat that blocks the vein and causes high cholesterol? Patient: Well food that has a lot of fat. Health coach: Like for example what food has a lot of fat?
Goal setting and action planning (#16)
Health coach: Would you like to make a new one, an action plan for exercising? Patient: That’s what I want, to be active so that I...I don’t know, exercising reduces my stress a lot. I love it because . . . so, I focus a lot on dancing and, since I like it, it reduces my stress a lot. Health coach: Right, right. It’s true, exercise reduces stress, sugar levels and blood pressure come down . . . It affects everything.
Providing emotional support (#10)
Health coach: Here you go and keep up the good work. You’re really working hard to bring down your blood pressure by eating better. Patient: Yeah.
Please cite this article in press as: C. Johnson, et al., What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.11.017
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C. Johnson et al. / Patient Education and Counseling xxx (2017) xxx–xxx Health coach: You’re walking. Patient: Yeah. Providing practical support (#30)
[Providing practical support in making an application for low-income housing] Clinician: Right. Um, because on my I wrote the letter. I think you had said that you needed a letter for housing, right? Health coach: I have a copy of the letter here. Patient: Right and my cousin told me they was supposed to respond. Clinician: Let’s fax it again. Um, because we have the number here. So, that is good. That is great. For some reason, that is not in the chart. We should probably copy this these things just to put them in the chart because that is a good string of information. Health coach: Okay. I will. Clinician: So, if you can re-fax it to that number, that would be great. Health coach: Okay.
Personal conversation (#14)
Patient: I like to taste all the spices that are in the pumpkin pie. Man, it’s so good. Health coach: Pumpkin pie’s is so good. I don’t think it’d be that hard to make. Patient: Yeah, it’s not. Health coach: ‘Cause I’ve done sweet potato . . . not a sweet potato pie. Patient: I like sweet potato pie, it’s really good. I love that stuff. I love sweet potato pie. It’s sort of like just like making pumpkin pie, you know . . . Health coach: Yeah, I would think so. Patient: You just use sweet potatoes. I’ve made that a couple of times, homemade, you know, sweet potato pie. Health coach: Do you make your own crust, your own pie crust or do you buy it?
Bridging between patient and clinician (#31) Clinician: The last time we saw you we got you to go to a physical therapist about your knee. Did that ever happen? Patient: I haven’t went yet . . . .I don’t know, everybody end up getting knee replacement and all that stuff, so I’m trying to take care of it myself. Health coach: Do you think the physical therapist would say you have terrible, terrible arthritis, we’re going to need to replace your knee? Patient: Well, I’m just saying what goes on with it, the pain . . . Clinician: So, what are you worried about the physical therapist? What are they going to say to you? Patient: I don’t want them to say that my bone is messed up. Clinician: Can I tell you what the physical therapist is going to say? Patient: What? Clinician: The physical therapists are going to say you have degenerative joint disease, which is, you know, arthritis in your knees . . . And we can teach you some exercises and some tricks as to how to walk with your cane so that it doesn’t get worse as fast as it might. Patient: Yeah. Clinician: It’s not up to the physical therapist to decide whether you need surgery or not. Patient: Okay, I’m going to go . . . Checking for understanding clinician recommendations (#22)
Health coach: Now, she doesn’t want you to be running. Patient: Okay, cool. Health coach: If you don’t want that knee to get worse. Patient: Alright. Health coach: So, instead of running what you can . . . What are you going to do? Patient: Walk fast. Health coach: So, what exercise did she tell you should do? Patient: To lay down and lift my leg up like this . . . Health coach: And . . . okay, and it’s supposed to strengthen this muscle that’s right here that goes down to your knee . . . So, when start doing the exercising you’re making the muscle on top of your legs get stronger.
clinical outcomes for chronic disease [15,19–22]. However we are aware of only one previous study that observed health coaching in practice [34]. This study reported health coaching by peer supporters with diabetes outside the medical setting, which was observed to evaluate the implementation of their recent training. In contrast, our study observed health coaching by medical assistants both at the time of the medical visit and during patient coach visits. This allowed us to assess observed behaviors with those expected based on the content of health coach training and on a previously developed model of health coaching, and to compare the content of coaching during medical visits to activities during one-on-one patient-coach visits. 4.1.1. Fidelity to health coach training Given the costs of implementing training programs for health coaches, it is important to determine to what extent coaches enact the skills they learn. All of the health coach participants in this study received training from the UCSF CEPC [24] [which focused on skill acquisition of specific behaviors (e.g., setting agendas, medication reconciliation, patient education, action planning)
that were aimed at engaging patients in their care. In this study, health coaches demonstrated many, but not all, of the skills that comprised the core of the curriculum. Agenda setting was used, albeit briefly, for most of the health-coach patient visits. In the previsits, health coaches did not set an agenda for the pre-visit itself, but did work with patients to identify goals for the following medical visit. Creating an agenda for the medical visit was usually led by the health coach but always included topics identified by the patient. Medication review and reconciliation with the medications in the medical record is considered a key health coach function in the training program and was observed during most visits, consistent with the one previous direct observation study [35]. Health coaches often combined their review of medications with patient education about the proper use of medications and how they fit with patients’ health goals. Patient education and information sharing also occurred as health coaches gathered additional information from patients. Health coaches were trained to ensure patient understanding of new information by using a strategy known as “ask-tell-ask.” We observed health coaching using this technique when asking patients if they knew their blood
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pressure and HbA1c goals (ask) and then reinforcing correct responses or providing correct information (tell). However, health coaches seldom used teach-back as a way of ensuring that patients understood the information presented. The limited degree to which health coaches checked for patient understanding is consistent with other studies observing whether health coaches [36] and physicians [31] closed the loop with patients. We also observed that although most health coaches checked in on different aspects of patients’ progress in making behavioral changes, there was little time spent developing new action plans, consistent with peer health coaching behavior reported by Goldman et al. [36]. This may be due to the fact that participants had been receiving health coaching for over 6 months; action planning may have occurred earlier in the relationship. 4.1.2. Alignment with conceptual models Behaviors observed in the current study were consistent with the conceptual model developed from a previous analysis of interviews with patients, family members, health coaches and clinicians [35]. Specifically, we observed health coaching behaviors directly related to 4 of the 7 themes noted in this model: patient education, personal support, decision support (goal setting and action planning) and bridging between patient and clinician. Exchanging personal information, such as recipes and information about families, can be interpreted as a process of relationship building, a fifth theme. The other themes in the conceptual model (shared characteristics and availability between visits) would be difficult to directly observe. 4.1.3. Comparison of coaching activities during the medical and the patient-coach visits Categories of coaching activities were identical for medical and patient-coach visits, with the exception of identifying goals for the clinical visit and reviewing clinician’s recommendations observed in the medical visit. Patient-coach visits were nearly twice as long, on average, as pre-visit meetings and focused more on action plans for behavioral changes, on emotional support, and gather additional information about the patient. Coaches participated during the clinical portion for 7 of the 10 medical visits, primarily in ways that helped bridge communication between the patient and clinician. Activities aimed at bridging communication between patients and clinicians were also observed in 5 of the 8 patienthealth coach visits. In contrast to the medical visit, during the patient-coach visits health coaches spent more time on goals and setting action plans and gathering additional information, and less on personal conversation. 4.1.4. Limitations The generalizability of this study is limited in that the patient participants received their primary care at three federally qualified health centers which were part of a single network. Health coaches were all trained at the same program. Also there were only five health coach participants, 3 of whom accounted for the majority of visits. Only interactions taking place in the examination room were recorded. It is possible that health coaches may have had additional interact with the patient outside the examination room. All patients had well established relationships with their health coaches and primary care clinicians; health coaching activities may be different earlier in the relationship. One of the programs that funded the health coach participants was ending soon which may have affected some of the health coaches’ behaviors. In addition, the study did not include the step of checking our results with the study participants (informant feedback or respondent validation).
