New Layer of Care
Consider integrating health and wellness coaching into your practice to improve patient compliance and outcomes.
By Linda Gogl, PT, DPT, OCS, CWC, CWP
Health care providers now practice in a rapidly changing landscape. In fact, the ground is shifting beneath our feet. To remain successful and profitable as a business and practitioner in America we are forced to navigate through uncharted waters manning the helm as best we can and attempting to “stay steady as she goes.”
The Affordable Care Act and other payer reforms are changing how health care is delivered and reimbursed—rewarding organizations that can deliver better patient-level results while often treating a greater volume. Much of this has been driven by the climbing cost of health care and has prompted a new model of delivering care with a focus on timely results. Health care providers are now held accountable for practice outcomes and will be reimbursed according to efficiency and skills in producing those outcomes.1
Evidence is abundant in the area of medical noncompliance and its effects on patient outcomes. According to the World Health Organization and other resources the cost of medical noncompliance or nonadherence is in the billions annually.2,5 This can be as simple as not filling a prescription,3 not following a home exercise program instruction, or to the greater extreme a lifestyle of high-risk health behaviors leading to a multitude of co-morbidities. Successful patient outcomes are correlated with education, experience, and skill of the provider. It is also well known that even with the highest level of skill and expertise, outcomes are at risk due to patient noncompliance.4
Research strongly suggests that medical noncompliance is 80 percent behavioral.4 Lifestyle Medicine states that “health is largely behavioral “and this recognition has created a whole new “layer of care.”3 The new practice model that is evolving includes integration of the behavioral mechanism in achievement of health care interventions and goals6,7. This is strongly supported by the research within the Behavioral Science and Lifestyle Medicine field, as well as within the Affordable Care Act.8 Health & Wellness Coaching is noted within the Affordable Care Act, as well as the National Prevention Strategy, as a component not only in prevention and wellness but also in rehabilitation and management of chronic illness and lifestyle diseases.9
The ACA and NPS also recommends cross-training health care providers with the skills of professional Health & Wellness Coaching to reduce noncompliance and health care costs.6 The WHO emphasizes the need for “empowering health professionals” with an “adherence counseling toolkit” adaptable to different socioeconomic settings. Such training needs to simultaneously address three topics: knowledge (information on adherence), thinking (the clinical decision-making process),and action (behavioral tools for health professionals).”2
The orthodox medical model in health care today is to “prescribe and treat” or “educate and implore.” The prevailing mindset is to provide an assessment of a patient’s health or wellness and then “tell them what to do.” As treatment-oriented professionals, we cultivated a model of belief that knowledge was the golden answer and that providing our patients with the education they were lacking would motivate them into action. It was thought this would then induce them to pursue wellness and to make any lifestyle changes required for a healthy life or to comply with a prescribed treatment program.6,7 As physical therapists, we are acutely aware of the astonishing lack of compliance for wellness and rehabilitation. This is evidenced by the volume of research highlighting poor compliance in following a simple home exercise program, as well as completion of an episode of care. For many patients this has not been an effective model.10
Numerous peer-reviewed studies demonstrate that practitioners proficient in their respective health care field, as well as in validated health coaching approaches—routinely deliver significantly better patient-level results than practitioners who are not.11,13,15,16,18,20,21,22,23 While physical therapy–specific skills are of primary importance to the physical therapy profession research now recognizes that successful outcomes are a combination of skilled treatment and behavioral management.
Health care is evolving to an integrated model out of necessity. Current professional trends have noted the transition of health care providers, including physical therapy, into prevention and wellness with primary focuses in the areas of obesity, metabolic syndrome, diabetes, heart disease, degenerative diseases, which are strongly correlated with high behavioral components and lifestyle. Lifestyle Medicine suggests that expertise in a field of health care specialty combined with training and competency in the coaching skills for behavioral change not only sharpens the practitioner’s tools but bridges the gap between “prescribe and treat” and patient outcomes.24,25,26
Health & Wellness coaches assist patients in achieving successful lifestyle changes and thereby improvements in patient compliance and outcomes. Coaches utilize a systematic process, based on behavioral change psychology, human motivation, health promotion, and professional coaching competencies. Coaching skills motivate patients to make the behavioral changes needed to support compliance, improve outcomes, and live healthier lives.12
Currently, Health & Wellness coaches are being incorporated into clinics, medical networks, hospitals, disease management companies, employee assistance programs, wellness programs, fitness centers, insurance companies, and within private companies and organizations. Health & Wellness Coaching in wellness programs is now considered best practice.14,17
Practicing coaches range from independent Health & Wellness Coaches to those who “wear two hats” of health care practitioner and coach. In addition, many universities are including Health & Wellness Certification programs within their health care curriculum.
As health care professionals we now face the twofold challenge of promoting prevention and wellness while also being part of the treatment solution. The people we serve span the entire continuum from those with severe health challenges to all who aspire for peak performance. As we zero in on the behavioral nature of health, it allows us an opportunity to serve our patients better. As health care professionals we are uniquely qualified to be the bridge between the orthodox medical model and the behavioral change approach that promotes improved patient compliance and outcomes. As the Affordable Care Act’s vision moves the nation’s model of care from “sick care” to “well care,” the physical therapy profession can be a strong player and greatly benefit by incorporating many opportunities available within the new integrated approach that is now becoming the new model of care.
