Health Coaches Help Patients with Diabetes Make Great Strides
It’s remarkable what time, attention and caring do,” Dr. Cathy Morrow says about the new health coaches who are helping diabetic patients at Dartmouth-Hitchcock. “It’s really making a difference.
Jennifer McFarlin heard the rustle of the potato chip bag as she walked into the living room. Drawn like a magnet to the sound, she saw her daughter seated on the couch watching television, enjoying an after-school snack.
“So I turned around and grabbed the chips – because they’re my favorite kind: salt and vinegar -- and I looked and saw how many I could have,” McFarlin says. “It was in between my meals. I don’t remember how many, but I started counting the chips. And I said ‘This is OK, this can be my snack.’ Before I would have just sat down and finished the bag.”
It was a small victory for McFarlin, who has been trying to control her Type 2 diabetes and lose weight as part of a new health coaching program at Dartmouth-Hitchcock.
Only a few months ago, she admits she might have snacked all day, her blood sugar would soar, and she would have taken a step backward in her fight to remain healthy. But now she has a secret weapon: a health coach who keeps tabs on her and weekly meetings to encourage her.
“They wanted me to try a diet – and that was very difficult for me,” McFarlin admits. “I didn’t really get the idea of the diet until I started working with my coach. I’d lose a few pounds; I’d gain a few pounds; I’d eat the wrong foods. I really need the support.”
Inger Imset, McFarlin’s health coach, smiles and nods her head in agreement. After their weekly appointment, Imset and McFarlin routinely walk 10,000 steps as part of the exercise program that is built into her treatment plan. “She’s made such great progress and she’s trying so hard.”
A new way of caring
McFarlin is one of about nearly 500 patients at Dartmouth-Hitchcock who have been identified with complex chronic diabetes. The team of health coaches actively engages with about 75 patients per month to help them reach their personal goals
More than 25 million Americans suffer from Type 2 diabetes and its complications, including high blood pressure, heart and circulation problems, kidney disease and dozens of other conditions that make them among the sickest and most expensive patients. One in 10 dollars spent on health care in the U.S. is attributed to caring for diabetics, who generally need more frequent treatments in emergency departments and from primary care physicians, endocrinologists and other specialists.
Dartmouth-Hitchcock is midway through a three-year national study, through the High Value Healthcare Collaborative (HVHC) of complex chronic diabetes patients. HVHC encompasses 19 health care systems, 70,000 clinicians and more than 100 million people. The goal of this project is to find out if there is a better way to treat people with chronic diseases, keep them healthier, and save medical costs in the process by using Shared Decision Making principles that were pioneered here at Dartmouth-Hitchcock 15 years ago. The HVHC project is funded by a three-year, $26 million grant from the Center for Medicare and Medicaid Innovation.
Imset, who joined The Dartmouth Institute project last year, has worked for Geisel School of Medicine for 16 years. She has been providing medical education for seven years and is passionate about utilizing the process of shared decision making to enhance the patient-clinician relationship.
“I come at this with an educational approach working with third-year medical students,” says Imset, who is a half-time coach. “Mostly it’s about finding out what is important to the patients to reach the goals for their healthcare needs.”
Many patients living with chronic disease feel helpless and experience a loss of hope. The role of the health coach is “helping patients set some realistic goals and help them shift what’s in their way so they can achieve those goals,” she explains.
Dealing with an ‘enormous disconnect’
“All of the medical information in a patient’s life may or may not have any meaning for them,” says Dr. Cathy Morrow, McFarlin’s primary care provider and a member of the team working with health coaching.
That’s where health coaches come in. We (physicians) don’t have anywhere near the time to fully understand the complexity of a patient’s life to ensure that we are thoroughly integrating their values and preferences into their treatment plans"
Morrow says that “the patients with chronic diseases we are trying to treat have challenges across a wide spectrum: social, economic, psychologic, complex arrays of medical issues, and very frequently general stress of life issues.”
It gets complicated, she admits. “Sometimes life happens to get in the way” of effective treatment.
“Until you have walked in the shoes of someone with a complex disease like diabetes, medical providers and society as a whole underestimate how it impacts every aspect of a patient’s life,” Morrow says. “And we physicians -- managing medications and making decisions in the context of the patient’s life -- have a complex task to integrate the best evidence and medical knowledge, relative to the reality of this individual person’s life. There is often an enormous disconnect there.”
It’s all about relationships
Health coaching mostly is about establishing a relationship with a patient that is often lacking in typical doctor-patient visits, says Belinda Ray, a full-time health coach with the Center for Shared Decision Making. So what exactly do they do?
“It’s all about establishing a relationship with a patient and to help them understand the difference between my role and other providers – I’m not serving a diagnostic function, I’m not giving advice or just following a provider’s recommendations, I’m trying to find out from the patient what their need is,” Ray says.
“We often fill a communication need that is not being met by their provider or team of providers,” Ray explains. “Many provider visits are problem-focused and the patient may not have time to ask a question or they are uncomfortable asking their provider. They either are intimidated or they don’t want to be a bother; they don’t want to be the problem. Particularly with diabetes patients we’re asking them to do something that is hard to do. These are hard behavioral changes to make and there is a reason they haven’t made them. We have to find those reasons.”
“A meeting with a provider often is routine, almost mechanical,” she says. “What we do is help unpack what a patient needs to make a change, establishing a reward system so they want to do it.
“It’s hard for people with chronic conditions to make changes,” Ray says. “They know what they are supposed to do but sometimes they don’t believe they can do it. They are hopeless about it.”
The role of the health coach is “instilling hope,” she says.
“We’re often asking them to take away something that often is very nurturing and comforting: food,” Ray explains. “You have to replace that with something that the patient wants, and help them identify what they want – to have more energy, to be able to walk around the block, to sit in a chair if they are extremely overweight.”
Identifying, building on strengths
What health coaches are trying to do is exactly what sports coaches do, Ray says. “We are identifying and building on strengths.”
Morrow agrees, saying that the health coaches are adding “a layer of integration of the realities of patient’s lives that is often neglected in patient care. It is a layer that care managers can’t provide because they have yet a different role, which is often simply connecting patients to resources. But the health coach’s personal engagement with the patient -- their day to day life -- makes an enormous difference.
Morrow added, “I want to emphasize how important I am finding health coaching to be to provide more effective care. Before the health coach availability I had worked on these same issues with Jen for more than a year and had made no progress. It wasn’t until Inger got involved that we had a mechanism to help translate between what I was saying in the office to what was actually happening in her home. Inger serves as that ‘connector’. So not only do I feel like I am providing better care but I am alerted to specific issues by Inger so that each subsequent visit is more effective in that we address areas of concern with clear and direct relevance to the patient. We are essentially providing much more personalized care. In this respect, the health coaches make my job easier.”
McFarlin would agree. Between February and May this year, she not only reached her goal of losing 10 pounds, her hemoglobin A1C (the best measure of diabetes control over time) dropped by 20 percent.
“The only difference in her treatment plan was the addition of health coaching and a willingness on Jennifer’s part to participate, Morrow says.”
“It’s remarkable what time, attention and caring do,” Morrow concludes. “It’s remarkable. It’s really making a difference.”