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4.2. Conclusions While this observation study found that health coaches engage in most of the activities for which they were trained, and which would be expected based on our conceptual models of health coaching, there were important exceptions notably not using teach-back to check understanding and seldom meeting with the patient after the clinical visit. While coaches engaged in similar activities during medical visit as in patient-health coach visits, the relative amount of time spent by type of activity differed substantially. 4.3. Practice implications Our findings have implications for how health coaches are trained and for how best to utilize and support health coaches. For example, teach-back should be more strongly emphasized in health coach training. The lack of consistent use of ‘closing the loop’ may be an issue of the need to vacate the exam room and could be addressed by arranging a different place to meet after the medical. Bridging communication between a patients and their doctor appears to be an important function and should be included in coach training and supported in practice. Most action-planning and medication review was done outside the medical visit, suggesting that separate time is needed, beyond the pre-visit, for this activity. Conflicts of interests None of the authors have any potential conflicts of interest to report. Acknowledgements The authors wish to acknowledge support of the UCSF Center for Excellence in Primary Care, including Dr. Kevin Grumbach and Dr. Thomas Bodenheimer. Research reported in this paper was funded through PatientCentered Outcomes Research Institute (PCORI) Award 1IP2PI000437. The views in this paper are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee. References [1] S. Palmer, I. Tibbs, A. Whybrow, Health coaching to facilitate the promotion of healthy behavior and achievement of health-related goals, Int. J. Health Promot. Educ. 41 (2003) 91–93. [2] K. Kivela, S. Elo, H. Kyngas, M. Kaariainen, The effects of health coaching on adult patients with chronic diseases: a systematic review, Patient Educ. Couns. 97 (2014) 147–157. [3] J.M. Olsen, B.J. Nesbitt, Health coaching to improve healthy lifestyle behaviors: an integrative review, Am. J. Health Promot. 25 (1) (2010) e1–e12. [4] R.R. Wing, R.W. Jeffery, N. Pronk, W.L. Hellerstedt, Effects of a personal trainer and financial incentives on exercise adherence in overweight women in a behavioral weight loss program, Obes. Res. 4 (5) (1996) 457–462. [5] M. Jordan, R.Q. Wolever, K. Lawson, M. Moore, National training and education standards for health and wellness coaching: the path to national certification, Glob. Adv. Health Med. 4 (3) (2015) 46–56. [6] J. Ammentorp, L. Uhrenfeldt, F. Angel, M. Ehrensvard, E.B. Carlsen, P.E. Kofoed, Can life coaching improve health outcomes? A systematic review of intervention studies, BMC Health Serv. Res. 13 (2013) 428. [7] R. Hale, J. Giese, Cost-effectiveness of health coaching: an integrative review, Prof. Case Manag. 22 (5) (2017) 228–238. [8] A. Ishani, N. Greer, B.C. Taylor, L. Kubes, P. Cole, M. Atwood, B. Clothier, N. ErcanFang, Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes: a randomized controlled trial, Diabetes Care 8 (2011) 1689–1694. [9] W. Palmas, D. March, S. Darakjy, S.E. Findley, J. Teresi, O. Carrasquillo, et al., Community health worker interventions to improve glycemic control in
Please cite this article in press as: C. Johnson, et al., What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.11.017
G Model PEC 5838 No. of Pages 8
8
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[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
people with diabetes: a systematic review and meta-Analysis, J. Gen. Intern. Med. 30 (2015) 1004–1. A. Philis-Tsimikas, A. Fortmann, L. Lleva-Ocana, C. Walker, L.C. Gallo, Peer-led diabetes education programs in high-risk Mexican Americans improve glycemic control compared with standard approaches: a Project Dulce promotora randomized trial, Diabetes Care 34 (2011) 1926–1931. American Public Health Association, American Public Health Association, (2017) . (Accessed 12 November 2017) http://www.apha.org/aphacommunities/member-sections/community-health-workers. Kangovi, S., Grande, D., Trinh-Shevrin, C. From rhetoric to reality community health workers in post-reform U.S. health care. New Engl J Med. 215; 372: 2277-79. Association of State and Territorial Health Officials, Community Health Workers (CHWs) Training/certification Standards, Association of State and Territorial Health Officials, 2017. http://www.astho.org/public-policy/publichealth-law/scope-of-practice/chw-certification-standards/, accessed 12 November 2017. T. Bodenheimer, R. Willard-Grace, A. Ghorob, Expanding the roles of medical assistants: who does what in primary care, J. Amer. Med. Assoc. Intern. Med. 174 (2014) 1025–1026. T. Freund, F. Peters-Klimm, C.M. Boyd, C. Mahler, J. Gensichen, A. Erler, et al., Medical assistant-based care management for high-risk patients in small primary care practices: a cluster randomized clinical trial, Ann. Intern. Med. 164 (2016) 323–330. A.M. Adelman, M. Graybill, Integrating a health coach into primary care: reflections from the Penn State Ambulatory Research Network, Ann. Fam. Med. 3 (Suppl 2) (2005) S33–S35. Z. Djuric, M. Segar, C. Orizondo, J. Mann, M. Faison, N. Peddireddy, M. Paletta, A. Locke, Delivery of health coaching by medical assistants in primary care, J. Am Board Fam Med. 30 (2017) 362–370. R.Q. Wolever, M. Jordan, K. Lawson, M. Moore, Advancing a new evidencebased professional in health care: job task analysis for health and wellness coaches, BMC Health Serv. Res. 16 (2016) 205. D.H. Thom, A. Ghorob, D. Hessler, D. DeVore, E. Chen, T.A. Bodenheimer, Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial, Ann. Fam. Med. 11 (2013) 137–144. R. Willard-Grace, D.H. Thom, D. Hessler, T. Bodenheimer, E.H. Chen, Health coaching to improve control of diabetes, hypertension and hyperlipidemia for low-income patients: a randomized controlled trial, Ann. Fam. Med. 28 (2015) 38–45. L. Ruggiero, A. Moadsiri, P. Butler, et al., Supporting diabetes self-care in underserved populations: a randomized pilot study using medical assistant coaches, Diabetes Educ. 36 (2010) 127–131.
