- Email: [email protected]
Health Coaching and the Management of Hypertension
BRIEF REPORT
Health Coaching and the Management of Hypertension Darlene Crittenden, DNP, FNP-BC, Sherry Seibenhener, DNP, FNP-BC, and Bernita Hamilton, PhD, RN ABSTRACT
Despite the multiple medications available for the management of hypertension (HTN), control remains suboptimal. The American Heart Association predicts a 9.9% increase in patients with HTN by 2030. Using a prospective prepost design, this pilot study used the health coaching model to examine the impact of health coaching on lifestyle modification in the management of HTN in a primary care setting. Study results showed health coaching as a promising approach for the management of HTN, demonstrated by a reduction of both systolic and diastolic blood pressure. Barriers encountered during the study revealed patient participation in managing HTN depended on having the necessary tools, education, and a holistic care approach. Keywords: health coach, hypertension, lifestyle modification Ó 2017 Elsevier Inc. All rights reserved.
C
hronic hypertension (HTN) is a major risk factor for cardiovascular disease; is the leading cause of death in the United States; and is highly associated with first heart attacks, first strokes, and congestive heart failure.1 Yet, despite the multiple medications available for the management of HTN, control remains suboptimal.2 The American Heart Association3; American Stroke Association4; and Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure5 recommend lifestyle modification (LSM) such as weight control; medication adherence; exercise; and a well-balanced, low-salt diet in their guidelines for the management of HTN. As shown by Go et al,1 evidence supports that LSM has a positive effect on blood pressure (BP) control, rigidity of the heart, and organ damage triggered by uncontrolled HTN. Providers are consistently lacking in the performance of patient LSM assessments for multiple reasons.6 A focus group study identified patient noncompliance and lack of engagement as barriers to providers’ performance of LSM assessments.7 Conversely, noncompliance and lack of engagement could be eliminated by providing patients with the tools and education necessary to become active participants in the management of their illness. As www.npjournal.org
stated by Whyte,8 improved behaviors are likely to occur when information is provided along with methods that inspire change. STUDY OVERVIEW
The pilot study was conducted at a privately owned family practice physician’s office. A nurse practitioner (NP) served as the health coach and the principal investigator of the study. Approval for the study was obtained from the institutional review board and the clinic physician. Participants were recruited by responding to a flyer while waiting for their scheduled office visit. Inclusion criteria consisted of patients 19 years of age and older with a medical diagnosis of HTN only. The prospective prepost design consisted of the health coach providing individualized education about HTN based on the Measure Up/Pressure Down Toolkit9 and assessed medication adherence using the Morisky Medication Adherence Scale 8.10 Based on Pender’s Health Promotion Model,11 participants were instructed to choose an LSM activity they felt was achievable, therefore giving value to their results. Lastly, participants were asked to take their BP 3 times a week. Pre- and postdata consisted of assessing participants’ BP, weight, understanding/knowledge of HTN and medications, The Journal for Nurse Practitioners - JNP
e1
and whether they felt a health coach would impact the management of their HTN. Predata information was collected during the scheduled office visit. Over an 8-week period, the health coach conducted biweekly phone calls to analyze patients’ perceived barriers to initiation and continuation of LSM activities and management of their HTN. Selfreported BP measurements were reviewed. Individualized education was conducted. Postintervention data were collected from patients returning to the office for a final study visit, from the patients’ medical record if they were unable to return to the office for their final visit, or by phone if the patient did not have access to transportation. OUTCOMES
The sample consisted of 21 adults 31 to 73 years old with an established primary diagnosis of HTN. The sample was mostly female (76.2%, n ¼ 16), greater than 50 years old (81%, n ¼ 17), and representative of the clinic population. As shown in Table 1, participants selected a variety of LSM plans for control of BP and improvement of health. Project findings support health coaching as a promising model for sustaining patient engagement in selected LSM plans and medication adherence for improved BP outcomes. Before health coaching, 12 (57.1%) participants reported unawareness of their BP goal, 14 (66.7%) reported nonadherence to any LSM recommendations on a regular basis, and 17 (81%) reported low adherence to their medication plan. After health coaching, participants reported awareness of their target BP (90.5%, n ¼ 19) and indicated health