Linda Gogl, PT, DPT, OCS, CWC, CWP, is PPS program chair for Combined Sections Meeting, partner and director of development for Real Balance Global Wellness Services, Inc, and The Wellness Coach Training Institute. She can be reached at linda@realbalance.com.
REFERENCES
1. Keegan, D., (2013). How to Keep your Income Up as RVU’s Transition Away. Medscape Business of Medicine. www.medscape.com/viewarticle/776111. 2013. Accessed November 2014.
2. World Health Organization: Defining Adherence. www.who.int/chp/knowledge/publications/adherence_Section1.pdf. Accessed November 2014.
3. Davies, M., Kermani,F., (2006). Patient Compliance: Sweetening the Pill. Book 2006.
4. Jing, Jin., Grant, Edward Sklar., Shu, Chuen Li., (2008). Factors affecting therapeutic compliance: A review from the patient’s perspective. Ther Clin Risk Management. Feb 2008; 4(1); 269-286.
5. The Atlantic: The $289 Billion Cost of Medication Noncompliance, and What to Do About It. www.theatlantic.com/health/archive/2012/09/the-289-billion-cost-of-medication-noncompliance-and-what-to-do-about-it/262222/, September 11, 2012 Accessed November 2014.
6. Improving Patient Adherence – Clinical Diabetes. http://clinical.diabetesjournals.org/content/24/2/71.full. by AM Delamater-2006.
7. Hayes E, McCahon C, Panahi MR, Hamre T, Pohlman K. Alliance not compliance: coaching strategies to improve type 2 diabetes outcomes. J Am Acad Nurse Pract. 2008 Mar;20(3):155-62. doi: 10.1111/j.1745-7599.2007.00297.x.
8. Affordable Care Act: www.healthcare.gov. Accessed November 2014.
9. National Prevention Strategy, Clinical and Community Preventive Services, National Prevention Council 2010. www.surgeongeneral.gov/initiatives/prevention/strategy/preventive-services.pdf. National Prevention Council Action Plan: Implementing the National Prevention Strategy. www.surgeongeneral.gov/initiatives/prevention/2012-npc-action-plan.pdf. National Prevention Council, National Prevention, Health promotion, and Public Health Council, 2013 Annual Status Report. June 25, 2012. www.cdc.gov/features/PreventionCouncil/ Accessed November 2014.
10. Sluijs EM1, Kok GJ, van der Zee J. Correlates of exercise compliance in physical therapy. Phys Ther. 1993 Nov;73(11):771-82; discussion 783-6.
11. Key Behavioral Intervention in Healthcare. Global Advances in Health and Medicine. 2013 July:2(4):38-57.
12. Arloski, M. (2009) Wellness Coaching for Lasting Lifestyle Change. Duluth MN: Whole Person Associates (2nd edition, 2014).
13. Wolever,R., et al. (2009) Duke Integrative Health Coaching. Type 2 Diabetes. Diabetes Educator, July/August 2010, Volume 36. No. 4.
14. Eddington.D. (2009) Zero Trends: Health as a Serious Economic Strategy. Health Management Research Center.
15. Bennett et al, Health Coaching for Patients With Chronic Illness. Fam Pract Manag. 2010 Sep-Oct;17(5):24-29.
16. http://journal.aarpinternational.org/a/b/2012/02/The-Future-of-Nursing-Transforming-Health-Care. Accessed November 2014.
17. Harris et al. The Institute of Medicine’s New Report on Living Well With Chronic Illness. Centers for Disease Control and Prevention. Volume 9 – September 20, 2012.
18. Lorig et al. Chronic Disease Self-Management Program, 2-year Health Status and Health Care Utilization Outcomes. Medical Care. Volume 39, Number 11, pp 1217-1223.2001.
19. Ruth Q. Wolever, Collaboration and Synergy in the Field of Health and Wellness Coaching: Naïve or Necessary? Global Adv Health Med. 2013;2(4):8-9.
20. Barbara M. Dossey, Darlene Hess. Professional Nurse Coaching: Advances in National and Global Healthcare transformation. Global Adv Health Med. 2013;2(4):10-16.
21. Leigh Ann Simmons, Ruth Q. Wolever. Integrative Health Coaching and Motivational interviewing: Synergistic Approaches to Behavior Change in Healthcare. Global Adv Health Med. 2013;2(4):28-35.
22. Jennifer S. Berna, MS, MS, PhD, MCHES, BCC, Wellness Coaching Outcomes in a Case Report of a Diabetic Native American Male. Global Advances in Health and Medicine, July 2013, Vol. 2, No. 4 : pp. 62-67.
23. Julie Schwartz Wellness Coaching for Obesity: A Case Report. Global Adv Health Med. 2013;2(4):68-70 Accessed November 2014.
24. Moore.M. Setting a gold standard for health and wellness coaching. www.lifestylemedicine.org/LMMB0112 Accessed November 2014.
25. Hayachi A, Kayama M, Ando K, Ono M, Suzukamo Y, Michimata A, Akiyama MO, Fukuhara S, Izumi SI. Analysis of subjective evaluations of the functions of tele-coaching intervention in patients with spinocerebellar degeneration. NeuroRehabilitation 2008; 23:159-169.
26. Coaching and Counseling Patients–A Resource from the American College of Preventive Medicine. 2009. Website http://c.ymcdn.com/sites/www.acpm.org/resource/resmgr/timetools-files/coachingclinicalreference.pdf Accessed November 2014.