[22] R. Benzo, K. Vickers, P.J. Novotny, S. Tucker, J. Hoult, P. Neuenfeldt, et al., Health coaching and chronic obstructive pulmonary disease rehospitalization: a randomized study, Am. J. Respir. Crit. Care Med. 194 (2016) 672–680. [23] R. Thackeray, R.M. Merrill, B.L. Neiger, Disparities in diabetes management practice between racial and ethnic groups in the United States, Diabetes Educ. 30 (2004) 665–675. [24] Center for Excellence in Primary Care (CEPC), Health Coaching Curriculum, CEPC, 2017 (Available at https://cepc.ucsf.edu/health-coaching-0). [25] E.H. Wagner, B.T. Austin, M. Von Korff, Organizing care for patients with chronic illness, Milbank Q. 74 (1996) 511–544. [26] A. Linden, S.W. Butterworth, J.O. Prochaska, Motivational interviewing-based health coaching as a chronic care intervention, J. Eval. Clin. Pract. 16 (2010) 166–174. [27] J.O. Prochaska, W.F. Velicer, The transtheoretical model of health behavior change, Am. J. Health Promotion. 12 (1997) 38–48. [28] A. Bandura, Health promotion by social cognitive means, Health Educ. Behav. 31 (2004) 143–164. [29] J.H. Hibbard, J. Stockard, E.R. Mahoney, M. Tusler, Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers, Health Serv. Res. 39 (4 Pt 1) (2004) 1005–1026. [30] T.T. Ha Dinh, A. Bonner, R. Clark, J. Ramsbotham, S. Hines, The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: a systematic review, JBI Database System Rev. Implement Rep. 14 (1) (2016) 210–247. [31] D. Schillinger, J. Piette, K. Grumbach, F. Wang, C. Wilson, C. Daher, et al., Closing the loop: physician communication with diabetic patients who have low health literacy, Arch. Int. Med. 163 (2003) 83–90. [32] J.B. Averill, Matrix analysis as a complementary analytic strategy in qualitative inquiry, Qual. Health Res. 12 (2002) 855–866. [33] J. Liddle, G. Carlson, K. McKenna, Using a matrix in life transition research, Qual. Health Res. 14 (2004) 1396–1417. [34] N.R. Sperber, M. Sandelowski, Voils Corrine I: Spousal support in a behavior change intervention for cholesterol management, Patient Educ. Counsel. 92 (2013) 121–126. [35] D.H. Thom, J. Wolf, H. Gardner, D. DeVore, M. Lin, A. Ma, Ibarra-Castro A, et al. A qualitative study of how health coaches support patients in making healthrelated decisions and behavioral changes, Ann. Fam. Med. 14 (2016) 509–516. [36] M.L. Goldman, A. Ghorob, D. Hessler, R. Yamamoto, D.H. Thom, T. Bodenheimer, Are low-income peer health coaches able to master and utilize evidence-based health coaching? Ann. Fam. Med. 13 (Supp1) (2015) S36–41.
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Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers Christopher Johnson* , George Saba, Jessica Wolf, Heather Gardner, David H. Thom Department of Family and Community Medicine, University of California, San Francisco School of Medicine, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 July 2017 Received in revised form 15 November 2017 Accepted 24 November 2017
Objective: To examine activities of health coaches during patient medical visits and when meeting oneon-one with patients at 3 urban federally qualified health centers. Methods: Encounters were videotaped and transcribed. Data was analyzed using a matrix analysis approach that allowed a priori identification of expected categories of activity, based on the health coach training model and previously developed conceptual framework, which were modified based on activities observed. Results: A total of 10 medical visits (patient, clinician and health coach), and 8 patient-coach visits were recorded. We identified 9 categories common to both medical and patient-coach visits and 2 categories unique to the medical visit. While observed activities were generally consistent with expected categories, some activities were observed infrequently or not at all. We also observed additional activity categories, including information gathering and personal conversation. The average amount of time spent on some categories of coaching activities differed substantially between medical visits and patient-coach visits. Conclusions: Health coaching activities observed differed in several respects to those expected, and differed between medical visits and coaching only visits. Practice implications: These results provide insights into health coaching behaviors that can be used to inform training and improve utilization of health coaches in practice. © 2017 Elsevier B.V. All rights reserved.
1. Introduction Health coaching is a patient-centered one-to-one process which assists patients in identifying and achieving their healthrelated goals through education and personal support [1–3]. In the U.S., health coaching has developed from or been incorporated into existing several existing support models, including the personal trainer model (typically paid for by individuals) [4–6]; the care or case management model using nurses or other licensed medical care professionals employed by health delivery systems to managing care of complex patients [7,8]; and the model of community health workers [9] (or ‘promotoras’ in Latino communities [10]) who usually work within the public health system to provide community-based care for low-income and vulnerable populations. [11–14] Health coaching by unlicensed
* Corresponding author at: 1001 Potrero Avenue Building 80/83, San Francisco, CA 94110, United States. E-mail address: [email protected] (C. Johnson).
health workers has also been incorporated into team care models to improve primary care for patients with chronic conditions in primary care [2,14–17]. As a member of the patient care team, health coaches assist patients to set goals and follow through on mutually agreed upon ‘action plans’ for behavioral changes [14,17]. While there have been efforts to establish certification and/or licensing requirements for independent, professional health coaches [18], there is no widely accepted certification program for health coaching by unlicensed health workers [13]. Health coaches also may provide patients with health-related information, help them navigate the health care system and make connections to community resources. Health coaching has been shown effective in improving management of diabetes and pulmonary disease and risk factors for cardiovascular disease [2,14,19–22]. Coaches may be particularly valuable in resource poor settings, where low-income communities bear a disproportionate burden of chronic disease and its complications, and are less likely to engage in effective self-management of their conditions [23]. Despite the increasing use of health coaching, there has been little if any direct observation of what coaches do in practice. In the
https://doi.org/10.1016/j.pec.2017.11.017 0738-3991/© 2017 Elsevier B.V. All rights reserved.