Table 1. Frequencies of Lifestyle Modification (LSM) Plan (N [ 21) n
%
Weight control
1
4.8
Regular exercise
9
42.9
Dash diet
2
9.5
No added salt
5
23.8
Decrease tobacco
3
14.3
1
4.8
LSM plans
Manage stress
e2
The Journal for Nurse Practitioners - JNP
coaching improved adherence to LSM and medications (81%, n ¼ 17). Chi-square analysis confirmed an increased commitment to participating in the management of their HTN (c21 ¼ 5.250, P < .05) and medication compliance (c24, ¼ 10.7222, P < .05). Paired sample t tests revealed a significant difference in the pre (mean ¼ 133.09, SD ¼ 15.36) and post (mean ¼ 125.33, SD ¼ 12.57) health coaching systolic BP (t20 ¼ 3.144; P < .01; 95% confidence interval, 2.61-12.91). Although there was no statistical significance, the diastolic BP decreased after intervention. BARRIERS
During the project, barriers threatened the achievement of project goals. Not all participants had access to home BP monitors and relied on transportation to community resources for BP monitoring. Those with home BP monitors reported the most regularly scheduled assessments. Moreover, visual affirmation of BP results confirmed the effectiveness of lifestyle changes and encouraged continued compliance, whereas those without BP monitors reported that not knowing their BP measurements left them ambivalent or discouraged about continuing LSM activities. Family support was an integral part of participant adherence to LSM. Participants relied on family members for help with grocery shopping, handling stressful behaviors, and encouraging exercise. However, health coaching focused solely on the participant. In retrospect, the inclusion of significant caregivers in the health coaching process could reinforce and encourage LSM. The target population for this project was patients from 1 primary care setting with a sole diagnosis of HTN. Including participants with a sole diagnosis of HTN resulted in the exclusion of patients with other chronic health problems such as diabetes. The small sample size and participants’ selection of varied LSM activities limited postintervention comparative analysis of lifestyle activities. IMPLICATIONS
The sustainability of health coaching is feasible in a primary care setting. Each participant in this study required 15 minutes of coaching, which equates to 4 Volume
-,
Issue
-, -/-
2017
patients per hour every other week to achieve positive outcomes. Although health coaching is not billable through Medicare, Medicare is adapting to the changes in health care by reimbursing for certain behavioral health interventions.12 Per the Centers for Medicare and Medicaid Services,12 follow-up phone calls/office visits are reimbursable based on outcomes on an individual basis. Additionally, there are certain illnesses that are closely associated to HTN that have billable codes for LSM education, namely, diabetes, kidney disease, and cardiovascular disease.13 This scenario heightens the urgency for NPs to take a stand for better patient outcomes through billable services for LSM in the management of HTN. Some third-party payers reimburse for education on LSM. As of January 15, 2017, Cigna insurance reimburses for preventive interventions. The interventions are described as health coaching but not named as such. The codes necessary for billing have been established, and HTN is included.14 Health care is transitioning to the community setting. Plans must be geared toward teaching patients how to actively participate in the management of their conditions more effectively. In response to a national strategy for quality improvement in patient health outcomes and population health, the US Department of Health and Human Services launched a national initiative aimed at preventing 1 million heart attacks and strokes by 2017.15 A portion of this campaign includes BP control.15 Home BP monitoring is a part of the strategy. The inability to participate in home BP monitoring because of the lack of equipment compromises patient care and patient outcomes. Uncontrolled HTN is known as the silent killer.16 Access to BP monitoring tools breaks the silence and allows confirmation of effective lifestyle changes. Payment for services is transitioning to outcomebased reimbursement. Reimbursement for health coaching on LSM and home BP monitors needs the attention of the public health community and the power and influence of NPs.
