Case Studies: Person-Centered Health Coaching in People With Negative Social Determinants of Health.

Social determinants of health are the conditions in the environment that influence health outcomes, such as housing, transportation, and neighborhoods. In this report, we examine 3 cases of participants with social risk factors who participated in a health coaching intervention study. The study was a science-based, nurse health coaching model provided to older adult participants in a Midwestern state designed to equip and empower them to achieve and maintain their health and optimum function to support independent living at home. The program was an 8-week virtual coaching method using weekly, 30-minute, 2-way video coaching sessions with participants. For each of the 3 cases, we describe the patterns of engagement, early and later health goals as coaching progressed, and the types of outcomes achieved. From these case studies, we illustrate how social determinants may affect the types of goals, processes, and potential outcomes achieved by participants of health coaching programs. From these insights, we propose directions in health policy and services and future research considerations.

A randomized trial of a theory-driven model of health coaching for older adults: short-term and sustained outcomes.

BACKGROUND: Healthy Lifetime, a theoretically driven, personalized health coaching program delivered electronically, including face-to-face videoconferencing, was developed to intervene in early aging to stave off functional decline and minimize the onset/exacerbation of chronic conditions. OBJECTIVE: To determine the efficacy of a theoretically driven, personalized health coaching program in participants 50 years and older with one or more chronic conditions using a randomized, controlled, pragmatic clinical trial methodology. METHODS: Participants were randomly assigned to the HL (n = 59) or a usual care (n = 63) group. The HL group received health coaching from a trained nurse over eight weeks. Outcomes were measured at baseline, eight weeks, and 20 weeks (after the 12-week no-treatment phase). Regression modeling with fixed-effect repeated measures was used to account for the longitudinal data collection. RESULTS: For the HL group, health habits increased at 8 weeks (3.1 units; SE = 1.0; p = .0005; effect size = .15). This difference was sustained at 20 weeks (2.4 units, SE = 0.2; p = .0005). Independent self-care agency improved at 8 weeks in individuals with high blood pressure (13.5 units; SE = 4.37; p = .0023; effect size = .3). However, that difference was not sustained at 20 weeks (p = .47). No significant improvements were shown in the usual care group at 8 weeks or 20 weeks. CONCLUSIONS: HL participants significantly improved their health habits at 8 weeks and sustained this improvement at week 20 (after a 12-week no-treatment phase) vs. the usual care group. Changing health habits alone has been shown to reduce all-cause morbidity and mortality in chronic disease. The high-functioning, community-dwelling older adults with chronic diseases we studied is an important target population for primary care practices to intervene early in aging to stave off the complications of chronic disease and functional decline. TRIAL REGISTRATION: ClinicalTrials.gov (record NCT05070923, 07/10/2021).

Pilot Study of a Motivational Interviewing Training on Practitioners' Skill Set for Patient Centered Communication.

PURPOSE: Increase practitioners' Motivational Interviewing (MI) skill set to develop intrinsic motivation and behavior change competencies. DESIGN: Pilot comparing intervention group with waitlist-control group. SETTING: Health Plan in northeast of U.S. INTERVENTION: Training program including a 3 day 19 hour MI training intensive, 1.5 hour follow-up skill-building trainings, and quality assurance review using an MI assessment tool paired with strengths-based mentoring. Cohort 1 (experimental group) received the intervention for 6-months and cohort 2 for 3 months (control group). MEASURES: Practitioners' MI skill set was assessed pre- and post-intervention using Motivational Interviewing Competency Assessment (MICA). Practitioners' MI knowledge and attitudes were assessed pre- and post-training using adapted Motivational Interviewing Knowledge and Attitudes Test (MIKAT). Active learning and confidence questionnaires were administered post-training. ANALYSIS: A generalized linear mixed model with repeated measures to analyze difference in MICA growth rates; paired T-test for MIKAT pre/post training analysis. Descriptive statistics for active learning and confidence. RESULTS: MICA scores significantly improved for both cohorts (P < .0001). Practitioners had significant increase in knowledge and attitudes for MI (P < .001) and confidence in using MI (P < .01). High levels of active learning were observed (93-100%). CONCLUSION: With planning, adequate resources/support, and iterative processes for adjustment, practitioners can improve their MI skill set in a short period of time with modest investment of practitioner resources.