Please cite this article in press as: C. Johnson, et al., What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.11.017
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current paper, we look into the ‘black box’ of health coaching activities, using direct observations of health coaches during both medical visits and one-on-one patient-coach visits outside of the context of the medical visit. 2. Methods 2.1. Study design The current study analyzed data from: 1) medical visits that included the patient, clinician and health coach; 2) patient-coach visits–individual meetings between health coaches and patients between medical visits; and 3) stimulated recall sessions–review of the videotapes of each of these types of visits by each participant (patient, health coach, clinician). Data were collected between December 3, 2012 and May 16, 2013. The study was approved by the University of California San Francisco Committee on Human Research (#12-09132). 2.2. Participants and setting The study was conducted at 3 urban public health primary care clinics (federally qualified health centers) serving low-income patients. Health coaches were medical assistants (allied, nonlicensed health workers who perform routine administrative and clinical tasks) who received approximately 40 h of training at the UCSF-CEPC [24]. While the content of the training was based on existing models (Chronic Care Model [25], Motivational Interviewing [26,27], Self-Efficacy [28], and Patient Activation [29], no single theoretical framework determined the content or processes of training. Training included instruction in active listening and nonjudgmental communication; harm reduction, navigating healthcare systems, creating self-management goals, and interactive communication including the use of ‘teach-back’ to assess patient understanding of new information and ‘close the loop’ in communication [30,31]. Health coaches were not trained to interpret clinical results or offer medical advice. 2.3. Recruitment and enrollment Health coaches, identified by clinic managers or other coaches, were contacted via email by a member of the study team. Those interested met with a member of the study team and provided informed consent. Participating coaches identified and made initial contact with patients that they coached. Members of the study team contacted patients expressing an interest in participating, and obtained informed consent prior to data collection. Primary care clinicians (physician, nurse practitioner, or physician assistant) of the participating patients were contacted by the study Principal Investigator (DT). Patients received $10 for the direct observation and $20 for their stimulated recall session. Health coaches and clinicians were paid $50 for participating in stimulated recall sessions. All patients, health coaches and research assistants were bilingual in English and Spanish. 2.4. Data collection Encounters between patients, health coaches and clinicians were videotaped. Videotapes were reviewed during stimulated recall sessions with each of the participants separately, generally within 2 weeks following the encounter. The purpose of the stimulated recall sessions was to allow participants to reflect and elaborate on parts of the encounter. Audio portions of the videotapes of the visits and audio tapes of the stimulated recall sessions were transcribed and personal identifying information was removed. In addition, participants completed a short survey
about demographics and other characteristics, including length of the relationship between the patient and primary care clinician. 2.5. Data analysis Our analytic goal for this paper was to categorize and describe coaching activities observed, informed by our previous study of how health coaches work with patients and our knowledge of the content of the training received by health coaches. We therefore chose an approach known as matrix analysis that allowed us to test the categories of activities we expected against the activities observed and to identify new categories. Matrix analysis [32] has been used in the analysis of qualitative data derived from structured or semi-structured interviews [32–34]. We initially identified categories of health coaching activities based on our knowledge of the health coach training and our previously reported model of how health coaches work with patients [35]. Using neutral descriptive labels for these a priori categories we then created a matrix of categories by visit and ‘mapped’ the content of each of the observed visits into the resulting cells. We created additional categories and modified existing categories as needed to best capture the activities observed. Final categories were chosen by consensus of the primary reviewers and tested for fidelity across all 3 reviewers (CJ, GS, DT). In addition to assessing categories of activities, we also looked for the use of ‘teach-back’ (asking patients to repeat new information in their own words) to close the communication loop. Data was analyzed by 3 members of our study team, a family physician (DT), a clinical psychologist (GS) and a post-baccalaureate pre-medical student (CJ). All transcripts were read by at least 2 study team members. Data from transcripts was entered into individual matrix cells in the form of paraphrased or quoted passages identified by line number to allow us to check back to the original passage. Transcripts for the stimulated recall sessions were reviewed to check our understanding of the content from the direct observations and help resolve any ambiguities from the direct observations, which were rare. Any disagreement in categorization of data was resolved by discussion. We also coded the time spent in each category of health coaching activity by listening to and timing the audio recordings for each encounter. 3. Results We recorded a total of 10 direct observations of medical visits (patient, clinician and health coach), three of which were with the same clinician. In 7 of the medical visits, the health coach met with the patient in a pre-visit, prior to the clinical visit with the doctor or other clinician. In 3 of the medical visits, the health coach also continued to meet after the clinical visit (post-visit). We also recorded 8 patient-coach visits, five of which were with the same health coach. All visits occurred in the context of an established relationship between the patient and health coach or clinician. These 18 visits involved 17 patients, 5 health coaches and 6 clinicians. Stimulated recall sessions were not conducted with clinicians for 4 of the 10 medical visits, due to scheduling conflicts. Patients and health coaches each completed stimulated recall sessions for 17 of 18 visits. Characteristics of participants are shown in Table 1. Nearly 60% of patients spoke Spanish as their primary language, and over 70% had been seeing their primary care clinician for more than 5 years. Health coaches were predominately female. All were bilingual in English and Spanish, as were half of the clinicians. Table 2 compares the final categories of activities arrived at after analysis of all transcripts to the initial categories. For example, we noted that in addition to the expected activity of medication review, health coaches often gathered additional information (e.g.,
Please cite this article in press as: C. Johnson, et al., What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.11.017
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N or range
% or mean
11 38 to 84 10
65% 60 59%
5 10 2
29% 59% 12%
7 4 6 12
41% 24% 35% 71%
Health Coaches (n = 5) Female Age (years) Bilingual Spanish/English (n, %)
4 24 to 38 5
80% 29 100%
Clinicians (n = 6) Female Age (years) Bilingual Spanish/English M.D. degree
2 39 to 61 3 4
33% 50 50% 67%
Patients (n = 17) Female Age (years) Spanish speaking Race/ethnicity Black/African-American Latino/Hispanic Asian Education < High school High school Some college Length of relationship with PCP 5 years
taking a blood pressure, reviewing results of laboratory tests, taking an ‘interval history’ of patient activities or changes since the last visit). Thus we created a new category of “gathering additional information” to capture these activities. We divided our original category of ‘patient support’ into ‘emotional support’ and ‘providing practical support” as these appeared to be distinctly
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different activities. We also noted an additional category we termed ‘personal conversation’ to capture talking about shared interests or sharing of personal information. The original category label ‘closing the loop’ refers to a communication model rather than a category of behaviors and was therefore changed to ‘reviewing clinician recommendations.’ Closing the loop is addressed separately below. In total, we identified 9 health coaching activity categories common to both medical visits and patient-coach visits and 2 additional categories unique to the medical visit (identifying goals for the visit and reviewing clinician recommendations). Time spent on activity by category during the 10 medical visits and 8 patient-coach visits are presented in Tables 3a and 3b, respectively. Pre-visits had a median length of almost 13 min, while the clinical portion of the medical visit were approximately twice as long on average. Health coaches participated in 9 of 10 clinical visit, albeit usually briefly. Patient-coach visits were nearly twice as long as pre-visits, on average. Activity categories are described below and sample quotations are in Table 4. Often activities in different categories were interleaved during the visit. For examples, medication review could segue into patient education or review of action plans before returning to medication review. Setting the agenda for the visit with health coach usually lasted less than a minute and was typically initiated by the health coach with patients asked to add items. Agenda setting was seen in 6 of 8 patient-coach visits but was done for only a single medical previsit. Identifying goals for the visit with clinician could be initiated by either the patient or the health coach. Items to be addressed during the visit were generally provided to the clinician and addressed
Table 2 Initial and final categories of health coaching activities. Context Medical Medical Medical Medical Medical Medical Medical Medical Medical Medical Medical
and patient-coach visits visit only (during pre-visit) and patient-coach visits and patient-coach visits and patient-coach visits and patient-coach visits and patient-coach visits and patient-coach visits and patient-coach visits and patient-coach visits visit only (during post-visit)
Final Categories
Initial Categories
Setting agenda with health coach Identifying goals for visit with clinician Medication review and reconciliation Gathering additional information Providing information and education Goal setting and action planning Providing emotional support Providing practical support Personal conversation Bridging between patient and clinician Reviewing clinician recommendations
Same Creating agenda for visit with clinician Same None Same Same Patient Support Patient Support None Same Closing the loop
Table 3a Patient-coach-clinician visit. Time (minutes:seconds) spent by category of health coaching activities. Darker shading indicates activities with longer mean durations. Study number
Duration of pre-visit Duration of medical visit Duration of post-visit Setting agenda with health coach Identifying goals for clinical visit Medication review and reconciliation Gathering additional information Providing information and education Goal setting and action planning Providing emotional support Providing practical support Personal conversation Bridging between patient and clinician Reviewing clinician recommendations *
6
13
14
22
30
31
33
34
36
37
Mean
Median
Range
None 19:19 None
24:13 13:02 None 0:00 2:45 2:11 1:42 4:37 3:26 0:10 1:35 6:48 0:00
25:51 22:46 None 0:20 1:09 8:35 0:00 0:00 8:49 0:15 0:55 4:11 1:27
7:30 16:20 12:10 0:00 3:30 0:00 0:45 0:50 1:05 0:14 3:50 1:15 2:07 3:11
12:48 21:47 None 0:00 1:15 0:00 3:34 1:05 0:00 0:05 0:00 1:24 1:23
3:33 16:25 3:40 0:00 0:04 0:00 0:30 0:12 0:22 0:10 0:10 0:00 1:05 1:01
11:05 34.16 2:10 0:00 0:10 0:43 1:34 1:15 6:35 0:25 1:35 2:55 0:40 0:00
None 40:29 None
None 32:17 None
16:18 46:44 None 0:00 4:39 2:40 0:19 0:34 0:15 0:00 0:12 2:35 2:37
14.49 28:14 1:48 0.03 1:56 2:01 1:38 1:13 2:56 0:11 1:11 2:35 1:13 0:27
12.48 25:38 2:10 0.00 1:15 0:43 1:33 0:50 1:05 0:10 0:55 2:44 1:16 0:00
3:35 25:51 13:02 46:44 0:00–12:10 0:00 0:20 0:04 3:30 0:00 8:35 0:00 4:37 0:00 4:37 0:00 8:49 0:00 0:25 0:00 3:50 0:00 6:48 0:00 2:37 0:00 3:11
0:20
4:37*
1:20
1:12
diabetic foot exam performed during the medical visit.
