In honor of World Health Day, IIN wants to say “thank you!” to the healthcare workers in our community. We’re providing content all month long that highlights the important work they are doing to keep our loved ones and communities healthy and safe now and well into the future. These incredible nurses, physicians, midwives, doulas, researchers, and Health Coaches are making our world a healthier place, one day at a time.
Health Coaches and the Health Coaching Philosophy
While health coaching has rapidly expanded into a lucrative career industry, many of those working in traditional healthcare settings have long been implementing the “health coaching philosophy” into their work. The concept that people need to be held accountable in order to reach their goals isn’t unique to the health field as physicians, nurses, and other practitioners understand that maintaining health is often a team effort.
David Thom, MD, PhD, clinical professor of medicine at Stanford School of Medicine, and Tom Bodenheimer, MD, MPH, professor of family community medicine at University of California, San Francisco School of Medicine, have been researching the value of health coaching for years. Specifically, they’ve looked at how the overarching health coaching philosophy can be implemented to improve patient care.
We asked them about their research and why Health Coaches are poised to improve the healthcare system from the inside out.
IIN: When did you first hear about health coaching? What inspired you to pursue research on how health coaching can improve health outcomes?
Dr. Bodenheimer: I heard about health coaching from Kate Lorig of the Stanford Patient Education Research Center, now called the Self-Management Resource Center. Kate is the pioneer of chronic disease self-management support, which is the same as health coaching. I met Kate around the year 2000, and the health coaching philosophy changed entirely how I took care of patients. (I was in primary care practice for 32 years.) When I left practice and came to the University of California, San Francisco, I decided to pursue research and training on health coaching.
Dr. Thom: I first heard about health coaching around 2008, when Tom Bodenheimer invited me to join his group, which was using health coaching as part of a new “teamlet” model for delivering primary care. As the name implies, the model used a small team – one physician plus two Health Coaches. Health Coaches met with the patient before the visit, were present during the visit, and met with the patient after the visit and between visits. Tom asked me to help with the data gathering and analysis of the impact of this model.
I was familiar with the team-based models of care but not with health coaching. I had encountered the component ideas and techniques and philosophy behind health coaching in different guises over the years and was impressed with how they had been integrated into the health coaching model. I thought health coaching had great promise and welcomed the challenge of conducting research in this area.
IIN: You’ve each authored many studies and clinical trials on the impact of health coaching on health outcomes. Have there been any in particular that stand out to you? Why?
Dr. Bodenheimer: Our two studies on diabetes and hypertension and hyperlipidemia are I think the best studies on our version of health coaching in the literature.
Dr. Thom: Our study where we trained patients with diabetes cared for in public health and community clinics as peer coaches for other diabetic patients stands out for a few reasons [the diabetes study Dr. Bodenheimer mentions above]. For one, it was our first study that was designed from the beginning as a research study. It was also novel in that the intervention was being delivered by laypeople who had the condition being studied – type 2 diabetes. But the main reason was a chance to see the impact of coaching on patients with diabetes and on the Health Coaches themselves. We also had tremendous support from medical providers once the study was underway and they could see the impact it was having on their patients.
IIN: Some studies that you’ve coauthored had groups that received health coaching from trained Health Coaches, while others had coaching from peers (peer coaching) with the same health issues, e.g., diabetes as you mentioned earlier. Regardless of the delivery, is it safe to say that any support to improve health outcomes outside a patient’s usual care is beneficial? Why or why not?
Dr. Bodenheimer: It depends. If, outside usual care, a patient has a health educator who contacts them via text about their diabetes and scolds patients who do not follow her instructions, then that isn’t helpful. Any intervention with a patient that uses the health coaching philosophy would be helpful. It’s the philosophy that counts, the ask-tell-ask interactions with patients, the touchback to make sure they understand what their care plan is, and healthy behavior change using the action plan technique that we teach in our trainings and used in our Health Coach studies.
Dr. Thom: I think health coaching can be very effective in a variety of circumstances and when employed by people from different backgrounds. I wouldn’t go so far as to say that any support to improve health outcomes outside a patient’s usual care is beneficial. I’ve seen many examples of what was intended as support to potentially cause harm, often by friends and family who try to help in controlling ways and sometimes by medical staff who unknowingly provide misinformation or who alienate patients by being overly directive. Engaging the patient where the patient is, and in a way the patient wants to be engaged, is critical but often not practiced without the benefit of health coach training.
