Health coaching for patients with diabetes: Changing behavior and health

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1 Fairview Health Services Fairview Medical Group Influencing patient behaviors and habits is difficult to accomplish in a short clinic visit. Since primary care providers struggle with insufficient time to engage patients, another clinical role was needed so patient s had enough time to discuss personal health goals. As part of a randomized control trial, we embedded five health coaches at various clinics and trained them in patient activation concepts and motivational interviewing, and provided a defined scope of practice. To create good habits, coaches worked with patients for six months. Embedded five health coaches within the care teams at various primary care clinics across our health system Coached patients saw significant improvement in their diabetes 5 (D5) pass rate (45% to 53%) Low activated patients receiving coaching had better final D5 scores than similar, highly activated patient PAM Coached patients perceived significant improvement in their coaching experience over time in terms of engagement, motivation and comprehensiveness of interactions Health coaching for patients with diabetes: Changing behavior and health PAM scores significantly increased from 2.84 to 3.42 from baseline to follow-up (20% increase) Given evidence that high PAM levels lead to lower emergency department use and total health care costs in our population (Hibbard, 2012; Mitchell, 2013), we deduce that our intervention should yield similar results

2 Fairview Health Services, Orthopedic Service Line and Institute for Athletic Medicine Low-back pain is costly and ever increasing in incidence. Despite many technological innovations and advances in medical knowledge, the U.S. is not producing better patient-reported outcomes for this large population. Targeted care and timely entry into physical therapy are recent trends in literature, but haven t been evaluated together. Creation of a Walk-in Spine Clinic to provide same day access to specialized physical therapy for patients who have either seen or talked to a primary care provider about their low-back pain Patient-reported outcomes around functional disability and psychosocial health provided basis for treatment as well as a measure of improvement over time Risk stratified physical therapy demonstrates short- and long-term benefits relative to the patient-reported outcomes of functional disability and psychosocial health Consistently using patient-reported outcome measures across care improve shared decision making Improving patients psychosocial health and functional ability long-term may lead to an increase of other healthy activities Patients can achieve meaningful outcomes with less utilization by accessing a same day, specialized walk-in physical therapy clinic The effects of early access to risk stratified physical therapy Imaging in primary care decreased from 56% to 21% for patients who are referred to the spine clinic One in five patients enter physical therapy at high risk for long-term disability due to psychosocial indicators; one in 20 patients leaving physical therapy remain high risk Targeted care pathways are effective at getting the right patient to the right provider at the right time

3 HealthPartners Department of Orthopaedic Surgery There s a need to adequately counsel patients regarding smoking cessation before elective orthopaedic surgery. We implemented a first-in-the-nation, free medical student run smoking cessation clinic to be integrated with an orthopaedic surgery clinic. Offers a free service to patients who might not otherwise take advantage of such care Takes advantage of a teachable moment in patient s lives (elective orthopaedic surgery) to promote positive behavioral change Reduces rates of smoking, thereby reducing perioperative morbidity and overall mortality Clinic available within the orthopaedic clinic, reduces number of trips for patients Service available every day during afternoon hours No appointment necessary Integrating a student-run smoking cessation clinic with an Orthopaedic Department at a Level 1 Trauma Center Reduces number of trips necessary for patients to receive care Reduces direct costs associated with smoking (e.g., cost of cigarettes, etc.) Reduces health care costs associated with perioperative complications Reduces societal costs associated with smoking-related adverse events Free service for patients

4 Allina Health In the U.S., 40 percent of deaths are attributed to poor nutrition, inadequate exercise, smoking, or hazardous drinking. About 95 percent of the population lives with an identifiable risk factor, and those risk factors are related to 75 percent of all chronic diseases. Most communities have organizations addressing wellness, but aren t coordinated and leave gaps; hospitals have no identified role in addressing the problem. We gave three-year, $450,000 grants, via the George Family Foundation, to hospital systems in 13 communities in Minnesota and western Wisconsin. The hospital systems developed unique Healthy Communities Partnership (HCP) programs to identify existing wellness resources, create community steering teams, identify gaps, develop strategies to address those gaps, screen residents and improve the health of their residents. Creates connections, encourages information/resource sharing and develops formal partnerships between health care and wellness resources within communities Creates formal ties between primary care and wellness Identifies immediate health concerns and risk factors Refers community members to appropriate follow-up resources Healthy communities partnership Documents coaching and wellness activities in the electronic medical record Provides coaching in partnership with primary care to tailor behavioral change to individual circumstances Expands health care presence into the community Reduces emergency procedures by identifying critical risks via screenings Moves upstream with health care, mitigating risk factors before they become chronic diseases Moves appropriate work from high-cost resources to lower-cost resources

5 Mayo Clinic Children s Center Creating readily available access to influenza is necessary to increase vaccine uptake. Capturing pediatric vaccine needs and eligibility by pediatric nurses is imperative for safe administration. Providing pediatric patients, families, and caregivers with influenza vaccinations creates a cocooning affect to protect children who have higher risks for complications. Mayo Clinic primary care clinics traditionally assess influenza vaccination status and offer vaccine during routine visits. The pediatric subspecialty outpatient clinic didn t routinely assess family members or caregivers vaccination status. PROCESS FOR CHANGE In 2011, the Mayo Clinic Children s Center initiated a family-centered influenza vaccination program. The program surveyed families interested in receiving vaccination and screened children for vaccine eligibility. Nurses and physicians provided information and encouraged vaccination. Vaccines were administered during appointments for those who requested one and were eligible. In 2012, the program expanded for children of any adult patients in an ambulatory setting at Mayo Clinic. RESULTS The pediatric specialty outpatient clinic administered: 120 influenza vaccines in 2010 (prior to program); 467 influenza vaccines in 2011; 1,050 influenza vaccines in 2012; and 1,518 influenza vaccines in 2013 Family-centered influenza vaccination program PREVENTIVE ADOPTION CONSIDERATIONS Pediatric patients, families and caregivers value combined services at appointments Assessment survey is valuable for understanding vaccine refusal and vaccine needs Adding intra-nasal immunizations and Tdap is a satisfier for families RECOMMENDATIONS FOR SUSTAINING THE GAINS Provide ongoing nursing and provider education and updates for the program Assess and evaluate feedback to adjust program for maximum use Designate allocated nursing to provide influenza vaccines Use a nursing influenza protocol to enhance administration and documentation Complete an annual review of evidence-based practice for vaccine administration