- With the healthcare industry embracing value-based care models, it will be important for providers to push for overall patient wellness. To that end, providers must help their patients adopt new healthy behaviors, a goal that is largely achievable with effective health coach strategies.
The responsibility of health coaching will be increasingly placed on clinicians, according to Melinda Huffman, BSN, MSN, CCNS, CHC, the co-founder of the National Society of Health Coaches (NSHC).
At NSHC, Huffman and her team develop best practices for health coaches across the country who are responsible for supporting patients as they undergo lifestyle changes geared toward improving their overall wellness. Those lifestyle changes can include picking up a healthier diet, beginning an exercise regimen, or quitting smoking, for example.
And while those duties have long been delegated to health coaches – non-clinical workers to help motivate and track the progress of patients working on lifestyle changes – it is high time that clinicians integrate health coaching into their clinical practices, as well.
“You can't separate wellness from the health or health conditions of a patient or an individual,” Huffman said in a recent interview with PatientEngagementHIT.com.
There are fundamental differences between a clinician and a health coach, the most prominent being diagnostic authority. Clinicians can engage patients within the context of the patient’s unique conditions, while a non-clinician should, for liability reasons, stray away from diagnostic activities.
This does not necessarily mean that a non-clinician health coach brings no value to the table, Huffman stated. However, as the healthcare industry continues to embrace goals of overall patient wellness and value-based care success, it would be beneficial for clinicians to adopt health coaching best practices.
“We have really promoted clinician health coaches because otherwise, you have health teachers,” Huffman said. “That's a very important distinction to make simply because, again, you can't separate health from someone's conditions. Anyone who has a chronic condition or who is at high- to moderate-risk should have a clinician health coach.”
But the notion of a clinician as a health coach is relatively new and breaks the mold of traditional medicine, Huffman explained. Traditionally, a clinician will be trained in the diagnostic and treatment aspects of healthcare – what goes on within the four walls of the hospital.
While clinicians have the knowledge to offer health guidance, this level of patient engagement has not been commonplace in healthcare. In this new era of value-based medicine, clinicians may consider patient engagement strategies that draw on health coaching best practices.
Fundamentally, this means clinicians must understand patient motivation.
“In health coaching, it's all about guiding your clients or your patients to move positively toward change. Health coaching is all about guiding behavior change,” Huffman explained.
For example, a clinician may determine that an exercise regimen is essential for an obese patient to regain a normal weight range and to reduce abnormally high blood pressure.
But those motivations might not resonate with the patient, and therefore might not result in the desired behavior change of exercising.
“It's the ‘but’ in the middle that makes the difference,” Huffman asserted. “That element keeps the patient stuck.”
In most cases, the patient will acknowledge that she needs to lose weight and exercise. But scheduling that time to exercise has proven difficult, the patient may report, especially when it would be much easier to maintain the status quo with which the patient is already comfortable.
That ‘but’ causes some friction, and until the health coach can help the patient find her true motivation, will keep her stuck in unhealthy habits.
“Health coaching is not counseling and it’s not psychotherapy,” Huffman explained. “It's a way of guiding individuals about their health in order to make changes that would improve their health. The wellness end and prevention piece in the industry absolutely will make this imperative because it is difficult to change behavior and there's all kinds of reasons why people don't change behavior.”
Changing a patient’s behavior and uncovering intrinsic motivation is no easy feat, Huffman acknowledged. Understanding behavior change is a nuanced art, and requires a careful set of patient-provider communication strategies to help uncover patient needs.
Clinicians can employ open-ended questions to spark a patient’s thoughts about her own motivation, Huffman recommended. Too often, physicians and other clinicians use “yes” or “no” questions, or even skip patient questioning altogether and simply prescribe a behavior change.
But when a clinician says to a patient, “you have to quit smoking,” it usually leads to the patient going to smoking cessation counseling saying, “I’m only here because my doctor told me to come.”
“When that's the case, then there's a lot of work to do to help them discuss and move toward quitting smoking if they do decide to,” Huffman said. “The patient is the change agent. Clinicians cannot force change, and that's one of the downsides of patient care. If you try to force, demand, shame the patient, or argue for change, it's not going to happen.”
Instead, it is important for clinicians to ask patients questions about their lifestyles, activities that are important to them, and their own overall health goals. These open-ended questions could reveal an unexpected intrinsic motivation that could lead to patient behavior change.
It is not abnormal for a patient or clinician to come up short during these conversations, either, Huffman said. Patient resistance to behavior change is a common problem that many clinicians must overcome when adopting health coach techniques.
“Recognizing that resistance is quite easy because the clinician can hear it in the patient’s voice. The patient will be very adamant,” Huffman advised.
Using motivational interviewing skills can help clinicians determine where the patient is, Huffman said, referencing the five stages of change, or the Transtheoretical Model. Those stages – which include precontemplation, contemplation, preparation, action, and maintenance – are important indicators of how the clinician should engage the patient.
For example, a patient in contemplation may respond best to the beginning stages of motivational interviewing during which the coach and patient are starting to identify motivating factors. A patient in the action stage of change will need feedback from her health coach and new strategies for effectively integrating behavior change into her lifestyle.
“We also teach our coaches how to determine what stage of change the individual is in and to use their skills within that,” Huffman said. “It's not about us motivating them, it's about guiding the conversation where they discover their own motivation. Sometimes the clients just simply aren't ready.”
In those cases, health coaches need to know when to allow patients to come to the realization on their own, a tall order for most clinicians. But accepting a patient’s lack of readiness to make a behavior change does not mean abandoning them, Huffman said.
Instead, clinician health coaches should reassure their patients, reminding patients that they are there for them and ready to work on behavior change when the patient feels ready.
“It has to be that way,” Huffman asserted. “You cannot force or direct that change in behavior. You can help them, you can help guide them to achieve it, but you can't force readiness.”
As noted above, the time is ripe for clinicians to adopt health coaching practices. Clinicians are well-positioned to lead health coaching because of their intimate knowledge of health conditions and a patient’s unique health needs.
The industry landscape allows for this, Huffman added. Value-based care models are calling for better patient activation in care. And with that, industry leaders are recognizing patients as the leaders of their own care.
“We as clinicians been trained that because we're the experts, we tend to be the director in the patient-provider relationship,” Huffman explained. “That has to change going forward. That's why health coaching has really become elevated in the eyes of medicine, nursing, Medicare and Medicaid, the accountable care organizations.”
Health coaching skills translate best to the point-of-care clinical encounter, she added.
“A clinician doesn’t have to come out of clinical practice to be a health coach,” Huffman concluded. “You can learn these skills and use them at the point of care. That's one of the emerging trends we see in health coaching is providing health coaching and health coaches at the point of care, wherever the point of care may be.”