2. Yadav RK, Magan D, Mehta N, Sharma R, Mahapatra SC. Efficacy of a shortterm yoga-based lifestyle intervention in reducing stress and inflammation: preliminary results. J Altern Complement Med. 2012;18:662-667. 3. American Heart Association. Changes you can make to manage high blood pressure. http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/ MakeChangesThatMatter/Changes-You-Can-Make-to-Manage-High-Blood -Pressure_UCM_002054_Article.jsp#.WIVbYZgrJNA. 2016. Accessed February 6, 2015. 4. American Stroke Association. Let’s talk about lifestyle changes to prevent stroke. http://www.strokeassociation.org/idc/groups/stroke-public/@wcm/@ hcm/documents/downloadable/ucm_309712.pdf. 2015. Accessed January 21, 2016. 5. James PA, Oparil S, Carter BL, et al. 2014 Evidence based guidelines for the management of high blood pressure in adults. Report from the panel member appointed to the Eighth Joint National Committee (JNC8). J Am Med Assoc. 2014;311(5):507-520. 6. Margolius D, Bodenheimer T, Bennett H, et al. Health coaching to improve hypertension treatment in a low-income, minority population. Ann Fam Med. 2012;10(3):199-205. 7. Howes F, Warnecke E, Nelson M. Barriers to lifestyle risk factor assessment and management in hypertension: a qualitative study of Australian general practitioners. J Hum Hypertens. 2013;27:474-478. 8. Whyte L. Coaching for life. Nurs Manag (Harrow). 2014;21(1):15. 9. American Medical Group Foundation. Measure Up/Pressure Down provider toolkit to improve hypertension control [toolkit]. http://www .measureuppressuredown.com/HCProf/toolkit.pdf. 2013. Accessed March 6, 2015. 10. Morisky DE, DiMatteo MR. Improving the measurement of self-reported medication nonadherence: final response. J Clin Epidemiol. 2011;64(3): 255-263. 11. Pender N. Health Promotion Model Manual. http://dhl.handle.net/2027.42/ 85350. 2011. Accessed January 21, 2016. 12. Centers for Medicare and Medicaid Services. Decision memo for intensive behavioral therapy for cardiovascular disease (CAG-00424N) [decision summary]. https://www.cms.gov/medicare-coverage-database/details/nca -decision-memo.aspx?NCAId¼248. 2011. Accessed January 12, 2017. 13. The US Centers for Medicare and Medicaid Services. Health education and wellness programs [consumer information]. https://www.medicare.gov/ coverage/health-education-and-wellness-programs.html. Accessed January 12, 2017. 14. Cigna. Cigna administrative policy: preventive care services. https:// cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/AD_ A004_administrativepolicy_Preventive_Care_Services.pdf?WT.z_ nav¼healthcare-professionals%2Fresources-for-health-care-professionals% 2Fhealth-and-wellness-programs%2Fcare-guideline%3BBody%3BPreventive %20Care%20Services%20%E2%80%93%20(A004)%. 2017. Accessed January 12, 2017. 15. MillionHearts. Be one in a million hearts [information sheet]. http:// millionhearts.hhs.gov/be_one_mh.html. 2014. Accessed March 6, 2015. 16. Makridakis S, DiNicolantonio JJ. Hypertension: empirical evidence and implications in 2014. Open Heart. 2014;1(1):e000048.
Darlene Crittenden, DNP, FNP-BC, NP-C, CMSRN, is a family nurse practitioner, hospitalist at Saint Frances Hospital in Columbus, GA, and can be reached at [email protected]. Sherry Seibenhener, DNP, FNP-BC, is an assistant professor of nursing and ASN program coordinator in the School of Nursing at Troy University, Montgomery, AL. Bernita Hamilton, PhD, RN, is a professor of nursing in the School of Nursing at Troy University, Montgomery, AL. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict.
