2. Health Coaching as a Strategy in the Team Practice Environment Leigh Ann Simmons, Ph.D. Assistant Professor, Medicine Senior Faculty Fellow for Clinical and Translational Research Integrative Health Coach Duke Integrative Medicine © (Copyright) 2011-12 Duke Integrative Medicine / Duke University Medical Center

3. Objectives Describe Duke’s model of coaching Summarize published research supporting use of Duke’s IHC in chronic disease care Review approaches to team-based care with coaching

4. What is Integrative Health Coaching (IHC)?

5. Why Integrative Health Coaching (IHC)? 75% US health care dollars ($1.87T) spent on chronic diseases 40% Premature U.S. deaths caused by lifestyle choices 35.8% U.S. adults who are obese 60-90% MD visits related to stress

6. Why IHC?

7. Lower mortality in population of interest Reduce risk factors for severe illness Change in actual health behaviors Identify and prepare patients to change health behaviors

8. What is IHC? Transtheoretical model Social ecological model Draws from: Psychology Adult learning theory Personal development Also has roots in:

9. What is IHC? Whole person approach Patients = life-long learners Personal values and sense of purpose  potential for change Goals linked to values and sense of purpose  sustain new behaviors

10. What is IHC? ResourcesSolutionsPerceptionParticipation Supportive alliance between patient and coach

11. Patient is at the center of care

12. What is IHC? Clarify goals Implement and sustain behaviors, lifestyles, and attitudes that promote optimum health Assist patients in reducing the negative effects of chronic conditions

13. What is IHC? Clinical, social, behavioral data Standardized health risk assessments Current / projected health status Personalization Individualized roadmap  desired health Patient’s readiness for change in the context of goals Planning

14. What is IHC? IHCMI PHP Wheel of Health Mindfulness Tool or Individual Vision Values Importance Confidence OARS Patient-centered Empathy SMART goals Tool

15. Does IHC work?

16. Evidence of Efficacy Growing body of work CVD, T2D Published studies CVD risk, postpartum weight retention, tinnitus Ongoing studies

17. Risk of Cardiovascular Disease 1 154 primary care patients 10 months personalized health planning Baseline HRA (blinded staff) Group education Individual phone coaching Usual Care Randomized 1 Edelman D, Oddone EZ, Liebowitz RS, et al. A multidimensional integrative medicine intervention to improve cardiovascular risk. J Gen Intern Med. 2006;21(7):728-734.

18. Intervention Structure 2 visits with MD/PA to discuss CVD risk (baseline and midpoint) Weekly then biweekly group education sessions with coach Created vision, clarified values, set SMART goals Biweekly individual telephonic coaching sessions

19. Primary Outcome: 10 Year Risk of CHD

20. Secondary Outcomes Blood pressure Lipids Body mass index Biological Exercise Nutrition Smoking Readiness to change Behaviors

21. Outcomes: Biological p> 0.01 for all

22. Behavioral Outcomes p 0.1 for smoking

23. Behavioral Outcomes: Readiness to Change

24. Randomized Controlled Trial RCT: Coaching n=27 vs. Control n=22 Pre-Post Coaching, Groups Combined: n=48 IHC for Type 2 Diabetes 2 2 Wolever et al. Integrative health coaching for patients with type 2 diabetes: A randomized clinical trial. Diabetes Educ. 2010;36(4):629-639. For >1 year: (1) Dx of Type 2 diabetes (2) On oral med(s)

25. Study Intervention 6 months individualized coaching Intake, 8 weekly, 4 biweekly, 1 monthly 14 phone sessions30-minute phone callsASK-20®, Essential Connections®

26. Study Sample Groups demographically similar Mean Age = 53 (8.4) yrs 78% Female 41% White, 55% AA, 4% Asian Mean Diabetes Duration = 11(6.7) yrs

27. Between-Groups Results: Barriers to Medication Adherence

28. Between-Groups Results: PAM

29. Between-Groups Results: Social Support

30. Within-Group Results: Exercise

31. Within-Group Results: Missed Medication

32. Within-Group Results: Blood Glucose Control

33. Research Implications: Chronic Disease Lifestyle behaviors Psychosocial outcomes Patient activation & readiness to change Medication adherence Clinical outcomes & risk

34. What does IHC look like in practice?

35. Provider Encounter Health Status Vision Values Focus Importance Confidence Goals 1 small action step Summarize: Here’s what I’ve learned about your health from my exam, test results, and our conversation. My concerns are …. SOAP = Objective, Assessment

36. Provider Encounter Health Status Vision Values Focus Importance Confidence Goals When you picture yourself in optimal health, what do you see? What is important about what you see in this picture? 1 small action step SOAP = Subjective

37. Provider Encounter Health Status Vision Values Focus Importance Confidence Goals Given what I’ve shared about your current health and risks AND given what you’ve identified as most important to your optimal health: What area are you most interested in changing in the next few months? What would those changes be? 1 small action step SOAP = Plan

38. Provider Encounter Health Status Vision Values Focus Importance Confidence Goals On a scale of 1-10, how confident are you that you can achieve it? On a scale of 1-10, how important is this change? 1 small action step SOAP = Plan

39. Provider Encounter Health Status Vision Values Focus Importance Confidence Goals SMART: What specific action can you take in the next 4 weeks that seems doable? Improve medication adherence  By the end of 4 weeks I will take all daily medications 5 out of 7 days. 1 small action step SOAP = Plan

40. Provider Encounter Health Status Vision Values Focus Importance Confidence Goals SMART: By the end of the week I will purchase a pill pack to organize medication by day and place one week’s worth of medications into pack. 1 small action step SOAP = Plan

41. Group-Based Care Disease prevention and management Weekly / Biweekly education and treatment In person or telephonic Group and/or individual coaching

42. Patient-Centered Medical Home All members of the health care team trained to use coaching skills Switches between education + coaching Nurse trained as coach Person’s only role is coaching Group and/or individual; onsite and/or telephonic Coach(es) on staff

43. Patient-Centered Medical Home Uses coaching skills as part of therapy Behavioral health specialist trained as coach Primary provider + RN + coach “Mini-Teams” within a practice

44. Can I bill for this? Personalized Health Planning Annual wellness visits GO438 $172 GO439 $111 Health & Behavior Assessments/Services CPT codes 96150-96155 $15-$50/15 min increments

45. Questions?

46. Acknowledgements CMS (CVD study) GSK (T2D study) Ruth Q. Wolever, PhD Linda Smith, P.A. Research Team, Duke IM