1. Lifestyle Coaching One-on-one Interventions for Health Behavior Change ORC Western Occupational Safety and Health Group June 15, 2006

2. Harvard Business Review “ Companies that take this approach gain some control over seemingly uncontrollable health care spending and create a win/win situation…” “An ounce of health is worth a pound of health care…”

3. The Economic Burden of Lifestyle Risks More than 50% of disease is preventable – due to lifestyle Total costs of obesity in 1995 exceeded $99 billion Research connects inactivity with: –Depression –Cancer –Heart disease –Stroke –osteoporosis

4. Empowering Behavior Change Start with proven behavior change models –Stages of change –Social cognitive theory –Theory of planned behavior

5. Applying These Models to Lifestyle Coaching Self-management education –Goal to assist health care consumers in improving their confidence in their ability to manage challenges associated with living a healthy life or with chronic disease Motivational interviewing –Expressing empathy, avoid directive or confrontational language –Develop a discrepancy between current behavior and overall goals and values

6. Traditional Care vs. Collaborative Care IssueTraditional CareCollaborative Care Relationship Health care provider is the expert in charge of change. Patient is passive. Patients empowered to be active. Expertise about change comes from both patient and provider. Goal of care Patient compliance with provider’s instructions. Collaboration in goal-setting and informed decision-making. Difficulties in making change Viewed as patient noncompliance, a personal deficit. Viewed as an expected part of change process, multiple strategies used to problem-solve around barriers and move forward. Problem-solving Provider does the problem-solving for patient. Provider teaches and assists patient in actively problem-solving throughout change process. Adapted from Bodenheimer et al. JAMA. 2002, 28 (2469 – 2475)

7. Traditional Patient Education vs. Self-Management Education Issue Traditional Patient Education Self-Management Education Educational content Information and technical skills about disease. Goal-setting and problem- solving skills. Theory underlying education Information delivery increases knowledge, which leads to health behavior change. Patient self-efficacy (self- confidence in ability to make change) leads to health behavior change. Goal of education Patient compliance with behavior change. Increased patient self- efficacy for making and maintaining change. Adapted from Bodenheimer et al. JAMA. 2002, 28 (2469 – 2475)

8. Critical Skills and Ongoing Strategies Assessment of behavior Build self-efficacy Goal-setting and problem- solving skills Support and make individualized plan

9. Research Supporting Behavior Change Interventions Meta analysis of treatments with motivational interventions show significant impact for lifestyles such as diet and exercise Self-management programs also effective for chronic diseases

10. Coaching Relationship Quality of relationship critical to effective change Collaboration rather than confrontation Beyond simple information delivery, training in health behavior change, motivational interviewing, self-management education

11. Goal-Setting and Action Plans Emphasizes short-term, achievable goals Success enhances motivation for additional change If not confident in ability to reach goal – modify it Action plans incorporate problem-solving techniques

12. Dealing With Barriers to Change Counselors help identify personal barriers that could result in failure Plan around barriers in advance More accepted by people who have been discouraged by information- only interventions

13. Measuring Success Self-report often used Validated measures of health behavior – weight loss, change in nutritional habits Importance of measuring change process, i.e. self-efficacy People who report greater confidence in ability to be physically active have higher levels of physical activity

14. Guiding Participants to Telephonic Programs Health Risk Assessment Existing chronic conditions Low and moderate risk (0-4 risk factors) HRA data feed to data management warehouse HRA data feed for incentive fulfillment High-risk (5+ risk factors) Data integration (claims, etc.) Incentive eligibility and fulfillment Disease management programs Telephonic lifestyle coaching programs Web lifestyle and behavior change programs

15. HRA Intervention Report Provide telephonic counselors with relevant data on high-risk individuals for follow-up intervention

16. Lifestyle Coaching Healthy practices Lifestyle Coaching Confidence Outcome General health

17. Participation Projection Model Percent of populationAction X%HRA completions dependant upon incentive 40%Identified as high-risk 40%High-risk participants consenting to receive a call 70% - 80%Consenting participants are reached 60%Enroll in program 35%Accept a one-time educational intervention 5%Decline counseling