IIN: In your opinion, how receptive are physicians and other healthcare professionals to hiring/having Health Coaches on staff? Do you think there are still perceptions and hurdles that must be overcome in order to fully embrace adding health coaching to the list of “usual care”?
Dr. Bodenheimer: There is no reimbursement for Health Coaches, which is why there are so few of them in the healthcare system. But to be clear, everyone should be a Health Coach. It is much more a function than a specific occupation. Doctors, NPs, PAs, nurses, pharmacists, health educators, etc., should all be using the health coaching philosophy with their patients all the time.
Dr. Thom: I think physicians and other healthcare professionals have understandable concerns about the employment of Health Coaches as a usual part of patient care. Among the concerns I’ve encountered are that the Health Coach will interfere with the professional-patient relationship or that Health Coaches are not sufficiently trained and/or will overstep their level of competence, providing poor information or counseling. Clinicians worry that adding another person or function will increase the complexity, meaning more work for them in coordination and communication, and that coaching patients will increase patients’ demands on their time for relatively unimportant reasons when they are already working as hard as they can to stay on top of the patients’ medical problems. At the systems level, the main concern is probably how to pay for the cost of health coaching – not just the time spent by Health Coaches but also the cost of additional structures for support and supervision.
Some concerns we have been able to address. We showed, for example, rather than interfering with the doctor-patient relationship, health coaching actually enhanced patients’ trust in their doctors. We also found that clinicians rated visits with health-coached patients as less demanding and were more likely to feel that they had adequate time with their patient. Clinicians also reported that Health Coaches supported patient self-management and bridged communication gaps between clinicians and patients.
IIN: What areas of health and medicine do you see as prime for Health Coach interventions?
Dr. Bodenheimer: Everything. Preventive care (disease and cancer screenings); chronic care (diabetes, hypertension, COPD, congestive heart failure, arthritis, depression). People with multiple diagnoses and high costs of care. People with moderate or severe dementia cannot be coached, but their families can.
Dr. Thom: Our work has focused on health coaching for low-income patients facing language, cultural, and educational barriers to management of chronic conditions, such as diabetes. However, a health coaching approach can benefit anyone facing health-related choices. For example, Dr. Manli Patel, an oncologist at Stanford, has shown that lay health workers trained using many of the principles of health coaching can help patients with terminal cancer identify goals and make decisions around end-of-life care, reducing symptom burden, symptoms of depression, and emergency department visits and hospitalizations.
IIN: In honor of World Health Day, we’re showcasing our community members who are working as healthcare professionals, such as nurses, midwives, and doulas. Dr. Thom, you’ve conducted studies in the area of women’s health, and Dr. Bodenheimer, you spent many years working in community health centers. These areas of health – community health, women’s health – have a symbiotic relationship. How do you think Health Coaches can (better) support people in these particular areas?
Dr. Bodenheimer: It doesn’t necessarily require the occupation of Health Coach. It requires everyone doing coaching as the basis of their interactions with patients. If community health centers could hire people who can do health coaching full-time and are well trained in the coaching philosophy, that would be great. But everyone working in a community health center should use health coaching with every patient.
Dr. Thom: I think the work done by nurses, midwives, and doulas has provided inspiration for health coaching, as they have been using many of the same techniques professionally for decades. Hopefully, the progress and success of health coaching has in turn provided them with inspiration and new tools or has helped refine the tools they were already using to communicate with and support their patients and clients.
I think both clinic-based and community-based Health Coaches can do a lot to support women’s health. I don’t know of any studies of Health Coaches working in ob-gyn practices, but I imagine they could be quite valuable. Ob-gyn is unique, I think, in being a surgical specialty that also functions in many places as a source of primary care for women. Community health workers, under a variety of names, have played a key role in women’s health for many decades and around the world. Many have embraced and been trained as Health Coaches and integrated coaching into their work. More can be done to make Health Coach training more available and finding ways to best support health coaching for women in underserved communities.
Anything else you think the IIN community would like to know?
Dr. Bodenheimer: Thank you for your work in health coaching.
Dr. Thom: My answers have been about health coaching in general, which is what I best know, rather than health coaching in the area of integrative nutrition and health. I think health coaching is a great fit whether done in a community or medical setting.
Learn more here about how Health Coaches play a vital role in the greater healthcare system!