AHIP Coverage (July/August 2007)
Guiding the Way to Wellness
Plans are increasingly relying on health coaches as part of the team or approach that encourages patients to adopt healthy habits.
By Jay Greene
Each day hundreds of health coaches—the personal trainers of the medical field—employed or contracted by health plans including Aetna, Group Health Cooperative, Blue Cross Blue Shield of North Carolina, and Independence Blue Cross are phoning thousands of members who have chronic conditions or are enrolled in wellness programs to answer questions and provide information and tools to improve their health. From offering advice on how to better manage diabetes to how to lose weight or stop smoking, the coaches—many of whom are registered nurses, dieticians, health educators, social workers, or certified case managers—are trained in motivational interviewing techniques, a non-confrontational type of conversation that seeks to reinforce members’ desire to maintain or improve health.
Health coaches have been used by insurers, health plans, and large employers in various ways since the 1980s. But employers’ efforts to reduce health care costs and identify employee health risks before they become expensive chronic conditions, and the increased enrollment in consumer-directed health care, have expanded the use of health coaching in the past three years, says Betsy Nota-Kirby, wellness design lead at Aetna, Hartford, Connecticut.
“Health coaches are trained not to preach when you talk with clients,” says Nota-Kirby, herself a health coach. “You elicit responses about what they want to work on and what interests them, and set a goal. You get one or two actionable items from them to help meet that goal.”
Aetna uses health coaches primarily in its wellness programs, some of which are geared toward smoking cessation, weight loss, and controlling high cholesterol, high blood pressure, and other health risks. Registered nurses in the plan’s case and disease management program also have been trained in health coaching to answer questions, promote lifestyle changes, and encourage members to follow treatment plans, Nota-Kirby says.
Disease management and case management staff generally work with 20 percent of the plan’s membership who have chronic conditions. “Wellness coaches deal with portions of the other 80 percent of members, some of whom may have looming health risks,” she adds.
Blue Cross and Blue Shield of North Carolina (BCBSNC), Chapel Hill, offers 11 types of health coaching programs focused on stress management, high blood pressure, high cholesterol, asthma, coronary artery disease, diabetes, migraine, fibromyalgia, prenatal care, tobacco cessation, and weight management.
“Coaching is designed to motivate and empower our members to change behaviors and improve their health,” says Heidi Deja, a BCBSNC spokeswoman. “We have had this in different forms for a few years but expanded it as part of our member health partnerships last year.”
BCBSNC’s Member Health Partnerships take a team approach to chronic care. As part of the team, health coaches or case managers work with members to ensure that they receive needed services. Enrollment in health coaching this year has been strong, Deja says.
Studies Illustrate Growth, Effectiveness
In 2007, 44 percent of large employers offered health coaching services to their employees and another 13 percent plan to do so in 2008, according to a survey by the National Business Group on Health, Washington, D.C., and Watson Wyatt, an Arlington, Virginia-based consulting firm. But does coaching improve health and help reduce costs? A growing number of peer-reviewed studies, internal reports, and anecdotal reports seem to confirm its effectiveness.
For example, only 8 percent of patients discharged from the University of Colorado Health Sciences Center who received coaching services visited an emergency room in the six months after their release, according to a study in the Sept. 25, 2006, issue of the Archives of Internal Medicine. On the other hand, 12 percent of patients who did not receive coaching went to an ER after their release during the same time period. The study of 750 patients also found that the program saved $845 in hospital costs per patient for those who did not visit the emergency room.
Another study, which appeared in the July 2005 Annals of Family Medicine, showed that using health coaches in a primary care setting led to 48 percent of overweight patients with a body mass index greater than 30 initiating a behavior change in eating habits, physical activity, or both. The coach provided support through in-person visits, e-mail, telephone contacts, or some combination every two to four weeks for up to six months, the study indicated.
“Health coaching has been proven in randomized trials to make a difference,” says David Grossman, M.D., medical director for preventive care with Group Health Cooperative, Seattle. “People can be helped using motivational techniques.”
In November 2006, Group Health began offering lifestyle coaching for six chronic conditions, including asthma, hypertension, depression, and coronary artery disease. Group Health also offers health coaching as part of its wellness program to help members make changes in eating habits, physical activity, and tobacco use and to reduce stress.
