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.
Published Online: October 09, 2015
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
Health Coaching Intervention
The health coaches included 3 certified medical assistants who attended 40 hours of health coach training over 6 weeks using a curriculum developed by the study team that included instructions on using active listening and nonjudgmental communication; helping with self-management skills for diabetes, hypertension, and hyperlipidemia; providing social and emotional support; assisting with lifestyle change; facilitating medication understanding and adherence; navigating the clinic; and accessing community resources. Training incorporated aspects of the CCM,2 Motivational Interviewing,26 and the Transtheoretical Model.27
Health coaches interacted with patients at medical visits, individual visits, and by phone calls. The minimum required frequency of contact was once every 3 months for in-person visits (often as part of a medical visit) and monthly for additional contacts such as phone calls. The health coach met with the patient before the visit for medication reconciliation, agenda-setting, and the review of lab numbers; usually stayed in the exam room during the medical visit and met with the patient afterward to review the care plan and check for patient understanding; and assisted the patient in making action plans28 to increase physical activity, improve healthy eating, reduce stress, or improve medication adherence. In addition, the health coach facilitated navigation of other resources, such as diagnostic imaging or referrals to specialists, by making follow-up appointments or facilitating introductions to behaviorists or other clinic resources.
After each contact with a patient, the health coach reported the type of contact (phone, medical visit, or in-person visit with the health coach only), approximate length of the visit, and topics covered from a list of possible activities (eg, review medication adherence, create or follow-up on an action plan).
Patients randomized to usual care continued to have visits with their clinician over the course of the 12-month period and had access to any additional resources that were part of usual care at the clinic, including diabetes educators, nutritionists, chronic care nurses, or educational classes.
Patient demographic characteristics were assessed by survey at the time of enrollment and at 12 months. Quality of care received was assessed by patient report using the previously validated Patient Assessment of Chronic Illness Care (PACIC) scale.29-32 The PACIC scale measures patient-reported receipt of services included in the CCM over the past 6 months using a 5-point Likert-type response scale ranging from 1 (“almost never”) to 5 (“almost always”). Three examples of items are: “Asked to talk about your goals in caring for your condition,” “Helped to make a treatment plan that you could carry out in your daily life,” and “Contacted after a visit to see how things were going.” The PACIC scale has been associated with increased physical activity, receiving appropriate laboratory assessments,29 greater engagement in all self-management behaviors, and higher quality of life.30 Scores are reported as the mean Likert score (range = 1-5) for all 20 items, as well as scores for each of the 5 domains (patient activation, delivery system design/decision support, goal-setting items, problem-solving/contextual counseling, and follow-up/coordination). Patient satisfaction with their primary care clinic was assessed by a single item: “How likely would you recommend your clinic to your friend or relative?” with a response scale from 1 (“definitely not recommend”) to 5 (“definitely recommend”) and analyzed as a dichotomous variable (“definitely recommend” vs “not definitely recommend”).33
Analyses were in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines for reporting results from clinical trials.34,35 Group comparisons were conducted using χ2 test for categorical data and analysis of variance for normally distributed continuous variables. PACIC data were treated as missing if less than two-thirds of the items were answered. Effect size (Cohen’s d) was calculated as the difference in change in PACIC score divided by the pooled standard deviations from both study arms at baseline and 12 months.36 Unadjusted change in PACIC scores between study arms was compared using t tests, while differences in the proportion of patients reporting they would definitely recommend their clinic at 12 months were compared using χ2 testing. Generalized Estimating Equation models were used to account for clustering by clinician and to additionally control for baseline levels of the outcome. All P values are 2-sided. The primary analysis was done without replacement of missing data (data assumed to be missing at random). Analyses were repeated using multiple imputation to test the assumption of missing at random using NORM version 2 software,37 which imputes data through the expectation-maximization algorithm. All other statistical analyses were performed using SPSS version 19.0 (SPSS Inc, Chicago, Illinois).
PDF is available on the last page.