Effect of a Biopsychosocial Intervention or Postural Therapy on Disability and Health Care Spending Among Patients With Acute and Subacute Spine Pain: The SPINE CARE Randomized Clinical Trial.

Importance: Low back and neck pain are often self-limited, but health care spending remains high. Objective: To evaluate the effects of 2 interventions that emphasize noninvasive care for spine pain. Design, Setting, and Participants: Pragmatic, cluster, randomized clinical trial conducted at 33 centers in the US that enrolled 2971 participants with neck or back pain of 3 months' duration or less (enrollment, June 2017 to March 2020; final follow-up, March 2021). Interventions: Participants were randomized at the clinic-level to (1) usual care (n = 992); (2) a risk-stratified, multidisciplinary intervention (the identify, coordinate, and enhance [ICE] care model that combines physical therapy, health coach counseling, and consultation from a specialist in pain medicine or rehabilitation) (n = 829); or (3) individualized postural therapy (IPT), a postural therapy approach that combines physical therapy with building self-efficacy and self-management (n = 1150). Main Outcomes and Measures: The primary outcomes were change in Oswestry Disability Index (ODI) score at 3 months (range, 0 [best] to 100 [worst]; minimal clinically important difference, 6) and spine-related health care spending at 1 year. A 2-sided significance threshold of .025 was used to define statistical significance. Results: Among 2971 participants randomized (mean age, 51.7 years; 1792 women [60.3%]), 2733 (92%) finished the trial. Between baseline and 3-month follow-up, mean ODI scores changed from 31.2 to 15.4 for ICE, from 29.3 to 15.4 for IPT, and from 28.9 to 19.5 for usual care. At 3-month follow-up, absolute differences compared with usual care were -5.8 (95% CI, -7.7 to -3.9; P < .001) for ICE and -4.3 (95% CI, -5.9 to -2.6; P < .001) for IPT. Mean 12-month spending was $1448, $2528, and $1587 in the ICE, IPT, and usual care groups, respectively. Differences in spending compared with usual care were -$139 (risk ratio, 0.93 [95% CI, 0.87 to 0.997]; P = .04) for ICE and $941 (risk ratio, 1.40 [95% CI, 1.35 to 1.45]; P < .001) for IPT. Conclusions and Relevance: Among patients with acute or subacute spine pain, a multidisciplinary biopsychosocial intervention or an individualized postural therapy intervention, each compared with usual care, resulted in small but statistically significant reductions in pain-related disability at 3 months. However, compared with usual care, the biopsychosocial intervention resulted in no significant difference in spine-related health care spending and the postural therapy intervention resulted in significantly greater spine-related health care spending at 1 year. Trial Registration: ClinicalTrials.gov Identifier: NCT03083886.

Integrating Lay Health Coaches Into Primary Care: Acceptability, Credibility, and Effectiveness From the Provider Perspective.

The purpose of this mixed-methods, cross-sectional study was to assess the acceptability, effectiveness, and credibility of lay health coaches from the perspective of primary care personnel during coach integration into primary care teams through the Management of Diabetes in Everyday Life (MODEL) study. Surveys of 46 primary care clinic personnel were conducted in June 2017 and July 2017 to assess the acceptability, effectiveness, and credibility of lay health coaches in the clinics. Clinic personnel rated coach acceptability, impact, and credibility on a five-point Likert scale as 3.78, 3.76-4.04, and 3.71-3.95, respectively. Additionally, interviews revealed support for a team-based approach and recognition of the potential of coaches to enhance care. In the interviews clinic personnel also reported a lack of provider time to counsel patients as well as a need for improved provider-coach communication.

Healthy Lifetime (HL): An Internet-Based Behavioral Health Coaching Protocol for Older Adults.

By 2060, the number of Americans 65 years and older will more than double, comprising nearly one-quarter of the population in the United States. While there are many advantages to living longer, a byproduct of aging is also a growing incidence of chronic illness and functional health limitations associated with a concurrent rise in chronic disease and disability that impair independent living in the community. We describe a personalized, behavioral health coaching protocol for early intervention that is delivered online to enhance a participant's independent functioning and to increase their self-care capacity with a goal to maintain independent living throughout aging. The electronic platform provides secure access to fillable surveys, health tracking, "just in time" communication with coaches and scheduling of two-way videos launched from the platform site. The 2-month protocol used two-way video conferencing which allowed high fidelity communication to sustain a complex behavioral intervention. Participants indicate high satisfaction with the intervention, the use of the platform, and the technology. While many health systems across the U.S. have ramped up virtual delivery of care in a proactive manner with now more than 70% of out-patient visits conducted through virtual delivery modes in some health systems, there remains much unevenness in this capability across the U.S. Our approach is to create a stable, interoperable, virtual outreach system for personalized professional health coaching that is complementary to medically oriented services that supports the health and functioning of participants as they age.