References 1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics-2013 update: a report from the American Heart Association. Circulation. 2013; 127:e6-e245.
www.npjournal.org
1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2017.02.010
The Journal for Nurse Practitioners - JNP
e3
Health Coaching and the Management of Hypertension Darlene Crittenden, DNP, FNP-BC, Sherry Seibenhener, DNP, FNP-BC, and Bernita Hamilton, PhD, RN ABSTRACT
Despite the multiple medications available for the management of hypertension (HTN), control remains suboptimal. The American Heart Association predicts a 9.9% increase in patients with HTN by 2030. Using a prospective prepost design, this pilot study used the health coaching model to examine the impact of health coaching on lifestyle modification in the management of HTN in a primary care setting. Study results showed health coaching as a promising approach for the management of HTN, demonstrated by a reduction of both systolic and diastolic blood pressure. Barriers encountered during the study revealed patient participation in managing HTN depended on having the necessary tools, education, and a holistic care approach. Keywords: health coach, hypertension, lifestyle modification Ó 2017 Elsevier Inc. All rights reserved.
C
hronic hypertension (HTN) is a major risk factor for cardiovascular disease; is the leading cause of death in the United States; and is highly associated with first heart attacks, first strokes, and congestive heart failure.1 Yet, despite the multiple medications available for the management of HTN, control remains suboptimal.2 The American Heart Association3; American Stroke Association4; and Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure5 recommend lifestyle modification (LSM) such as weight control; medication adherence; exercise; and a well-balanced, low-salt diet in their guidelines for the management of HTN. As shown by Go et al,1 evidence supports that LSM has a positive effect on blood pressure (BP) control, rigidity of the heart, and organ damage triggered by uncontrolled HTN. Providers are consistently lacking in the performance of patient LSM assessments for multiple reasons.6 A focus group study identified patient noncompliance and lack of engagement as barriers to providers’ performance of LSM assessments.7 Conversely, noncompliance and lack of engagement could be eliminated by providing patients with the tools and education necessary to become active participants in the management of their illness. As www.npjournal.org
stated by Whyte,8 improved behaviors are likely to occur when information is provided along with methods that inspire change. STUDY OVERVIEW
The pilot study was conducted at a privately owned family practice physician’s office. A nurse practitioner (NP) served as the health coach and the principal investigator of the study. Approval for the study was obtained from the institutional review board and the clinic physician. Participants were recruited by responding to a flyer while waiting for their scheduled office visit. Inclusion criteria consisted of patients 19 years of age and older with a medical diagnosis of HTN only. The prospective prepost design consisted of the health coach providing individualized education about HTN based on the Measure Up/Pressure Down Toolkit9 and assessed medication adherence using the Morisky Medication Adherence Scale 8.10 Based on Pender’s Health Promotion Model,11 participants were instructed to choose an LSM activity they felt was achievable, therefore giving value to their results. Lastly, participants were asked to take their BP 3 times a week. Pre- and postdata consisted of assessing participants’ BP, weight, understanding/knowledge of HTN and medications, The Journal for Nurse Practitioners - JNP
e1
and whether they felt a health coach would impact the management of their HTN. Predata information was collected during the scheduled office visit. Over an 8-week period, the health coach conducted biweekly phone calls to analyze patients’ perceived barriers to initiation and continuation of LSM activities and management of their HTN. Selfreported BP measurements were reviewed. Individualized education was conducted. Postintervention data were collected from patients returning to the office for a final study visit, from the patients’ medical record if they were unable to return to the office for their final visit, or by phone if the patient did not have access to transportation. OUTCOMES
