PCORI funded the Pilot Projects to explore how to conduct and use patient-centered outcomes research in ways that can better serve patients and the healthcare community. Learn more.

Background

Health coaching has been proposed as a relatively inexpensive and effective means to improve management of chronic conditions including diabetes, asthma, hypertension, and chronic obstructive pulmonary disease. Coaches may be particularly valuable in resource-poor settings, where minority and low-income communities bear a disproportionate burden of chronic disease and its complications and are less likely to engage in effective self-management of their conditions. Health coaches in primary care usually work with patients on “everyday decisions” such as taking medications, engaging in physical activity, or making dietary changes. Although previous qualitative studies have investigated shared decision making between patients and clinicians and self-management support for patients by care coordinators, little research has addressed how health coaches support patients in making decisions and changing behaviors.

Project Purpose

This study was designed to achieve the following objectives: (1) to develop a better understanding of how health coaches, as members of the patient care team, work with patients in making health-related decisions; (2) to apply a mixed-methods research model responsive to the needs of patients; and (3) to gain insight into new possibilities for engaging patients, ascertaining and responding to patient preferences, and supporting patients in making choices.

Study Design

Qualitative study using focus groups and individual interviews with patients, patients’ families and friends, health coaches, and clinicians. Direct observation with stimulated recall of visits between patients, health coaches, and primary care clinicians.

Participants, Interventions, Settings, and Outcomes

Participants included all health coaches working, or who had recently worked, at each of six urban community health clinics; the patients they had coached; the patients’ primary care providers; and family members. The study was conducted at six urban public health primary care clinics serving low-income patients that have used health coaches for at least one year.

Data Analysis

Transcribed data were stripped of personally identifiable information and imported into ATLAS.ti. The researchers used multistaged coding based on grounded theory. All transcripts were independently read by at least two members of the study team, with discrepancies in the assignment of codes resolved either between the readers or by the entire group as necessary. Initially, readers assigned descriptive labels to key passages, and similar labels were grouped to create an initial set of “concept codes” (open coding). Concept codes were combined into broader “category codes” and organized into themes through group discussion and consensus reasoning (axial coding). This process included disaggregation of the category codes and reorganization of some original concept codes. Finally, selective coding was used to identify the relationships among themes, which are presented as a conceptual model.

Findings

Analysis of the interview and focus group data identified the following core features (themes) of successful coaching: peer relationship, availability and continuity, a strong relationship based on mutual trust, providing personal as well as practical support, and bridging between patients and their clinicians. Researchers found that the relationship between the patient and health coach, particularly the degree of trust, was central to effective coaching. Shared characteristics between the coach and patient, and the frequency, duration, and nature of contacts were important for initiating a trusting relationship, which provided the basis for effective health coaching. Health coaching activities that supported patient decision making were grouped into four broad themes of education, personal support, direct decision support, and acting as a bridge between patients and their clinicians. These activities in turn strengthened the relationship between the coach and the patient.

Limitations

This study was conducted with public health “safety net” clinics only, and coaches were trained using a well-developed curriculum. The generalizability of these findings to other populations and to health coaches with different training is not known.

Conclusions

The central importance of the coach-patient relationship in the model developed in this study is consistent with previous studies of nursing support. This study takes a further step toward understanding the development of a strong, trusting relationship with a health coach and how a strong relationship provides the basis for effective coaching. Specifically, the researchers found that the peer-like relationship between patients and health coaches was important for establishing a closer, trusting relationship where patients felt able to be more open and engaged. This was in contrast to the inequality in social power between patients and clinicians. Health coaches often supported patients by acting as a bridge between patients and their clinicians, thereby reducing the power differential. These observations fit well with a recent review that found power inequality between patients and clinicians to be a major barrier to patient participation in shared decision making. These themes and the resulting conceptual model can be used in training and supporting health coaches.