Strengthening the Impact of Digital Cognitive Behavioral Interventions Through a Dual Intervention: Proficient Motivational Interviewing-Based Health Coaching Plus In-Application Techniques.

BACKGROUND: The COVID-19 pandemic has accelerated the adoption of digital tools to support individuals struggling with their mental health. The use of a digital intervention plus human coaching ("dual" intervention) is gaining momentum in increasing overall engagement in digital cognitive behavioral interventions (dCBIs). However, there is limited insight into the methodologies and coaching models used by those deploying dual interventions. To achieve a deeper understanding, we need to identify and promote effective engagement that leads to clinical outcomes versus simply monitoring engagement metrics. Motivational interviewing (MI) is a collaborative, goal-oriented communication approach that pays particular attention to the language of change and is an effective engagement approach to help people manage mental health issues. However, this approach has been traditionally used for in-person or telephonic interventions, and less is known about the application of MI to digital interventions. OBJECTIVE: We sought to provide a dual intervention approach and address multiple factors across two levels of engagement to operationalize a dCBI that combined cognitive behavioral therapy-based techniques and MI-based interactions between the digital health coach (DHC) and user. METHODS: We reviewed hundreds of digital exchanges between DHCs and users to identify and improve training and quality assurance activities for digital interventions. RESULTS: We tested five hypotheses and found that: (1) users of a dual digital behavioral health intervention had greater engagement levels than users of a noncoached intervention (P<.001); (2) DHCs with a demonstrated competency in applying MI to digital messages had more engaged users, as measured by the DHC-to-user message exchange ratio (P<.001); (3) the DHC-to-user message exchange ratio was correlated with more engagement in app activities (r=0.28, 95% CI 0.23-0.33); (4) DHCs with demonstrated MI proficiency elicited a greater amount of "change talk" from users than did DHCs without MI proficiency (H=25.12, P<.001); and (5) users who were engaged by DHCs with MI proficiency had better clinical outcomes compared to users engaged by DHCs without MI proficiency (P=.02). CONCLUSIONS: To our knowledge, this pilot was the first of its kind to test the application of MI to digital coaching protocols, and it demonstrated the value of MI proficiency in digital health coaching for enhanced engagement and health improvement. Further research is needed to establish coaching models in dCBIs that incorporate MI to promote effective engagement and optimize positive behavioral outcomes.

The Impact of Nurse Health-Coaching Strategies on Cognitive-Behavioral Outcomes in Older Adults.

The practice of nurse health coaching (NHC) draws from the art and science of nursing, behavioral sciences, and evidence-based health-coaching methods. This secondary analysis of the audio-recorded natural language of participants during NHC sessions of our recent 8-week RCT evaluates improvement over time in cognitive−behavioral outcomes: change talk, resiliency, self-efficacy/independent agency, insight and pattern recognition, and building towards sustainability. We developed a measurement tool for coding, Indicators of Health Behavior Change (IHBC), that was designed to allow trained health-coach experts to assess the presence and frequency of the indicators in the natural language content of participants. We used a two-step method for randomly selecting the 20 min audio-recorded session that was analyzed at each time point. Fifty-six participants had high-quality audio recordings of the NHC sessions. Twelve participants were placed in the social determinants of health (SDH) group based on the following: low income (

Design of the Spine Pain Intervention to Enhance Care Quality And Reduce Expenditure Trial (SPINE CARE) study: Methods and lessons from a multi-site pragmatic cluster randomized controlled trial.