The sample consisted of 21 adults 31 to 73 years old with an established primary diagnosis of HTN. The sample was mostly female (76.2%, n ¼ 16), greater than 50 years old (81%, n ¼ 17), and representative of the clinic population. As shown in Table 1, participants selected a variety of LSM plans for control of BP and improvement of health. Project findings support health coaching as a promising model for sustaining patient engagement in selected LSM plans and medication adherence for improved BP outcomes. Before health coaching, 12 (57.1%) participants reported unawareness of their BP goal, 14 (66.7%) reported nonadherence to any LSM recommendations on a regular basis, and 17 (81%) reported low adherence to their medication plan. After health coaching, participants reported awareness of their target BP (90.5%, n ¼ 19) and indicated health
Table 1. Frequencies of Lifestyle Modification (LSM) Plan (N [ 21) n
%
Weight control
1
4.8
Regular exercise
9
42.9
Dash diet
2
9.5
No added salt
5
23.8
Decrease tobacco
3
14.3
1
4.8
LSM plans
Manage stress
e2
The Journal for Nurse Practitioners - JNP
coaching improved adherence to LSM and medications (81%, n ¼ 17). Chi-square analysis confirmed an increased commitment to participating in the management of their HTN (c21 ¼ 5.250, P < .05) and medication compliance (c24, ¼ 10.7222, P < .05). Paired sample t tests revealed a significant difference in the pre (mean ¼ 133.09, SD ¼ 15.36) and post (mean ¼ 125.33, SD ¼ 12.57) health coaching systolic BP (t20 ¼ 3.144; P < .01; 95% confidence interval, 2.61-12.91). Although there was no statistical significance, the diastolic BP decreased after intervention. BARRIERS
During the project, barriers threatened the achievement of project goals. Not all participants had access to home BP monitors and relied on transportation to community resources for BP monitoring. Those with home BP monitors reported the most regularly scheduled assessments. Moreover, visual affirmation of BP results confirmed the effectiveness of lifestyle changes and encouraged continued compliance, whereas those without BP monitors reported that not knowing their BP measurements left them ambivalent or discouraged about continuing LSM activities. Family support was an integral part of participant adherence to LSM. Participants relied on family members for help with grocery shopping, handling stressful behaviors, and encouraging exercise. However, health coaching focused solely on the participant. In retrospect, the inclusion of significant caregivers in the health coaching process could reinforce and encourage LSM. The target population for this project was patients from 1 primary care setting with a sole diagnosis of HTN. Including participants with a sole diagnosis of HTN resulted in the exclusion of patients with other chronic health problems such as diabetes. The small sample size and participants’ selection of varied LSM activities limited postintervention comparative analysis of lifestyle activities. IMPLICATIONS
The sustainability of health coaching is feasible in a primary care setting. Each participant in this study required 15 minutes of coaching, which equates to 4 Volume
-,
Issue
-, -/-
2017
patients per hour every other week to achieve positive outcomes. Although health coaching is not billable through Medicare, Medicare is adapting to the changes in health care by reimbursing for certain behavioral health interventions.12 Per the Centers for Medicare and Medicaid Services,12 follow-up phone calls/office visits are reimbursable based on outcomes on an individual basis. Additionally, there are certain illnesses that are closely associated to HTN that have billable codes for LSM education, namely, diabetes, kidney disease, and cardiovascular disease.13 This scenario heightens the urgency for NPs to take a stand for better patient outcomes through billable services for LSM in the management of HTN. Some third-party payers reimburse for education on LSM. As of January 15, 2017, Cigna insurance reimburses for preventive interventions. The interventions are described as health coaching but not named as such. The codes necessary for billing have been established, and HTN is included.14 Health care is transitioning to the community setting. Plans must be geared toward teaching patients how to actively participate in the management of their conditions more effectively. In response to a national strategy for quality improvement in patient health outcomes and population health, the US Department of Health and Human Services launched a national initiative aimed at preventing 1 million heart attacks and strokes by 2017.15 A portion of this campaign includes BP control.15 Home BP monitoring is a part of the strategy. The inability to participate in home BP monitoring because of the lack of equipment compromises patient care and patient outcomes. Uncontrolled HTN is known as the silent killer.16 Access to BP monitoring tools breaks the silence and allows confirmation of effective lifestyle changes. Payment for services is transitioning to outcomebased reimbursement. Reimbursement for health coaching on LSM and home BP monitors needs the attention of the public health community and the power and influence of NPs.
