Health coaching: adding value in healthcare reform.

During the last decade, debate about the nation's ailing healthcare system has moved to the forefront. In 2010, the Patient Protection and Affordable Care Act (PPACA) was signed into law. This groundbreaking piece of legislation impacts every aspect of the health industry, affecting everyone from doctors and health-care facilities to insurers and benefits consultants to business owners and patients. The ultimate goal of PPACA is to decrease the number of uninsured Americans and reduce the overall costs of healthcare.

INTRODUCTION

During the last decade, debate about the nation's ailing healthcare system has moved to the forefront. In 2010, the Patient Protection and Affordable Care Act (PPACA) was signed into law. This groundbreaking piece of legislation impacts every aspect of the health industry, affecting everyone from doctors and health-care facilities to insurers and benefits consultants to business owners and patients. The ultimate goal of PPACA is to decrease the number of uninsured Americans and reduce the overall costs of healthcare.

Most experts agree that fundamental improvement in healthcare economics depends heavily on a three-part strategy:

Shifting from an economic model based on fee-for-service treatment of illness, with a natural bias toward doing more, to an outcomes model with compensation for improvement in health;

Reducing consumption of medical care by improving health; and

Increasing consumers' focus on and accountability for their health and healthcare costs.

This focus has invigorated the health coaching industry. Employment opportunities for health coaches are growing exponentially as the provisions of healthcare reform are implemented.

The concept of the coach as “one who instructs or trains” was established long ago. With its roots in athletics and sports, coaching has made a socially accepted transition into virtually all aspects of life, including health. However, in attempting to define health coaching, one finds there are a variety of definitions put forth by the industry vs one clear, concise, and widely accept definition. In 2003, an article in the International Journal of Health Promotion and Education described the variation in this manner:

What is coaching? There are many definitions of coaching. Four are summarized below:

Coaching is unlocking a person's potential to maximize their own performance. It is helping them to learn rather than teaching them—a facilitation approach (Whitmore 1992, based on Gallwey, a tennis expert).

Coaching – Directly concerned with the immediate improvement of performance and development of skills by a form of tutoring or instruction—an instructional approach (Parsloe 1995).

Coaching – The art of facilitating the performance, learning and development of another—facilitation approach (Downey 1999).

Psychologists have developed another variation:

Coaching psychology is for enhancing well being and performance in personal life and work domains with normal, non-clinical populations, under-pinned by models of coaching grounded in established adult learning or psychological approaches (adapted Grant and Palmer 2002).

It can probably be assumed that these definitions should reflect the nature of coaching as practiced by many practitioners. Therefore, the key aspects of coaching, depending upon the model of coaching being applied, appear to include enhancing wellbeing, learning, facilitation, tutoring, social support, instruction, development of skills and improving performance. In addition, coaching is usually goal and solution focused (Grant 2001).

This foundational variation in definition and lack of uniform criteria for the coaching process sets the stage for variation in practical application. This diversity is also the root cause of variability in and potential for unwarranted care in medical practice. The industry is responding to such challenges by focusing on the goals of health coaching.

It is generally accepted that coaching, particularly within the health field, is a process-driven activity that helps individuals transform their goals into action. Significant research has been conducted in the field of health coaching to help better define the processes and techniques that are most likely to result in positive outcomes. The processes involve foundational elements of building trust and rapport along with strong interpersonal communications. The health coaching communications processes are guided by techniques such as motivational interviewing.

Research shows knowledge alone does not promote change, but when motivation is added to the equation, change is likely to occur.3-5 An article in the Journal of Medical Ethics states that providing access to health-care is important; however, equally important is the need to “empower individuals to take responsibility for their own health.” One of the most widely deployed methodologies to create this environment for individuals is a one-to-one interaction between a skilled change agent (a health coach) and a motivated individual.

Coaching, particularly health coaching, can take place in a variety of settings and use a variety of delivery mechanisms, ranging from a one-to-many relationship to the most intimate and arguably beneficial one-to-one relationship. With its roots in the telephonic delivery model of live one-to-one real-time interaction, the individual model of coaching interaction has changed over time to include a variety of modalities of coaching delivery. Specifically, these models include digital media (video), as well as online, onsite, and telephonic methods that include both talk and text messaging. Advancing technology and consumer adoption of these technologies are helping drive the growing need for complete integration of information and experience—integration of online/self-directed change and coaching-supported change. The modalities are all designed to encourage an individualized approach that allows interaction with the participant in his or her preferred method. Many coaching relationships ultimately include a variety of deployed modalities designed to meet the needs and preferences of individuals while helping guide them to their ultimate goal of adopting healthy lifestyle behaviors and making informed medical decisions.

Sustainable behavior change, however, is very difficult. This is why interventions that are shown to be successful in clinical trials frequently are not successful in real-world scenarios. Creating an environment of individual support and guidance can help facilitate lasting change at every stage in the health continuum. Health coaches can help individuals change the behaviors that create health risks—key drivers of future costs—as well as help them to better self-manage their chronic health conditions and reduce costs.