BACKGROUND: Low back and neck pain (together, spine pain) are among the leading causes of medical visits, lost productivity, and disability. For most people, episodes of spine pain are self-limited; nevertheless, healthcare spending for this condition is extremely high. Focusing care on individuals at high-risk of progressing from acute to chronic pain may improve efficiency. Alternatively, postural therapies, which are frequently used by patients, may prevent the overuse of high-cost interventions while delivering equivalent outcomes. METHODS: The SPINE CARE (Spine Pain Intervention to Enhance Care Quality And Reduce Expenditure) trial is a cluster-randomized multi-center pragmatic clinical trial designed to evaluate the clinical effectiveness and healthcare utilization of two interventions for primary care patients with acute and subacute spine pain. The study was conducted at 33 primary care clinics in geographically distinct regions of the United States. Individuals ≥18 years presenting to primary care with neck and/or back pain of ≤3 months' duration were randomized at the clinic-level to 1) usual care, 2) a risk-stratified, multidisciplinary approach called the Identify, Coordinate, and Enhance (ICE) care model, or 3) Individualized Postural Therapy (IPT), a standardized postural therapy method of care. The trial's two primary outcomes are change in function at 3 months and spine-related spending at one year. 2971 individuals were enrolled between June 2017 and March 2020. Follow-up was completed on March 31, 2021. DISCUSSION: The SPINE CARE trial will determine the impact on clinical outcomes and healthcare costs of two interventions for patients with spine pain presenting to primary care. TRIAL REGISTRATION NUMBER: NCT03083886.

Using Best Practices to Address COVID-19 Vaccine Hesitancy: The Case for the Motivational Interviewing Approach.

Future control of the coronavirus disease 2019 (COVID-19) pandemic is dependent on the uptake of the COVID-19 vaccine. Many factors have swayed the public's perception of this coronavirus and the new vaccinations, including misinformation, heightened emotions, and the divisive and tumultuous partisan climate. As such, vaccine hesitancy may be more prevalent for the COVID-19 vaccine than others. Healthcare workers are trusted sources of information and have the opportunity to influence an individual's choice to take the vaccine. For those who initially present as unwilling to be vaccinated, trying to persuade them with facts and scare tactics may cause more resistance. By using the communication approach of motivational interviewing, practitioners can support autonomy to reduce defensiveness, use a guiding style to elicit ambivalence and provide information, address personal agency to ensure that their patients understand that their efforts can reduce risk, and evoke a person's own argument for vaccination to decrease vaccine hesitancy.

The management of diabetes in everyday life study: Design and methods for a pragmatic randomized controlled trial comparing the effectiveness of text messaging versus health coaching.

Background African American patients with uncontrolled diabetes living in medically underserved areas need effective clinic-based interventions to improve self-care behaviors. Text messaging (TM) and health coaching (HC) are among the most promising low-cost population-based approaches, but little is known about their comparative effectiveness in real-world clinical settings. Objective Use a pragmatic randomized controlled trial design to determine the comparative effectiveness of TM and HC with enhanced usual care (EC) in African American adults with uncontrolled diabetes and multiple chronic health conditions. Methods/design The Management of Diabetes in Everyday Life (MODEL) study is randomizing 646 patients (n = 581with anticipated 90% retention) to 3 intervention arms: TM, HC, and EC. Participants are African American adults living in medically underserved areas of the Mid-South, age ≥ 18, with uncontrolled diabetes (A1c ≥ 8), one or more additional chronic conditions, and who have a phone with texting and voicemail capability. Primary outcome measures: the general diet, exercise, and medication adherence subscales of the revised Summary of Diabetes Self-Care Activities questionnaire assessed at one year. Secondary outcomes: diabetes-specific quality of life, primary care engagement, and average blood sugar (A1c). The study will also assess heterogeneity of treatment effects by six key baseline participant characteristics. Conclusions We describe the design and methods of the MODEL study along with design revisions required during implementation in a pragmatic setting. This trial, upon its conclusion, will allow us to compare the effectiveness of two promising low-cost primary care-based strategies for supporting self-care behaviors among African Americans individuals with uncontrolled diabetes. ClinicalTrials.gov registration number: NCT02957513.

Co-occurrence and coaction of stress management with other health risk behaviors.

This study provides a preliminary investigation of the role of stress management in multiple behavior change. Risk status on stress management and five health behaviors (healthy eating, exercise, alcohol, smoking, and depression management) was assessed before and after a multiple behavior change intervention. Findings suggested a link between stress management and a worse health risk behavior profile at baseline. Results also showed relationships between improved stress management over 6 months and heightened odds of improving on specific behaviors as well as improving one's overall behavioral risk profile. Particularly strong links between stress management and energy balance and other affective behaviors were observed.

A comprehensive hospital-based intervention to reduce readmissions for chronically ill patients: a randomized controlled trial.

