Abstract
Purpose:
Describe health plan member-level participation, completion, and 6-month outcomes for 5 lifestyle health coaching programs offered by an integrated delivery and financing system (IDFS) over 6 years.
Design:
Case series study of 5 lifestyle programs with 180-day follow-up.
Setting:
Large Western PA integrated delivery and financing system (IDFS) deployed multiple coaching modalities for diverse insurance-member enrolled population.
Participants:
A total of 14 591 health plan members choosing a lifestyle health coaching program.
Intervention:
Evidence- and curriculum-based lifestyle health coaching programs delivered by 1 of 4 interactive modalities.
Measures:
A single metric was used as an overall indicator of clinical success for each program. Success measures include a ≥5% reduction of self-reported baseline weight, meeting physical activity guidelines, and 7-day point prevalence abstinence from tobacco. For stress and nutrition, where no single target measure exists, a metric was created that represented a net improvement across all key outcomes measured.
Analysis:
The proportion of members meeting target outcomes were calculated and described across all time points and modalities.
Results:
At 180 days, 77% of enrolled members reported reduced stress, 7% quit tobacco, 50.5% met physical activity guidelines, 65.2% improved nutrition, and 44.2% lost 5% or more of baseline weight.
Conclusion:
This evaluation describes the real-world effectiveness of evidence- and curriculum-based lifestyle improvement programs delivered by trained health coaches to a diverse health plan member population.
Purpose
Preventable lifestyle diseases are increasingly recognized as major drivers of rising health-care costs. 1,2 Health-care delivery systems and insurance plans are proactively deploying innovative approaches to optimize the health of their member and patient populations. 3 Traditional methods for addressing behavior change which rely solely on patient education have produced limited results, giving rise to the field of health coaching over the past decade. There are limited published reports of positive outcomes for health coaching, 2 and there is significant variability in both the design and delivery of programs. 4 These factors have yielded inconsistent evidence of health coaching’s effectiveness and future direction. 2,4
Recently, the International Consortium of Health and Wellness Coaches (ICHWC) has initiated standardization by credentialing health coach training programs and certifying individual health coaches. 5 The purpose of this study is to preliminarily describe 6-month changes in lifestyle behaviors and outcomes among UPMC Health Plan members participating in 1 of 5 programs delivered by health coaches trained using an ICHWC transitionally approved training program. We evaluated member enrollment, completion, and self-reported outcomes known to be associated with clinically defined success.
Methods
Design
Case series study of health plan members enrolled in 1 of 5 lifestyle programs (Table 1).
Program Description and Target Outcome Metrics, 2010 to 2015.
Sample
All UPMC Health Plan members are eligible to participate in lifestyle health coaching programs. Members were enrolled by either calling a health coach directly or by being contacted by a health plan staff member who encouraged enrollment based on health assessment and claims risk stratification. All UPMC Health Plan program participants agree to program terms and conditions and consent that personal health information relevant to the program will be used by UPMC Health Plan in accordance with the UPMC Health Plan Notice of Privacy Practices. This study received internal health plan approval for publication.
Measures
Each health coaching program included structured assessments at enrollment and 30, 90, and 180 days postprogram completion. Program completion was defined as completing a minimum of 4 of 6 sessions for nutrition, physical activity, stress, and tobacco cessation; and 6 of 8 sessions for weight management. A single metric that reflected clinically defined improvement was created for each program to serve as a target behavior or outcome (Table 1). For stress and nutrition, where no single target measure exists, a metric was created that represented a net improvement across all key outcomes measured.
Intervention
UPMC Health Plan provides health coaching using evidence- and curriculum-based lifestyle programs in the areas of weight management, physical activity, nutrition, tobacco, and stress (Table 1). Programs were built upon accepted clinical guidelines and informed by health behavior intervention and evaluation best practices. Health coaches were bachelor and master’s degree-level personnel (eg, health educators, nutritionists, exercise physiologists) trained using The UPMC MyHealth Coach Academy, the internal health coach training program of UPMC Health Plan, which is transitionally approved by the ICHWC. All health coaches, regardless of background and previous training, complete UPMC Health Plan’s 12-week health coach training program which includes 140.5 classroom hours of synchronous training, followed by ongoing, individual coach mentoring, group skills–building sessions (1.5 hours monthly), and ongoing quality assurance review. The quality assurance and evaluation process provides continuous monitoring and feedback of health coaching sessions and allows for evaluation of individual coach performance against critical health coaching competencies and benchmark attributes such as skill, techniques, professionalism, content, and effectiveness.
After a discussion with a health coach, who engaged in motivational interviewing and assessed readiness based upon The Transtheoretical Model, the member chose and enrolled in a lifestyle program. Members also chose 1 of 4 interactive program delivery modalities: individual telephonic, individual in-person, telephonic-based group, or in-person group. A weekly 1:1 coaching session consisted of 20 to 30 minutes of health coach and participant engagement. Weekly group sessions were 50 minutes in duration and included 8 to 12 participants. Sessions were paired with a program-specific workbook, tool kit, and behavior maintenance journal. Health coaches worked with members to understand reasons for making lifestyle changes, overcome ambivalence, gain skills, set attainable goals, problem-solving barriers, engage social support, access resources, be accountable and maintain progress toward program and personal goals.