2. Yadav RK, Magan D, Mehta N, Sharma R, Mahapatra SC. Efficacy of a shortterm yoga-based lifestyle intervention in reducing stress and inflammation: preliminary results. J Altern Complement Med. 2012;18:662-667. 3. American Heart Association. Changes you can make to manage high blood pressure. http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/ MakeChangesThatMatter/Changes-You-Can-Make-to-Manage-High-Blood -Pressure_UCM_002054_Article.jsp#.WIVbYZgrJNA. 2016. Accessed February 6, 2015. 4. American Stroke Association. Let’s talk about lifestyle changes to prevent stroke. http://www.strokeassociation.org/idc/groups/stroke-public/@wcm/@ hcm/documents/downloadable/ucm_309712.pdf. 2015. Accessed January 21, 2016. 5. James PA, Oparil S, Carter BL, et al. 2014 Evidence based guidelines for the management of high blood pressure in adults. Report from the panel member appointed to the Eighth Joint National Committee (JNC8). J Am Med Assoc. 2014;311(5):507-520. 6. Margolius D, Bodenheimer T, Bennett H, et al. Health coaching to improve hypertension treatment in a low-income, minority population. Ann Fam Med. 2012;10(3):199-205. 7. Howes F, Warnecke E, Nelson M. Barriers to lifestyle risk factor assessment and management in hypertension: a qualitative study of Australian general practitioners. J Hum Hypertens. 2013;27:474-478. 8. Whyte L. Coaching for life. Nurs Manag (Harrow). 2014;21(1):15. 9. American Medical Group Foundation. Measure Up/Pressure Down provider toolkit to improve hypertension control [toolkit]. http://www .measureuppressuredown.com/HCProf/toolkit.pdf. 2013. Accessed March 6, 2015. 10. Morisky DE, DiMatteo MR. Improving the measurement of self-reported medication nonadherence: final response. J Clin Epidemiol. 2011;64(3): 255-263. 11. Pender N. Health Promotion Model Manual. http://dhl.handle.net/2027.42/ 85350. 2011. Accessed January 21, 2016. 12. Centers for Medicare and Medicaid Services. Decision memo for intensive behavioral therapy for cardiovascular disease (CAG-00424N) [decision summary]. https://www.cms.gov/medicare-coverage-database/details/nca -decision-memo.aspx?NCAId¼248. 2011. Accessed January 12, 2017. 13. The US Centers for Medicare and Medicaid Services. Health education and wellness programs [consumer information]. https://www.medicare.gov/ coverage/health-education-and-wellness-programs.html. Accessed January 12, 2017. 14. Cigna. Cigna administrative policy: preventive care services. https:// cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/AD_ A004_administrativepolicy_Preventive_Care_Services.pdf?WT.z_ nav¼healthcare-professionals%2Fresources-for-health-care-professionals% 2Fhealth-and-wellness-programs%2Fcare-guideline%3BBody%3BPreventive %20Care%20Services%20%E2%80%93%20(A004)%. 2017. Accessed January 12, 2017. 15. MillionHearts. Be one in a million hearts [information sheet]. http:// millionhearts.hhs.gov/be_one_mh.html. 2014. Accessed March 6, 2015. 16. Makridakis S, DiNicolantonio JJ. Hypertension: empirical evidence and implications in 2014. Open Heart. 2014;1(1):e000048.
Darlene Crittenden, DNP, FNP-BC, NP-C, CMSRN, is a family nurse practitioner, hospitalist at Saint Frances Hospital in Columbus, GA, and can be reached at [email protected]. Sherry Seibenhener, DNP, FNP-BC, is an assistant professor of nursing and ASN program coordinator in the School of Nursing at Troy University, Montgomery, AL. Bernita Hamilton, PhD, RN, is a professor of nursing in the School of Nursing at Troy University, Montgomery, AL. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict.
References 1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics-2013 update: a report from the American Heart Association. Circulation. 2013; 127:e6-e245.
www.npjournal.org
1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2017.02.010
The Journal for Nurse Practitioners - JNP
e3