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The American Journal of Managed Care October 2015
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Health Coaching by Medical Assistants Improves Patients' Chronic Care Experience
David H. Thom, MD, PhD, MPH; Danielle Hessler, PhD; Rachel Willard-Grace, MPH; Denise DeVore, BA; Camille Prado, BA; Thomas Bodenheimer, MD, MPH; and Ellen H. Chen, MD
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Health Coaching by Medical Assistants Improves Patients' Chronic Care Experience

David H. Thom, MD, PhD, MPH; Danielle Hessler, PhD; Rachel Willard-Grace, MPH; Denise DeVore, BA; Camille Prado, BA; Thomas Bodenheimer, MD, MPH; and Ellen H. Chen, MD
Medical assistants trained as health coaches substantially improved patient-reported primary care under the Chronic Care model measured by the Patient Assessment of Chronic Illness Care.
ABSTRACT

Objectives: We sought to test the hypothesis that training medical assistants to provide health coaching would improve patients’ experience of care received and overall satisfaction with their clinic.

Study Design: Randomized controlled trial.
 
Methods: Low-income English- or Spanish-speaking patients aged 18 to 75 years with poorly controlled type 2 diabetes, hypertension, and/or hyperlipidemia were randomized to receive either a health coach or usual care for 12 months. Patient care experience was measured using the Patient Assessment of Chronic Illness Care (PACIC) scale at baseline and at 12 months. Patient overall satisfaction with the clinic was assessed with a single item asking if they would recommend the clinic to a friend or family member. PACIC and satisfaction scores were compared between study arms using generalized estimating equations to account for clustering at the clinician level. 
 
Results: PACIC scores were available from baseline and at 12 months on 366 (76%) of the 441 patients randomized. At baseline, patients receiving health coaching were similar to those in the usual care group with respect to demographic and other characteristics, including mean PACIC scores (3.00 vs 3.06) and the percent who would “definitely recommend” their clinic (73% and 73%, respectively). At 12 months, coached patients had a significantly higher mean PACIC score (3.82 vs 3.13; P <.001) and were more likely to report they would definitely recommend their clinic (85% vs 73%; P = .002).
 
Conclusions: Using medical assistants trained in health coaching significantly improved the quality of care that low-income patients with poorly controlled chronic disease reported receiving from their healthcare team.
 
Am J Manag Care. 2015;21(10):685-691
Take-Away Points
 
The Chronic Care model (CCM) has been widely applied to the transformation of primary care. Health coaching can incorporate functions of the CCM, including patient education, navigation, collaborative goal setting, and personal support. We found that medical assistants trained as health coaches substantially improved patient-reported quality of care under the CCM, as measured by the Patient Assessment of Chronic Illness Care (PACIC) in a randomized controlled trial. 
  • Mean PACIC scores (range 1 to 5) increased over 12 months from 3.00 to 3.83 in the coached group versus from 3.06 to 3.13 in the usual care group, an effect size of 0.77 which was highly significant (P <.001). 
  • The proportion of patients reporting they would definitely recommend their clinic to family and friends increased from 73% to 85% in the coached group, but was unchanged in the usual care group (P = .002). 
  • We conclude that medical assistants trained as health coaches can substantially improve patient-reported quality of care received from their healthcare team and satisfaction with their clinic.
The provision of high-quality, patient-centered primary care for patients with chronic conditions has been identified as a priority for US healthcare.1 A widely used model for improving care is the Chronic Care model (CCM),2 which is based on 6 elements identified from an extensive literature review of interventions: self-management support, decision support, delivery system design, clinical information systems, healthcare organization, and community resources. The CCM has been broadly applied as a model for improving chronic care and has been linked to better outcomes of care.3 Many studies have examined interventions to improve the quality of care under the CCM, including practice redesign,4 specially trained practice nurses,5 and telemedicine support.6 The key elements of the CCM are part of the primary care medical home movement,7,8 which has demonstrated success in improving quality of care and patient satisfaction while holding down costs.9-11
 
One approach to improving the quality of chronic care is the use of health coaches as part of the healthcare team.12 Health coaching by health workers or peers trained as coaches has emerged as an effective model to improve the management of several chronic conditions, including asthma in children,13 as well as diabetes,14-16 hypertension,17,18 or a combination of cardiovascular risk conditions19 in adults.  Health coaches incorporate functions of patient education, navigation, collaborative goal setting, and personal support,20,21 which are all components of the CCM.
 
In contrast to health educators, health coaches help patients choose health goals and create action plans to achieve those goals, in addition to supporting the patient in achieving those goals. Health coaches frequently have contact with patients outside of medical visits, and while they do provide substantial emotional support, they are not therapists. In contrast to case managers who are usually health professionals (eg, registered nurses, pharmacists), health coaches can be unlicensed members of the support staff, such as medical assistants or health workers, who are more likely to be culturally and linguistically concordant with patients. Medical assistants—one of the fastest growing allied health professions22—are likely to be available in primary care practices,23,24 so we sought to assess the extent to which medical assistants trained as health coaches could improve the quality of care received by the patient based on the CCM.
 
METHODS
Study Design
The Health Coaching in Primary Care (HCPC) study was a randomized controlled trial of 12 months of health coaching versus usual care for low-income patients with uncontrolled type 2 diabetes, hypertension, and/or hyperlipidemia. Patients who received health coaching were more likely to achieve the primary outcome of control for 1 or more of the conditions for which they were enrolled.19 In this paper, we reported on the effect of health coaching on patient-reported quality of care received from their primary care clinic, as well as satisfaction with their clinic.
 
Setting, Participants, Enrollment, and Randomization
A detailed description of the HCPC study design and methods has previously been published.25 Briefly, the study was conducted at 2 safety net clinics in San Francisco from March 2011 to May of 2013. Patients were considered eligible if they were between the ages of 18 and 75 years, spoke Spanish or English, could be reached by phone, and had poorly controlled diabetes (glycated hemoglobin >8%), hypertension (systolic blood pressure ≥140 mm Hg), or hyperlipidemia (low-density lipoprotein ≥160 mg/dL for patients without diabetes or ≥100 mg/dL for patients with diabetes). A total of 664 eligible patients were identified at the 2 clinic sites, of which 441 (66.4%) consented and were enrolled (see Figure). After enrollment and completion of baseline measures, participants were randomized to the health coaching arm (n = 224) or the usual care arm (n = 217) by opening the next randomly ordered, sealed envelope.
 


 
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