Analysis
The data were gathered and prepared using the statistical analysis environment, SAS, Version 9.4 (TS1M2), to integrate data across multiple sources and provide a review of outcomes for all 5 programs. To preliminarily evaluate program effectiveness, the proportion of members who completed each program, comparison of program completers versus noncompleters, completion rates by insurance product line, and the proportion of members meeting target outcomes were calculated and described across all time points and modalities.
Results
A total of 14 591 members enrolled in 1 or more lifestyle health coaching programs. On average, enrollees were 47.3 years old and 74.1% female. Enrollees by insurance product were commercial (75.7%), Medicare (13.4%), Medicaid (9.9%), and exchange (1%). Approximately 80% of members chose to enroll in 1:1 telephonic coaching sessions with 20% in other modalities.
Among enrolled members, 44.4% completed their respective program (Table 2). On average, completers were 49.9 years old and 43.4% female, compared to 46.9 years old and 56.6% female for noncompleters. Completion rates were highest among commercial (51.1%) compared to individual (32.7%) and government (24.4%) members, and higher among those who were referred by a physician and/or called a health coach directly (53.2%) compared to those contacted by a health plan staff member (49.1%). Completers participated in an average of 6 sessions and noncompleters participated in an average of 2 sessions. Among completers, target outcomes met at 180 days ranged from 7% who quit tobacco use to 77% who reported reduced stress (Table 2).
Program Enrollment, Completion, and Outcomes, by Program (n = 14 591), 2010 to 2015.
a Follow-up includes clients reached at follow-up (completers and noncompleters).
Discussion
As the health, medical, and economic burden of preventable chronic disease continues to rise, the need to define new approaches to initiate and sustain healthy behavior change becomes increasingly important. By designing and deploying evidence- and curriculum-based coaching programs with health coaches skilled in motivational interviewing and content area expertise, we observed high levels of engagement, program fulfillment, and rates of behavior change. This study adds to a growing body of literature by presenting program outcomes that meet or exceed published standards and/or clinically accepted practice guidelines where they exist 6,7,12 and represents a large and diverse sample.
This study had several limitations. All outcomes were self-reported rather than verified by clinical, biometric, or laboratory values. Second, these interventions were not randomized; participants likely experienced higher baseline motivation relative to the general health plan population, thus limiting our ability to construct a comparison group. Further, a lack of comparison or control group may limit interpretations as behavior may have changed in the absence of intervention and activated patient likely self-referred or agreed to participate. Third, these are real-world evaluation data; our completion rates cannot be directly compared with research studies that have higher completion rates due to intensity of follow-up available. Thus, findings from this study should be considered preliminary and more rigorous evaluation is warranted in the future. However, these programs were implemented across a large population, making our descriptive findings informative, generalizable and applicable to real-world conditions.
As health coaching becomes increasingly important to health improvement, disease management and shared decision-making, and as national certification emerges, the need for developing new and scalable approaches to effectively train coaches and provide health coaching programs will grow. Our experience describes the real-world effectiveness of evidence- and curriculum-based lifestyle programs delivered by highly trained health coaches to a large health plan member population. Currently in the literature, there aren’t other health plan-driven, published data available to better understand real-world engagement and follow-up to such programs. Future areas of study should include understanding the impact of physician “prescription” on engagement rates 13 compared to traditional health plan referral routes and investigating optimal coaching delivery modalities (eg, individual/group, telephonic, web-based, self-monitoring devices, etc) to increase participation, promote program completion, and produce the desired outcomes. Moreover, more rigorous design is needed to meaningfully assess the impact of these interventions on health outcomes and costs.
So What?
What Is Already Known on This Topic?
There is great variability in the field of health coaching with regard to how interventions are designed, delivered, and evaluated.
What Does This Article Add?
This article demonstrates evidence- and curriculum-based health coaching program delivery with program outcomes that meet or exceed published standards and/or clinically accepted practice guidelines where they exist. No health plans (to our knowledge) have shared their lifestyle health coaching program content/structure, lifestyle health coach training and quality assurance practices, or evaluation approach.
What Are the Implications for Health Promotion Practice or Research?
As the ICHWC continues to board certify health coaches, researchers and practitioners in the field will be given the opportunity to standardize coach training, program delivery, and evaluation. Although more rigorous evaluation is warranted, this article does describe a comprehensive approach to health coach program design, health coach training, and standardized evaluation based on valid and reliable scales available in the literature.
Footnotes
Acknowledgments
The authors acknowledge the contributions of our partners and stakeholders that made this work possible: The UPMC Health Plan telephonic and on-site lifestyle health coaches and leadership (Lisa Wallace, Tish Rohan, Christian Gabarda, Elana Barkowitz, Stephen Doyle, Jennifer Liberati, and Nicolette Shriver), analysts within UPMC WorkPartners Commercial Analytics (Eric Hepler, Erica Brunngraber, and Frank Seguiti), The Center for High Value Healthcare (Dr William Shrank), and Dr Tim Cline (former Senior Director of Clinical Training & Development), and UPMC Health Plan Clinical Training & Development Team (Kayla Tannehill, Joe Matsko, Laura Yautz, and Bonnie Gillis).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.