OBJECTIVES: Medicare penalizes hospitals with 30-day readmissions above their expected rates. Hospitals have responded by implementing transitional care interventions; however, there is limited evidence to inform the development of a successful intervention. STUDY DESIGN: Parallel-group, stratified, randomized controlled trial. METHODS: A total of 512 patients hospitalized at 2 community hospitals, with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD), were randomly assigned to the intervention (n = 253) or usual care (n = 259). The intervention encompassed a 90-day hospital-based transitional care program. The primary end points were 30- and 90-day all-cause readmissions. Secondary measures included all-cause emergency department (ED) visits and mortality. RESULTS: On average, study participants were 67 years of age, 57% female, and 70% insured by Medicare. There was no statistical difference between treatment groups on 30-day readmission incidence rates (difference, 0.040; 95% CI, -0.047 to 0.127; P = .36), or 90-day readmission incidence rates (difference of 0.035; 95% CI -0.122 to 0.192; P = .66). Groups also did not differ in ED visit incidence rates at 30 or 90 days. The mortality rate among patients with CHF showed no difference between groups (risk ratio = 0.90; 95% CI, 0.40-2.05). However, for COPD, mortality at 90 days was lower in the intervention group than in the usual care group (risk ratio = 0.28; 95% CI, 0.10-0.83). CONCLUSIONS: Stand-alone community hospitals may be unable to prevent readmissions despite the use of comprehensive, evidence-based intervention components that are within their control. Better collaboration between hospitals and community-based providers is needed to ensure continuity of care for discharged patients. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: NCT01855022.

Commitment strength in motivational interviewing and movement in exercise stage of change in women.

PURPOSE: Motivational interviewing (MI) increasingly is used in behavior change counseling. We explored whether commitment verbalized in an initial MI session predicted subsequent physical activity behavior. DATA SOURCES: As part of a 12-week walking program targeted at rural women, an initial MI session was held that was audio-recorded. We measured commitment strength during this MI session, stage of change (SOC) pre- and postintervention, and minutes of physical activity performed during the 12-week intervention for the 20 women in the intervention. CONCLUSIONS: Commitment strength was significantly correlated with SOC, and SOC was significantly correlated with physical activity behavior. However, commitment strength did not predict physical activity. Further research is needed to determine if commitment strength predicts subsequent physical activity. IMPLICATIONS FOR PRACTICE: Understanding the role of the strength of a commitment statement made during an initial MI session could assist the APN in directing follow-up MI sessions. This information could be useful in improving the cost effectiveness and efficiency of conducting MI.

The Healthy Ageing Model: health behaviour change for older adults.

Proposed is a model of primary care for older adults with chronic health conditions that focuses on active engagement in health care. The Healthy Ageing Model is anchored in established theory on motivation and health behaviour change. The model draws on empirical and applied clinical underpinnings in such diverse areas as health promotion and education, treatment of addictions or obesity, management of chronic diseases, goal-setting, and coaching techniques. The conceptual foundation for the Healthy Ageing Model is described first, followed by a brief description of the key characteristics of the model. In conclusion, suggestions are offered for the clinical application and for further developing the model.

Motivational interviewing-based health coaching as a chronic care intervention.

OBJECTIVE: To evaluate the impact of motivational interviewing-based health coaching on a chronically ill group of participants compared with non-participants. Specifically, measures that could be directly attributed to a health coaching intervention on chronic illness were assessed. DESIGN: Quasi-experimental study design. SETTING: A large medical university in the north-west United States. METHODS: One hundred and six chronically ill programme participants completed a health risk survey instrument prior to enrolment and again at approximately 8 months. Outcomes were compared with 230 chronically ill non-participants who completed the survey twice over a similar time frame. Inverse probability of treatment weights were used in conjunction with the propensity score to correct for selection bias. RESULTS: Compared with non-participants, programme participants improved their self-efficacy (P = 0.01), patient activation (P = 0.02), lifestyle change score (P = 0.01) and perceived health status (P = 0.03). Fewer participants increased their stages of change risk over time than non-participants (P < 0.01), and more participants decreased their stages of change risk over time than non-participants (P = 0.03). CONCLUSION: These results support motivational interviewing-based health coaching as an effective chronic care management intervention in impacting outcome measures that could also serve well as a proxy in the absence of other clinical or cost indices.