Please cite this article in press as: C. Johnson, et al., What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.11.017
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Table 3b Patient-coach visit. Time (minutes:seconds) spent by category of health coaching activities. Darker shading indicates activities with longer mean durations. Study number
Patient-coach visit Setting agenda with health coach Medication review and reconciliation Gathering additional information Providing information and education Goal setting and action plans Providing emotional support Providing practical support Personal conversation Bridging patient and clinician
10
16
21
26
27
28
30
35
Mean
Median
Range
38:20 0:35 3:19 2:39 1:16 15:02 1:05 5:40 6:32 1:09
30:16 1:34 1:29 3:42 2:29 14:47 0:49 2:36 0:50 0:00
32:03 0:15 7:02 7:40 2:18 0:43 0:30 6:05 0:00 3:00
21:41 0:00 0:00 1:18 4:12 13:36 1:27 0:52 0:10 0:00
22:42 0:15 1:02 4:49 1:41 5:45 0:55 0:00 0:06 0:42
24:48 0:35 0:00 1:10 4:44 14:01 1:50 0:38 0:52 0:25
27:55 0:00 5:01 1:07 0:28 0:00 0:00 14:35 0:46 5:02
25:04 0:34 1:35 7:45 1:00 2:20 2:39 0:15 2:15 0:00
27:51 2:26 2:26 3:46 2:42 4:47 1:09 3:50 1:26 1:22
26:29 0:25 1:32 3:11 2:24 6:41 1:00 1:44 0:48 0:34
21:41 0:00 0:00 0:37 0:28 0:00 0:00 0:00 0:00 0:00
during the visit. This activity, unique to medical visits, and was observed in all 7 pre-visits, though for 2 pre-visits only a single item was noted. Medication review and reconciliation included coaches asking patients the specific name of medications and confirming the dosage consumed by the patient. In some cases, coaches also asked patients about the purpose of the medication as well. This process revealed if a patient had stopped taking a certain medication without alerting the coach or the clinician or had trouble filling a prescription. Patients also signaled to the health coach if they wanted to alter medication usage. Activities related to patient education and review of health goals often occurred during the medication review. Medication review usually occurred during the beginning of a visit but was sometimes dispersed throughout the visit. This activity occurred in 4 of the 7 pre-visits and 6 of 8 patient-coach visits. Time spent doing medication review was highly variable, ranging from less than a minute to over 8 min. Gathering additional information occurred when coaches asked patients questions and gained information. Common areas were dietary patterns, living situation, significant life events that might cause stress, exercise habits, specific health goals, recent health history, any specific pain or symptoms, and current psychological and emotional health. Taking blood pressure, conducting a foot exam and checking test results were also included in this category. Information gathering was seen in all but 1 visit, ranging in duration from less than a minute to over 7 min. On average, coaches spent more time gathering information during the patient-coach visit (median of over 3 min) than the pre-visit (median of one and a half minutes). Providing information and education was seen in response to patients’ questions and when topics arose during the visit. Examples of information were providing patients with resources to community exercise classes, sharing a recipe for healthy food, directing patients to psychological counseling services and directing patients to medical waste services. Education included explaining the purpose of medications, teaching patients about interpreting vital signs or test results and identifying healthy foods. In providing education, health coaches generally first assessed the patient’s level of understanding as they were trained to do. This activity occurred in all but 1 visit and was substantially longer, on average, in patient-coach visits than in pre-visits. While coaches often assessed patient knowledge before providing new information, we did not observe any examples ‘closing the loop’ in communication by using ‘teach-back’ to reassess the retention and comprehension of new information. Goals and action planning was noted when health coaches and patients talked about patients’ efforts to make changes in behavior such as increasing exercise, decreasing meal sizes, altering their diet, and decreasing stress levels. Health coaches suggested or reinforced concrete health goals including setting a target weight,
38:04 1:34 7:02 7:45 4:44 14:47 2:39 14:35 6:32 5:02
exercising a determined number of hours a week, altering dietary patterns by increasing and decreasing intake of specific food groups, and providing patients with precise vital numbers to work towards achieving. Though often not explicitly referred to as ‘action planning’, this activity was the most common activity during the patient-coach visit, with a median of nearly 7 min, compared to approximately a minute during the pre-visit. Emotional support refers to praise and encouragement for making changes or improving measures of blood pressure or diabetes control. Typically this occurred in the form of brief comments throughout the visit, (e.g., “that’s great!”) but could also be more detailed and extended during the coach-patient visit. Providing practical support included reviewing upcoming appointments, calling a pharmacy to check on a medication, faxing forms or connecting patient with community resources. Examples of practical support were observed during all but 2 visits, generally occupying less than 3 min, though requiring substantially more time (over 14 min) during one patient-coach visit. Personal conversation refers to talking about topics such as shared interests, family, and recent experiences. Nearly twice as much time was spent in personal conversation during the pre-visit, usually while waiting for the clinician to arrive. Bridging between patient and clinician, while not explicitly part of health coach training, was noted to be an important activity in previous analysis of interviews with patients, patient family members, health coaches and clinicians. Bridging during the medical visit refers to coach activities that improved communication and understanding between patient and the clinician, including correcting misunderstandings, providing additional information, advocating for the patient, or supporting a clinician’s recommendation. In the context of the patient-coach visit, bridging refers to the coach stating they would communicate with the clinician on the patient’s behalf. Reviewing clinician recommendations following the clinical visit was observed in only 3 of 10 medical visits. Topics reviewed included medication changes, exercise instructions, new appointments and lab tests. In 2 visits the health coach assessed the patient’s understanding of the clinician’s recommendation (see example in Table 4), though without using teach-back test for patient understanding. 4. Discussion and conclusions 4.1. Discussion Health coaching is emerging as a valuable way to engage patients in their care and improve their health. A growing body of literature now includes conceptual models of health coaching, delineates roles and responsibilities of health coaches, and demonstrates how they can improve patient satisfaction and
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C. Johnson et al. / Patient Education and Counseling xxx (2017) xxx–xxx Table 4 Sample quotes for selected health coaching activities with study identification number. Setting agenda with health coach (#10)
Health coach: Alright. So, today I want to talk about, I’m gonna follow-up on your action plan. Patient: Hmm-hmm. Health coach: Remember we set up an action plan? Patient: Hmm-hmm. Health coach: I also want to talk about your medications. Patient: Yeah. Health coach: So, I took your blood pressure. We’ll talk about that. Patient: Hmm-hmm. Health coach: And your blood sugar. Patient: Hmm-hmm. Health coach: And is there anything you want to talk about? Patient: Oh, [Chuckling] maybe my blood pressure because why it’s like that. Health coach: Okay. Alright, we can talk about that.
