Beyond the bottom line

A growing number of health management companies are going beyond simply measuring outcomes and are looking under the hood of their health coaching programs to make sure their offerings are actually causing the intended results.

Ariel Linden, DrPH, MS, president of Linden Consulting Group in Hillsboro, OR, says exploring the actual nuts and bolts of a health coaching program shows a company where its program is making gains and engaging members and highlights areas of concern. If a company cannot show improvements in patient activation, Linden says he isn’t confident that companies can accurately attribute its health coaching programs to a positive outcome.

Linden says he sees more interest in the DM space on this kind of view, but the majority of DM programs are still not properly reviewing their programs and, subsequently, not providing the best health coaching. As a health service researcher, Linden says he is just as interested in those kinds of causal pathways as he is the bottom line.

Linden and Susan Butterworth, PhD, director of Oregon Health & Science University’s Health Management Services in Portland, run a program that performs stem-to-stern review of health coaching programs.

One way to review a health coaching program is by randomly selecting calls between coaches and patients using measures to review whether a coach is proficient in motivational interviewing—Motivational Interviewing Treatment Integrity Code—and how the patient is progressing in his or her health—Patient Activation Measure (PAM).

That’s not to say that any person can listen to a call and effectively track motivational interviewing techniques. That kind of expertise takes training and knowledge. By reviewing calls, Butterworth says she is able to accurately weigh whether the intervention is effective and is responsible for patient and bottom-line improvements.

Companies can use these methods to conduct regular review of their programs and consider their effectiveness. Through the process, Butterworth also reviews hiring, materials, training groups, managers, and how they support the coaches. After a thorough review, Butterworth says its gives her more confidence that the intervention caused the results.

Chris Delaney, CEO of Insignia Health in Portland, OR, says the PAM effectively segments a population based upon levels of activation and the performance of nearly 100 self-management behaviors, helping coaching programs achieve higher levels of member activation, reduce unwarranted utilization, and allocate resources more effectively.

The 10- and 13-question PAM, which is used in about 15 countries, segments people into four levels:

  • Level 1 (starting to take a role in their healthcare): 10%15% of adults
  • Level 2 (building knowledge and confidence): 25%30% of adults
  • Level 3 (taking action in their healthcare): 32%37% of adults
  • Level 4 (maintaining behaviors): 20%24% of adults

Delaney says the PAM, developed by Judy Hibbard, DrPH, and her colleagues at the University of Oregon, offers a wealth of insight not found in other measurement tools, such as health risk assessments (HRA).

Although many HRAs have dozens of questions that gauge a person’s health status and functioning, these assessments do not tackle the underlying drivers to healththe self-management competencies that are largely responsible for health status and future risk.

“We’re trying to capture the insights most relevant to effecting behavior change, and we think we have that in the Patient Activation Measure,” he says.

Motivational interviewing

Linden says motivational interviewing training is key. Ongoing trainingnot just sessions when a person is hiredensures that health coaches use proper methods.

For health coaches to engage and activate people with chronic disease goes beyond having call center nurses with clinical backgrounds.

Without the proper training, the medically trained often do not know how to bring about change. One way to do this is to show empathy and not try to force someone to make a change. Nurses shouldn’t push patients before they are ready. “Empathy happens to be one of the most important traits,” says Linden.

Although call center nurses have clinical backgrounds, Linden says that is not as important as understanding how to elicit behavior change. In fact, he says, a layperson with motivational interviewing expertise can perform a call center function better than a clinical nurse. “This is a meat-and-potatoes behavior change. This is the kind of thing that no one in the industry is ever talking about,” he says.

However, Butterworth says nurses with clinical backgrounds are needed because those coaches understand diseases and symptoms. “I still think people need to use their clinical expertise because they can recognize symptoms and know the right questions to ask,” she says.

Ways to measure a health coaching program’s effectiveness

The following four steps can help gauge whether a health coaching program is successful, says Chris Delaney, CEO of Insignia Health in Portland, OR:

  • Establish a baseline score with the Patient Activation Measure (PAM)
  • Readminister the PAM on a regular basis to assess programs and optimize as needed
  • Review utilization metrics, such as pharmacy benefit management and claims data
  • Analyze available biometric data including changes in BP, blood sugar, cholesterol, and weight

Avoid these health coaching mistakes

One common mistake that health coaching nurses make is that they give patients information or advice before they are ready to make a health change, says Susan Butterworth, PhD, director of Oregon Health & Science University’s Health Management Services in Portland, OR. Nurses should assess a person’s readiness to change. “When a person shows resistance, instead of backing off and reading that as ‘I need to change my approach,’ [untrained nurses] push harder,” Butterworth says of health coaches who are not following motivational interviewing principles.

“There are studies that show that that kind of resistance, where someone is pushing on someone to make that change, and the person is giving you the ‘yeah, but’ dance ... that actually predicts negative clinical outcomes,” says Butterworth. “So, in a sense, [when a coach pushes too hard], that’s not just neutral, they are doing harm.”

If a patient is showing resistance, Butterworth says, a coach should explore the person’s ambivalence and find out what is holding the person back. She says people want to be healthy but, for many, that’s difficult to do. It’s like cleaning the garage, she says. You know you should do it, but there are plenty of good reasons to delay the chore. “The only thing that makes it different is that with cleaning out the garage, you’re not going to die from it,” she says.

Butterworth says it’s difficult for many because people have used unhealthy habits such as cigarettes as a coping mechanism. In effect, by pushing a person away from tobacco, you are removing a crutch. “What we do is help them to explore what they would like to do, and then, once motivated, we help them find a plan that helps them address those barriers and helps give them substitutes [to the crutches].”

Butterworth says health coaches can’t help people change until those people stop resisting and start talking about how they might benefit from changing their behaviors. Instead of reciting barriers to health, the people begin to discuss ways to improve their behaviors.

“What makes a really good collaborative team is when the coach comes in with their expertise, but they acknowledge that the patient has just as much to do with solving the problem, and they work together to solve the problem,” says Butterworth.

Another mistake call center nurse systems make is that they spend too much time following a script rather than teaching nurses how to effectively talk to patients. “I’m pretty anti-script, because scripts are antithesis to the whole notion of being with the patient where they are in their state of readiness to change,” says Butterworth.

Chris Delaney, CEO of Insignia Health in Portland, OR, says a critical way to bring activation is to “start where the patient is” and through gaining knowledge and confidence. “If you lack confidence, you’re not going to be terribly motivated,” he says.

DaVita-Village Health changes to motivational interviewing

One DM company that created a health coaching program with motivational interviewing is DaVita-Village Health in Vernon Hills, IL, a DM company that focuses on end-stage renal disease.

Andrew Hayek, president of DaVita-Village Health, says his company implemented the programs to help members with such areas as staying current on flu shots. The coaches are able to explore why some members may reject flu shots, such as a friend’s negative experience with the shot. The coaches find the root cause and then explore the best way to resolve that barrier, such as interaction with a physician. This kind of health coaching requires asking open-ended questions and a heavy dose of listening, Hayek says, adding that DaVita-Village Health’s leadership changed to motivational interviewing for its health coaches in 2007 because they believed it would work in its patient population. The company’s nurses focus on helping patients who are at risk of a near-term hospital admission. Hayek says the company has not had the program in place long enough to have specifics about how it has affected patients and costs. “I think that our experience is too new to draw conclusions that should be applied elsewhere. However, our thinking and our work has reflected that patients’ decisions play a role in care, and that thoughtfulness of getting to root cause as to why patients may make decisions that results in less-than-best practices being delivered is important,” he says.




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