The 2010 World Economic Forum (WEF) identified eight well-known health behaviors as the major contributors to the fifteen most costly chronic conditions. The health behaviors identified by the WEF are smoking, physical inactivity, poor diet, alcohol consumption levels, poor standard-of-care compliance, poor stress management, insufficient sleep, and lack of health screening. Unlike some risk factors for chronic conditions, each behavior identified by the WEF is within an individual's ability to control. What's more, individuals are also faced daily with a myriad of health decisions ranging from items as simple as which prescription medication to choose (generic or brand name) to complex decisions about surgical treatments. Coaches can provide tools and guidance to help consumers make educated decisions about these important medical and treatment options.,

A GROWING FIELD

The rising need to focus on health behavior change at the individual level, particularly the imperative to reduce risk associated with chronic conditions, is driving public health professionals into the health coaching field. Like many growing industries, health coaching is quite varied in workplace opportunity as well as requisite training and credentialing. Individual practitioners often come to the field one of three ways: out of personal interest, from the public health sector, or from the medical field. Each of these directions brings with it associated variation in the education, training, and credentials of the health coaching professional.

Personal interest as a route of entry is seen in some of the high-profile individuals in the field (eg, personal trainer Jillian Michaels). This route of entry does not require any specialized educational background or related credentials. Rather, this route is often based on an individual's personal experience and interest coupled with a commercially available training or credentialing program. Most employment opportunities for coaches in this category are limited to that of solo practitioner.

By common definition, public health is the science and art of preventing disease, prolonging life, and promoting health through organized community efforts. Public health practitioners most often have an academic background in the public health field. This educational background couples community-based modalities with those that are applicable at the individual level. Many health coaches with public health academic preparation are credentialed as Certified Health Education Specialists. This credential requires that an academic degree explicitly be in a discipline of health education. Employment opportunities for health coaches from a public health background are most often found in local healthcare entities (physician offices, clinics, hospitals, etc); employer-sponsored wellness programs (employed by a company as onsite wellness coordinator/coach); or at specialty vendors providing coaching services to employer-sponsored wellness programs.

Healthcare professionals have long provided health education to patients, frequently with mixed results due to time constraints, reimbursement, and resource availability. Additionally, the orientation of “expert practitioner informing passive patient” is contradictory to the model of empowerment and self-direction that is critical in effective health coaching. The goal of practitioner-provided education historically was focused on specific disease processes, with a focus on treatment options and individual responsibilities for self-management (eg, medication, special diets, exercise guidelines). As the need for increased personal responsibility for health has increased, the healthcare community has met the need with increased opportunities for credentialed healthcare professionals to enter the health coaching profession. Healthcare professionals are considered to be those with academic preparation and credentialing in a healthcare field (eg, MD, RN, RD, CDE, EP). Most healthcare professionals who work in the health coaching field are not required to hold any additional credentials related specifically to health coaching. Their training as healthcare professionals coupled with direct employer-provided training is the usual standard, though independent training programs and academic educational offerings have expanded individuals' professional development options in the last decade. The majority of employment opportunities for healthcare professionals as health coaches are found in locations similar to the public health field—health-care entities (physician offices, clinics, hospitals, etc), employer-sponsored wellness programs, and specialty vendors providing services to employer-sponsored wellness programs. The one major addition to this is the opportunity for employment within health plans at organizations providing medical insurance coverage.

The PPACA and its focus on greater patient responsibility and accountability for individual health will only increase the need for health coaching as a profession and open opportunities for practitioners within the field. Individual motivation for engaging in health coaching can come intrinsically or extrinsically. Intrinsically motivated individuals are the ones who decide on their own to modify their behavior and ultimately impact their health. Extrinsically motivated individuals are those who are motivated by an employer-provided incentive associated with healthcare insurance coverage. The sources of health coaching available to these individuals and the payment mechanism for that coaching varies as well.

Coaching participants who engage with a solo practitioner typically pay for services out of pocket, whereas individuals who engage in health coaching via healthcare entities—physician offices, clinics, hospitals, etc; employer-sponsored wellness programs; or an organization providing medical insurance coverage—typically do not pay on an individual level for coaching services. Rather, services are covered as part of medical insurance benefits provided by an employer. The payment mechanism tied to medical insurance benefits ultimately may be the most critically assessed in terms of a cost-benefit outcome. As PPACA continues to be implemented, an increase in credits to the plan sponsor (employer, in this case) is also increasing. This may provide additional motivation to enhance the coaching services offered.

Careful scrutiny of the health coaching industry to provide meaningful outcomes to both individuals involved in the coaching process and the payor of those services has led to an interesting dichotomy of challenges. The health coaching industry has responded to the changing landscape and resulting challenges by expanding its scope and opportunities for individuals to enter the field as well as by expanding the modalities available to engage with participants and help them meet individual goals. Variability in physician practice patterns is a well-documented driver of unnecessary care and associated costs., To prevent a replication of this same challenge within health coaching, the next logical step in the equation is for the industry to reach consensus on health coaching as a professional endeavor.