Identifying goals for the clinical visit (#22)
Health coach: What are the reasons why you want to see the doctor today? Patient: I want to see the doctor today because I’m always in pain, so much pain. Health coach: Okay, so you want pain meds. Patient: Um hmm. Health coach: Anything else? Patient: No, I have a little knee trouble on the right side. Health coach: Anything else that you want to talk to her about? Patient: Oh, cough medicine. I need some cough medicine bad. Health coach: Anything else you want to talk to her about? Patient: No, that’s about it. Everything else is going pretty good. Health coach: Do you need any refills on any medications? Patient: Blood pressure, high blood pressure. Health coach: Let’s see, do you have any papers or forms or letters that you need her to fill out or sign for you? Patient: No.
Medication review and reconciliation (#21)
Patient: . . . but I can’t find it. So, I haven’t had no blood pressure medicine in about two days . . . I might have a refill, I don’t know. It starts with an L. Health coach: (Lisinopril?) Patient: Uh-huh. Health coach: And hydrochlorothiazide? Patient: That’s the cholesterol? Health coach: That’s for your blood pressure too. Patient: It is? . . . I thought it was for my cholesterol. Health coach: Here, let me write that out for you. Patient: So, they’re both for the blood pressure? Health coach: These are the two medications that you need for your blood pressure. Patient: Okay. So, this one might . . . it must be for the cholesterol? Health coach: Yes. Patient: Okay, that’s the one I take at bed time. But I thought . . . I had it mixed up; I thought that one was for the cholesterol.
Gathering additional information (#27)
Patient: And I feel like a shiver when I inject [insulin] in the morning. I tried it twice, I injected but it gave me shivers . . . . So, I decided I wouldn’t inject, I would just take the pill. Health coach: Okay. Well, yeah, right? And how many times has . . . your sugar came out low? Patient: It happened twice. Health coach: What time did it come down? What time was it when your sugar dropped? Patient: Oh, twelve-forty. Health coach: And what time did you eat that morning? Patient: I had breakfast at nine. Health coach: Okay, very well. Yeah, I’m going to write all this down for the doctor because she also wants to see what . . . what are your numbers and what you are doing and all of that, to see what is . . . if the insulin is working
Providing information and education (#35)
Health coach: Do you remember where the number for your cholesterol should be at? What number? Patient: 130. Health coach: Very good. 130. What is cholesterol? Patient: Well it’s accumulated fat . . . Health coach: What would happen if all of this had fat here [pointing to a picture of the heart]. What would happen? Patient: Well there is a cardiac arrest. Health coach: Why? What happens? Is it [the artery] closed or is it open? Patient: It is closed . . . Health coach: What type of food do you eat that blocks the vein and causes high cholesterol? Patient: Well food that has a lot of fat. Health coach: Like for example what food has a lot of fat?
Goal setting and action planning (#16)
Health coach: Would you like to make a new one, an action plan for exercising? Patient: That’s what I want, to be active so that I...I don’t know, exercising reduces my stress a lot. I love it because . . . so, I focus a lot on dancing and, since I like it, it reduces my stress a lot. Health coach: Right, right. It’s true, exercise reduces stress, sugar levels and blood pressure come down . . . It affects everything.
Providing emotional support (#10)
Health coach: Here you go and keep up the good work. You’re really working hard to bring down your blood pressure by eating better. Patient: Yeah.
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C. Johnson et al. / Patient Education and Counseling xxx (2017) xxx–xxx Health coach: You’re walking. Patient: Yeah. Providing practical support (#30)
[Providing practical support in making an application for low-income housing] Clinician: Right. Um, because on my I wrote the letter. I think you had said that you needed a letter for housing, right? Health coach: I have a copy of the letter here. Patient: Right and my cousin told me they was supposed to respond. Clinician: Let’s fax it again. Um, because we have the number here. So, that is good. That is great. For some reason, that is not in the chart. We should probably copy this these things just to put them in the chart because that is a good string of information. Health coach: Okay. I will. Clinician: So, if you can re-fax it to that number, that would be great. Health coach: Okay.
Personal conversation (#14)
Patient: I like to taste all the spices that are in the pumpkin pie. Man, it’s so good. Health coach: Pumpkin pie’s is so good. I don’t think it’d be that hard to make. Patient: Yeah, it’s not. Health coach: ‘Cause I’ve done sweet potato . . . not a sweet potato pie. Patient: I like sweet potato pie, it’s really good. I love that stuff. I love sweet potato pie. It’s sort of like just like making pumpkin pie, you know . . . Health coach: Yeah, I would think so. Patient: You just use sweet potatoes. I’ve made that a couple of times, homemade, you know, sweet potato pie. Health coach: Do you make your own crust, your own pie crust or do you buy it?