18. Corporate Culture Considerations Assess current sensitivities Trust issues impact receptivity to consent

19. Mayo Clinic Telephonic Lifestyle Coaching Programs Personalized treatment plans and counseling for key lifestyle issues: Mayo Clinic Tobacco Quitline Mayo Clinic Weight Advisor Mayo Clinic Exercise Advisor Mayo Clinic Nutrition Advisor Mayo Clinic Stress Advisor

20. Integrated with Mayo Clinic HRA Focus on high-risk individuals Collaborative self-management model drawing upon Stanford research and Mayo expertise Lifestyle Coaching Model

21. Collaborative Self-Management Model One-to-one relationship with counselor Participant generated goals and action plans Internal motivation more effective than external motivation Building confidence through self-efficacy model Leading to sustainable change

22. Lifestyle Coaching Process Flow Intake Call Participant enrolled if ready, or directed to resources to help move along behavior change continuum. Assessment Call  Behavior change counselor conducts 30- minute assessment  Reviews risk factors, identifies medical conditions, medications  Provides detailed explanation of how program works and benefits of program  Goals are set based on participant input Education Call  Resources reviewed specific to participant risk factors  Encouragement to call when ready to enroll Behavior Change Facilitation – Series of Calls Over 6 Months  Review progress towards goals – set new goals for next call  Check confidence level for achieving set goals  Coach on barriers, triggers, learn from successes  Arm with relapse prevention strategies  Participant may contact counselor between calls for additional support. Outcome Calls – at Program Conclusion and at 6 Months  Outcomes measured are module-specific and includes satisfaction, efficacy, behavior change and goal achievement

23. Lifestyle Coaching Qualifications Intake workers – initial call –Customer service experience Counselors –Four-year degree in psychology, social work, sociology, nursing or counseling –Trained in motivational interviewing techniques and self-management education principles

24. Lifestyle Coaching Training Training with content experts and medical consultants Motivational interviewing training from nationally certified trainer Preceptor training with veteran staff Ongoing access to content and medical experts

25. Lifestyle Coaching Reports Eligible participants –Unable to contact –Contact but decline –Enrolled Enrollees by program Program satisfaction Program outcomes

26. Mayo Clinic Healthy Weight Advisor Six-Month Outcomes 49% lost weight and maintained weight loss 35% of those who lost weight, lost more than five pounds 57% increased confidence in ability to manage their weight

27. Mayo Clinic Exercise Advisor Six-Month Outcomes 64% increased the amount of time they spent exercising 38% maintained weight loss as a result of being in the program 37% increased their confidence in their ability to increase their physical activity

28. Mayo Clinic Nutrition Advisor Six-Month Outcomes 61% increased their healthy eating choices 39% lost weight and maintained weight loss 61% increased their confidence in ability to maintain healthy eating habits

29. Mayo Clinic Stress Advisor Six-Month Outcomes 62% increased confidence in ability to manage stress 75% experienced fewer stress-related physical symptoms than at the beginning of the program 57% increased the total amount of stress-related techniques used

30. Mayo Clinic Tobacco Quitline Outcomes Industry leading quit rates: 42% at 6 months 37% at 12 months 6 Months12 Months % of enrollees

31. Lifestyle Coaching Program Satisfaction 90% of participants would recommend program to others 90% 5% 2% 1% No Yes Maybe Don’t Know Refused

32. Trend to Offer Incentives for Participation in Behavior Change Programs Educational Benefits-linked Cash Gift certificates e-Gift certificates Paid time off Drawings for trips Mayo Clinic books

33. Employees Favor Benefit-Linked Incentives for Healthy Change Lifestyle IssueMenWomen Stop-smoking programs 68%74% Join a gym 58%62% Join a weight reduction or management program 63%66% Source: Wall Street Journal Online/Harris Interactive Health-care Poll. Dec. 2005. N = 2,007

35. Keys to Effective Lifestyle Risk Reduction Identify company-specific cost drivers (HRA) Give programs adequate breadth, depth and reach Leverage existing resources – buy-in at the top Integrate (teams, efforts and data) Use incentives Use a multimodal communications approach Measure and analyze outcomes to guide program decisions Know your data (costs, risks, etc) and how to integrate it

36. Questions