Evidence-Based Health Coaching Models and Approaches

In a review of behavior change approaches used in health care, Linden and Roberts described eight models that support individual, interpersonal or community behavior change.7 A subsequent review of behavior change models by Linden, Roberts and Butterworth described five additional approaches.8 While there are a number of promising behavior change models and approaches, motivational interviewing-based health coaching is the only technique that has been consistently demonstrated to impact positive health behaviors in health care settings. Motivational interviewing has been described as a “directive (goal-oriented), client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”9

Motivational interviewing is a foundational approach that guides goal setting, information delivery, motivation-building, and behavior change planning, implementation and follow-up.

Motivational interviewing outperforms simple advice-giving-based approaches in 80% of clinical studies5 and has been shown effective for supporting better health care outcomes across the care continuum.10

Given the productivity and accountability demands facing clinicians in primary care, wellness, disease management and care management settings, it is essential that evidence-based health coaching interventions be patient-centered, systematic and brief. Brief, health-related motivational interviewing (as opposed to longer, more counseling-oriented motivational interviewing approaches often used by many psychologists or other professionals) works particularly well because it is patient-centered, effective, and ideally suited for the types of short, face-to-face and telephonic settings where health coaching services are often delivered. Initial sessions of 30 minutes to 1 hour in duration (depending on the nature and complexity of the individual’s needs) followed by 10-30 minute follow-up sessions are typically recommended. When combined with standard medical treatment or patient education interventions, a single motivational interviewing session can be effective—with the typical protocol ranging from three to five sessions.5

Clinicians in usual health care settings, as well as those practicing in wellness, disease management, and care management settings frequently cite patient engagement (participation in health management programs) as a major barrier to patient change. Yet, systematic, evidence-based steps are frequently not utilized to improve initial and ongoing engagement.

One engagement-related measure, the Patient Activation Measure (PAM), asks people about their beliefs, knowledge, skills and confidence regarding health-related behaviors. Based on the responses to the PAM, individuals are then assigned an “activation score.” Higher patient activation levels have been linked with better patient lifestyle management, self-care and a reduction of health care expenses.11 Combining patient activation measurement and tailored motivational interviewing-based health coaching improves how well patients take care of themselves and consequently reduces visits to the doctor and the emergency room, and reduces health care utilization.12

The Information-Motivation-Behavioral Skills (IMB) model,13 developed by Fisher and Fisher is another more integrated, evidence-based model for blending patient education, motivation building and behavior change support. The IMB Model has been validated in many studies to support better clinical outcomes. The three components of this model are described below:

Elicitation. Elicitation of existing levels of health promotion information, motivation, behavioral skills, and health promotion behavior.

Intervention. Design and implementation of empirically targeted interventions to address health promotion, information, motivation, behavioral skills, and behavior deficits.

Evaluation. Evaluation of intervention impact on health promotion information, motivation, behavioral skills and health promotion behavior.

The IMB model provides a shared framework for health coaches who work across the continuum to support health in primary care, community and population health improvement settings. It also reconciles three orientations, objectives, and activities that are frequently not well-integrated across or within usual health care and population health improvement settings.

The information component of the model addresses traditional health care education activities. Individuals must have accurate and actionable information about how to manage health care risks and conditions.

The motivation component addresses common motivational issues such as poor patient engagement, activation or “resistance.”

The behavior skills component is also essential, because patients often need guidance planning, organizing or implementing a change plan.

While motivational interviewing specifically targets motivational factors, it also has value as a patient-centered foundation that engages and activates patients, delivers information, and builds behavior skill sets.

The effectiveness of brief, evidence-based health coaching has been well established, but in real-world applications, health coaching often has not been integrated and tailored to meet the broader goals of population health improvement as detailed by Andersen & Sidorov.14 That must change. In a 2009 review of health coaching in health management, Butterworth, Linden and McClay15 found that effective health management programs must combine key components of population health improvement with evidence-based health coaching as described below:

Candidates for health coaching must be correctly identified based on risk to ensure wise use of resources.

Patient recruitment efforts must be maximized to support enrollment and engagement.

A valid coaching technique, such as motivational interviewing, must be used.

The health coaching delivery method, frequency and duration must be tailored to the population or person.

The program must measure fidelity to the health coaching technique and patient impact.

 

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