Bridging between patient and clinician (#31) Clinician: The last time we saw you we got you to go to a physical therapist about your knee. Did that ever happen? Patient: I haven’t went yet . . . .I don’t know, everybody end up getting knee replacement and all that stuff, so I’m trying to take care of it myself. Health coach: Do you think the physical therapist would say you have terrible, terrible arthritis, we’re going to need to replace your knee? Patient: Well, I’m just saying what goes on with it, the pain . . . Clinician: So, what are you worried about the physical therapist? What are they going to say to you? Patient: I don’t want them to say that my bone is messed up. Clinician: Can I tell you what the physical therapist is going to say? Patient: What? Clinician: The physical therapists are going to say you have degenerative joint disease, which is, you know, arthritis in your knees . . . And we can teach you some exercises and some tricks as to how to walk with your cane so that it doesn’t get worse as fast as it might. Patient: Yeah. Clinician: It’s not up to the physical therapist to decide whether you need surgery or not. Patient: Okay, I’m going to go . . . Checking for understanding clinician recommendations (#22)
Health coach: Now, she doesn’t want you to be running. Patient: Okay, cool. Health coach: If you don’t want that knee to get worse. Patient: Alright. Health coach: So, instead of running what you can . . . What are you going to do? Patient: Walk fast. Health coach: So, what exercise did she tell you should do? Patient: To lay down and lift my leg up like this . . . Health coach: And . . . okay, and it’s supposed to strengthen this muscle that’s right here that goes down to your knee . . . So, when start doing the exercising you’re making the muscle on top of your legs get stronger.
clinical outcomes for chronic disease [15,19–22]. However we are aware of only one previous study that observed health coaching in practice [34]. This study reported health coaching by peer supporters with diabetes outside the medical setting, which was observed to evaluate the implementation of their recent training. In contrast, our study observed health coaching by medical assistants both at the time of the medical visit and during patient coach visits. This allowed us to assess observed behaviors with those expected based on the content of health coach training and on a previously developed model of health coaching, and to compare the content of coaching during medical visits to activities during one-on-one patient-coach visits. 4.1.1. Fidelity to health coach training Given the costs of implementing training programs for health coaches, it is important to determine to what extent coaches enact the skills they learn. All of the health coach participants in this study received training from the UCSF CEPC [24] [which focused on skill acquisition of specific behaviors (e.g., setting agendas, medication reconciliation, patient education, action planning)
that were aimed at engaging patients in their care. In this study, health coaches demonstrated many, but not all, of the skills that comprised the core of the curriculum. Agenda setting was used, albeit briefly, for most of the health-coach patient visits. In the previsits, health coaches did not set an agenda for the pre-visit itself, but did work with patients to identify goals for the following medical visit. Creating an agenda for the medical visit was usually led by the health coach but always included topics identified by the patient. Medication review and reconciliation with the medications in the medical record is considered a key health coach function in the training program and was observed during most visits, consistent with the one previous direct observation study [35]. Health coaches often combined their review of medications with patient education about the proper use of medications and how they fit with patients’ health goals. Patient education and information sharing also occurred as health coaches gathered additional information from patients. Health coaches were trained to ensure patient understanding of new information by using a strategy known as “ask-tell-ask.” We observed health coaching using this technique when asking patients if they knew their blood
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pressure and HbA1c goals (ask) and then reinforcing correct responses or providing correct information (tell). However, health coaches seldom used teach-back as a way of ensuring that patients understood the information presented. The limited degree to which health coaches checked for patient understanding is consistent with other studies observing whether health coaches [36] and physicians [31] closed the loop with patients. We also observed that although most health coaches checked in on different aspects of patients’ progress in making behavioral changes, there was little time spent developing new action plans, consistent with peer health coaching behavior reported by Goldman et al. [36]. This may be due to the fact that participants had been receiving health coaching for over 6 months; action planning may have occurred earlier in the relationship. 4.1.2. Alignment with conceptual models Behaviors observed in the current study were consistent with the conceptual model developed from a previous analysis of interviews with patients, family members, health coaches and clinicians [35]. Specifically, we observed health coaching behaviors directly related to 4 of the 7 themes noted in this model: patient education, personal support, decision support (goal setting and action planning) and bridging between patient and clinician. Exchanging personal information, such as recipes and information about families, can be interpreted as a process of relationship building, a fifth theme. The other themes in the conceptual model (shared characteristics and availability between visits) would be difficult to directly observe. 4.1.3. Comparison of coaching activities during the medical and the patient-coach visits Categories of coaching activities were identical for medical and patient-coach visits, with the exception of identifying goals for the clinical visit and reviewing clinician’s recommendations observed in the medical visit. Patient-coach visits were nearly twice as long, on average, as pre-visit meetings and focused more on action plans for behavioral changes, on emotional support, and gather additional information about the patient. Coaches participated during the clinical portion for 7 of the 10 medical visits, primarily in ways that helped bridge communication between the patient and clinician. Activities aimed at bridging communication between patients and clinicians were also observed in 5 of the 8 patienthealth coach visits. In contrast to the medical visit, during the patient-coach visits health coaches spent more time on goals and setting action plans and gathering additional information, and less on personal conversation. 4.1.4. Limitations The generalizability of this study is limited in that the patient participants received their primary care at three federally qualified health centers which were part of a single network. Health coaches were all trained at the same program. Also there were only five health coach participants, 3 of whom accounted for the majority of visits. Only interactions taking place in the examination room were recorded. It is possible that health coaches may have had additional interact with the patient outside the examination room. All patients had well established relationships with their health coaches and primary care clinicians; health coaching activities may be different earlier in the relationship. One of the programs that funded the health coach participants was ending soon which may have affected some of the health coaches’ behaviors. In addition, the study did not include the step of checking our results with the study participants (informant feedback or respondent validation).