“After [the member] fills out a health risk assessment, and if you meet certain standards and provide a phone number, you will get a call from a health coach,” Grossman says. “That person’s function is to improve behavior and to connect [members] with lifestyle management programs.”
Over the past two years, Independence Blue Cross, Philadelphia, has experienced quality improvements and cost savings using health coaches. As part of its disease management program, IBC offers health coaching for patients with any of 22 chronic and complex conditions, says Kimberly Siejak, IBC’s manager of population health and wellness.
An IBC study found that the plan’s disease management program, Connections Health Management Program, lowered medical cost trends by nearly 3 percent during the program’s second year and improved the health of members with chronic illnesses. More than 235,000 IBC members have at least one of the five most common chronic illnesses—diabetes, asthma, chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease—and 98 percent participate in the Connections program.
“Absolute costs are not going down. What we did was blunt the trend,” Siejak points out. She says the savings come from reductions in avoidable hospital admissions and outpatient services. For example, the IBC study revealed that the number of inpatient days for privately insured HMO and PPO members with chronic conditions who participated in the program was 22 percent less than expected. Reduced hospital admissions also improve care and the state of health for patients.
Employers and Medicare See a Need
“We started coaching because we heard from employer groups that wanted innovative approaches to help employees with chronic conditions,” Siejak says. “The coaches work with members on any health-related issue.”
IBC’s health coaches are provided 24 hours a day, seven days a week by Health Dialog, a Boston-based care management company, says Mary Jane Favazza, the company’s senior vice president of client services and business development. “We have a team of health coaches who work every day with members to try and engage people with behavior change. We answer questions and provide information on health issues people have.”
Responding to employer demand, IBC has expanded its Connections program to include end-stage renal disease, multiple sclerosis, Parkinson’s, and rheumatoid arthritis. The program also offers coaching and educational resources for members making decisions about treatment options, including whether to have surgery.
In 2005, the Centers for Medicare and Medicaid Services (CMS) launched Medicare Health Support, a pilot program that offers health coaches to Medicare beneficiaries to advise those with chronic illnesses about medical choices, preventive care, and other issues.
The program, which is administered by private health care companies, is designed to help Medicare beneficiaries determine which questions to ask their physicians and to reduce confusion. Health coaches receive a capitated fee per Medicare beneficiary per month based on the geographic area. Health care companies that do not save at least 5 percent on the medical costs for Medicare beneficiaries who participate in the program compared with those in a control group must return their fees to CMS. A CMS spokesman says results of the three-year program will not be available until mid-2008, but initial data suggest the program is working.
Identifying Coaching Candidates
While each plan uses a slightly different process to identify members for health coaching, more plans are relying on a combination of health risk assessments (HRAs) and predictive modeling software to select candidates. Under contract with IBC, Health Dialog uses specialized predictive modeling software to identify candidates for health coaching and disease management programs. Predictive modeling takes data from medical, pharmacy, laboratory, radiology, and other sources to help pinpoint high-risk or high-cost patients with chronic conditions.
“We try and collect as much information on the population as we can,” Favazza says. “Our predictive modeling software is designed by IBC for what they are trying to accomplish.”
Most plans allow members to self-refer into health coaching programs through online enrollment or by phone. Referrals also are made by physicians, discharge planners, and case managers.
At Aetna, health coaches contact members who have completed annual HRAs and scored high enough for a wellness session, Nota-Kirby says. HRAs include questions about levels of physical activity, eating habits, and tobacco use. Members are also asked their height, weight, and medical history. The questionnaire typically takes about 15 to 20 minutes to complete.
At BCBSNC, members receive a personalized health report outlining their health status and risks once the HRA is completed. The report may suggest actions to improve their health. After the plan identifies members for Member Health Partnerships, staff sends them program summaries, enrollment information, and enrollment surveys with questions about their health behaviors, knowledge of their health conditions, effects of these conditions on their ability to work, and limitations in daily activities.
Each program participant is paired with either a health coach or a case manager, depending on member preference and the complexity of the member’s health care issue. Individuals with complex needs generally work with case managers.
But Grossman cautions that simply providing members with HRAs and personal health reports falls short of motivating members to change unhealthy behavior or join wellness programs. “The evidence shows that people who fill out HRAs don’t change behavior unless they are engaged [by health coaches or another clinical team member]. Coaches are trained to motivate people to change their behavior.”