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4.2. Conclusions While this observation study found that health coaches engage in most of the activities for which they were trained, and which would be expected based on our conceptual models of health coaching, there were important exceptions notably not using teach-back to check understanding and seldom meeting with the patient after the clinical visit. While coaches engaged in similar activities during medical visit as in patient-health coach visits, the relative amount of time spent by type of activity differed substantially. 4.3. Practice implications Our findings have implications for how health coaches are trained and for how best to utilize and support health coaches. For example, teach-back should be more strongly emphasized in health coach training. The lack of consistent use of ‘closing the loop’ may be an issue of the need to vacate the exam room and could be addressed by arranging a different place to meet after the medical. Bridging communication between a patients and their doctor appears to be an important function and should be included in coach training and supported in practice. Most action-planning and medication review was done outside the medical visit, suggesting that separate time is needed, beyond the pre-visit, for this activity. Conflicts of interests None of the authors have any potential conflicts of interest to report. Acknowledgements The authors wish to acknowledge support of the UCSF Center for Excellence in Primary Care, including Dr. Kevin Grumbach and Dr. Thomas Bodenheimer. Research reported in this paper was funded through PatientCentered Outcomes Research Institute (PCORI) Award 1IP2PI000437. The views in this paper are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee. References [1] S. Palmer, I. Tibbs, A. Whybrow, Health coaching to facilitate the promotion of healthy behavior and achievement of health-related goals, Int. J. Health Promot. Educ. 41 (2003) 91–93. [2] K. Kivela, S. Elo, H. Kyngas, M. Kaariainen, The effects of health coaching on adult patients with chronic diseases: a systematic review, Patient Educ. Couns. 97 (2014) 147–157. [3] J.M. Olsen, B.J. Nesbitt, Health coaching to improve healthy lifestyle behaviors: an integrative review, Am. J. Health Promot. 25 (1) (2010) e1–e12. [4] R.R. Wing, R.W. Jeffery, N. Pronk, W.L. Hellerstedt, Effects of a personal trainer and financial incentives on exercise adherence in overweight women in a behavioral weight loss program, Obes. Res. 4 (5) (1996) 457–462. [5] M. Jordan, R.Q. Wolever, K. Lawson, M. Moore, National training and education standards for health and wellness coaching: the path to national certification, Glob. Adv. Health Med. 4 (3) (2015) 46–56. [6] J. Ammentorp, L. Uhrenfeldt, F. Angel, M. Ehrensvard, E.B. Carlsen, P.E. Kofoed, Can life coaching improve health outcomes? A systematic review of intervention studies, BMC Health Serv. Res. 13 (2013) 428. [7] R. Hale, J. Giese, Cost-effectiveness of health coaching: an integrative review, Prof. Case Manag. 22 (5) (2017) 228–238. [8] A. Ishani, N. Greer, B.C. Taylor, L. Kubes, P. Cole, M. Atwood, B. Clothier, N. ErcanFang, Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes: a randomized controlled trial, Diabetes Care 8 (2011) 1689–1694. [9] W. Palmas, D. March, S. Darakjy, S.E. Findley, J. Teresi, O. Carrasquillo, et al., Community health worker interventions to improve glycemic control in
Please cite this article in press as: C. Johnson, et al., What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.11.017
G Model PEC 5838 No. of Pages 8
8
C. Johnson et al. / Patient Education and Counseling xxx (2017) xxx–xxx
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
people with diabetes: a systematic review and meta-Analysis, J. Gen. Intern. Med. 30 (2015) 1004–1. A. Philis-Tsimikas, A. Fortmann, L. Lleva-Ocana, C. Walker, L.C. Gallo, Peer-led diabetes education programs in high-risk Mexican Americans improve glycemic control compared with standard approaches: a Project Dulce promotora randomized trial, Diabetes Care 34 (2011) 1926–1931. American Public Health Association, American Public Health Association, (2017) . (Accessed 12 November 2017) http://www.apha.org/aphacommunities/member-sections/community-health-workers. Kangovi, S., Grande, D., Trinh-Shevrin, C. From rhetoric to reality community health workers in post-reform U.S. health care. New Engl J Med. 215; 372: 2277-79. Association of State and Territorial Health Officials, Community Health Workers (CHWs) Training/certification Standards, Association of State and Territorial Health Officials, 2017. http://www.astho.org/public-policy/publichealth-law/scope-of-practice/chw-certification-standards/, accessed 12 November 2017. T. Bodenheimer, R. Willard-Grace, A. Ghorob, Expanding the roles of medical assistants: who does what in primary care, J. Amer. Med. Assoc. Intern. Med. 174 (2014) 1025–1026. T. Freund, F. Peters-Klimm, C.M. Boyd, C. Mahler, J. Gensichen, A. Erler, et al., Medical assistant-based care management for high-risk patients in small primary care practices: a cluster randomized clinical trial, Ann. Intern. Med. 164 (2016) 323–330. A.M. Adelman, M. Graybill, Integrating a health coach into primary care: reflections from the Penn State Ambulatory Research Network, Ann. Fam. Med. 3 (Suppl 2) (2005) S33–S35. Z. Djuric, M. Segar, C. Orizondo, J. Mann, M. Faison, N. Peddireddy, M. Paletta, A. Locke, Delivery of health coaching by medical assistants in primary care, J. Am Board Fam Med. 30 (2017) 362–370. R.Q. Wolever, M. Jordan, K. Lawson, M. Moore, Advancing a new evidencebased professional in health care: job task analysis for health and wellness coaches, BMC Health Serv. Res. 16 (2016) 205. D.H. Thom, A. Ghorob, D. Hessler, D. DeVore, E. Chen, T.A. Bodenheimer, Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial, Ann. Fam. Med. 11 (2013) 137–144. R. Willard-Grace, D.H. Thom, D. Hessler, T. Bodenheimer, E.H. Chen, Health coaching to improve control of diabetes, hypertension and hyperlipidemia for low-income patients: a randomized controlled trial, Ann. Fam. Med. 28 (2015) 38–45. L. Ruggiero, A. Moadsiri, P. Butler, et al., Supporting diabetes self-care in underserved populations: a randomized pilot study using medical assistant coaches, Diabetes Educ. 36 (2010) 127–131.
[22] R. Benzo, K. Vickers, P.J. Novotny, S. Tucker, J. Hoult, P. Neuenfeldt, et al., Health coaching and chronic obstructive pulmonary disease rehospitalization: a randomized study, Am. J. Respir. Crit. Care Med. 194 (2016) 672–680. [23] R. Thackeray, R.M. Merrill, B.L. Neiger, Disparities in diabetes management practice between racial and ethnic groups in the United States, Diabetes Educ. 30 (2004) 665–675. [24] Center for Excellence in Primary Care (CEPC), Health Coaching Curriculum, CEPC, 2017 (Available at https://cepc.ucsf.edu/health-coaching-0). [25] E.H. Wagner, B.T. Austin, M. Von Korff, Organizing care for patients with chronic illness, Milbank Q. 74 (1996) 511–544. [26] A. Linden, S.W. Butterworth, J.O. Prochaska, Motivational interviewing-based health coaching as a chronic care intervention, J. Eval. Clin. Pract. 16 (2010) 166–174. [27] J.O. Prochaska, W.F. Velicer, The transtheoretical model of health behavior change, Am. J. Health Promotion. 12 (1997) 38–48. [28] A. Bandura, Health promotion by social cognitive means, Health Educ. Behav. 31 (2004) 143–164. [29] J.H. Hibbard, J. Stockard, E.R. Mahoney, M. Tusler, Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers, Health Serv. Res. 39 (4 Pt 1) (2004) 1005–1026. [30] T.T. Ha Dinh, A. Bonner, R. Clark, J. Ramsbotham, S. Hines, The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: a systematic review, JBI Database System Rev. Implement Rep. 14 (1) (2016) 210–247. [31] D. Schillinger, J. Piette, K. Grumbach, F. Wang, C. Wilson, C. Daher, et al., Closing the loop: physician communication with diabetic patients who have low health literacy, Arch. Int. Med. 163 (2003) 83–90. [32] J.B. Averill, Matrix analysis as a complementary analytic strategy in qualitative inquiry, Qual. Health Res. 12 (2002) 855–866. [33] J. Liddle, G. Carlson, K. McKenna, Using a matrix in life transition research, Qual. Health Res. 14 (2004) 1396–1417. [34] N.R. Sperber, M. Sandelowski, Voils Corrine I: Spousal support in a behavior change intervention for cholesterol management, Patient Educ. Counsel. 92 (2013) 121–126. [35] D.H. Thom, J. Wolf, H. Gardner, D. DeVore, M. Lin, A. Ma, Ibarra-Castro A, et al. A qualitative study of how health coaches support patients in making healthrelated decisions and behavioral changes, Ann. Fam. Med. 14 (2016) 509–516. [36] M.L. Goldman, A. Ghorob, D. Hessler, R. Yamamoto, D.H. Thom, T. Bodenheimer, Are low-income peer health coaches able to master and utilize evidence-based health coaching? Ann. Fam. Med. 13 (Supp1) (2015) S36–41.
Please cite this article in press as: C. Johnson, et al., What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.11.017