Positive Feedback
Surveys by IBC have shown that members are highly satisfied with the plan’s health coaching program, notes Siejak. Some 86 percent of members said their impression of IBC was positively influenced by the program and 87 percent were satisfied or very satisfied with the program. “We have members who provide comments about the program and they always are positive. It improves their quality of life,” Siejak says.
Ninety-six percent of IBC members with chronic conditions said they were able to follow their health coach’s guidance, 85 percent of those members with chronic conditions felt that speaking with a health coach improved the quality of care they received from their doctor, and 74 percent reported that speaking with a health coach improved their ability to talk to their physicians.
Grossman says the Group Health program is too young to identify cost savings or return on investment, but he believes coaching supports physicians in their efforts to improve patients’ health. “We get very positive feedback from our doctors,” he points out. “They like to refer patients to lifestyle coaches because it gives patients opportunities for extended discussions on their health. The coach performs as a virtual member of the health care team and members see that as an added plus.”
Deja says BCBSNC members and physicians give high marks to health coaches and the Member Health Partnerships program. About 86 percent of members actively participating in the program said they were satisfied with it.
“They are seeing results such as returning to work earlier, long-term behavior changes, and improved health and productivity,” Deja says. For example, over the past several years the number of diabetes-related hospital admissions among members enrolled in the program declined by 13 percent, and the rate of inpatient hospitalizations for congestive heart failure declined by 38 percent.
Siejak says physicians and their staffs have more limited time to spend with their patients. “The health coach has as much time as he or she needs to spend with the member,” she explains. “We don’t want to interfere with the primary care physician’s relationship with the patient. Everything that the program does tries to support the provider’s treatment program. We encourage members to get their blood pressure checked and take medications.”
Some plans offer incentives for members to participate in health coaching programs. BCBSNC members enrolled in the Member Health Partnerships program who have diabetes receive free blood glucose meters and home delivery of testing supplies, and members with asthma can order free peak flow meters to monitor their lung capacity.
The Next Frontier
Grossman believes expansion of health coaching depends primarily on demonstrated success and member acceptance. “I see a lot of activity in this area, but we need rigorous analysis and evaluation of outcomes and cost management,” he emphasizes. “We also need to assess how health is improved by using coaching as part of the primary care team.”
Siejak says employers want to use health coaching for more chronic diseases and wellness programs. “They want coaches to interact more broadly with the employee population to talk about lifestyle risks, preventive behaviors, and health screening.”
Tomorrow’s health coaches also will need to address cultural competency issues, notes Favazza. “We need to better reach audiences where English is not the first language. There are a lot of work-access issues, and we are working with providers to try to become more tightly integrated.”
How Does Health Coaching Work?
Health coaches work with members one on one primarily through phone calls to provide health reminders and information to help members become more knowledgeable about their conditions. Coaches encourage members to follow up regularly with their doctors. They help members understand and follow physicians’ treatment plans. Health coaches also may help develop questions to ask during doctor visits, says Mary Jane Favazza, Health Dialog’s senior vice president of client services and business development, and can suggest referrals to behavioral health care practitioners, case management services, smoking cessation programs, or other health plan programs to address member needs.
Depending on needs or preferences, coaches work with members 10 to 30 minutes or longer, according to Betsy Nota-Kirby, Aetna’s wellness design lead. Sessions are weekly at first, then may taper off to regular monthly calls. However, members are encouraged to call at any time, she adds.
Health Dialog’s initial calls generally are short—three to four minutes—unless the member is comfortable, and then they can run 12 to 16 minutes. “It depends whether they know they are referred. We don’t want them to feel overwhelmed,” Favazza notes.
Once members are referred, Favazza says health coaches find that 80 percent of members are willing to talk during the first year after the referral. Of that percentage, up to 90 percent of members regularly participate in the health coaching program.
Janet Ferry is a health coach and registered nurse with Health Dialog who is certified through an internal certification program, Shared Decision Making. Some plans, including Aetna, use the national certification program Well Coaches, which is endorsed by the American College of Sports Medicine.
Ferry, who also trains other health coaches, says a coach’s main goal is to connect with people and help them make health care decisions based on their own values and preferences. “I identify gaps in care that members may wish to eliminate and change to promote both quality of life and longevity. As these gaps are identified, I coach members regarding their awareness of what motivates their self-care and what barriers may prevent them from adopting and maintaining a healthy lifestyle.”
Jay Greene is a freelance writer in St. Paul, Minnesota.
