COACHING AND COUNSELING TIME TOOL
A Resource from the American College of Preventive Medicine
A TIME TOOL FOR CLINICIANS
ACPM's Time Tools provide an executive summary of the most up-to-date information on delivering preventive services to patients in the context of a clinical visit. Information presented is based on evidence presented in peer-reviewed journals.Please refer to the Coaching and Counseling Clinical Reference for more information.
Coaching and Counseling Patients
Physicians Are the Key – But It Takes a Team…and a Process
The majority of Americans make poor choices regarding their health. They eat poorly, don’t get enough physical activity, are non-compliant with their medications and don’t take an active role in managing their chronic conditions. Evidence is mounting that such poor choices underlie much of the burden of chronic disease, premature deaths, and healthcare costs. The potential rewards of improved behaviors are enormous.
The Role of Primary Care
Primary care physicians are the ideal purveyors of health behavior change interventions.
Americans average 2-3 doctor visits per year. They look to their doctors for advice and direction. Advice from a doctor has always been one of the strongest motivators of behavior change, or at least making an attempt. Every visit is an opportunity to advise needed change, and offer support. But, advice alone is seldom sufficient to change patient behaviors.
Most patients do not know how to sustain behavior changes; they need education, strategies and support, that is, they need counseling to create new behaviors. Unfortunately, behavior change counseling is not part of usual care. Providers struggle to provide more than advice due to time constraints, limited reimbursement and lack of training in behavior counseling. As a result, few patients receive the guidance they need.
The Emergence of Behavior Change Coaching
Behavior change coaching has emerged as a unique intervention to fill the gap. Coaching is not medical care. Nonclinical staff can be as effective as physicians in this aspect of care. The process is not difficult, but it requires some training and practice. Coaching is different than counseling in that it focuses strictly on the behavior the patient wants to change. It does not deal with psychological issues or complex behavioral issues. They are the realm of credentialed counselors and therapists. These professionals can certainly coach behavior change, but coaches cannot counsel beyond behavior change. Coaching is simpler and more cost effective, and for many patients is all that is needed to facilitate change.
Motivational Interviewing: The Key to Success
Coaching behavior change uses motivational interviewing techniques to explore and resolve the patient’s ambivalence regarding the behavior in question. It is a different style of communication than most clinicians are used to – more listening and negotiating, soliciting the patient’s feelings. The patient’s values, concerns and capabilities are the focus. Assisting patients in setting goals, defining an action plan, and navigating the path to reach their goals is the role of the coach. Ongoing follow-up and support is also part of this role.
The coaching process uses the patient’s readiness to change to determine the direction of counseling and the patient’s ratings of the importance of the change and confidence in carrying it out to guide the goal setting and action planning.
Physicians may actually play a relatively minor role in the coaching/counseling process, but their enthusiastic support is essential.
Some Good News
Lifestyle medicine is gaining credibility, not only for preventing chronic disease, but also for managing it.
With each update of the USPSTF recommendations, more indications for behavior change counseling are supported.
More guidance is available -- not only in coaching and counseling, but in overcoming barriers and implementing office systems.
Innovative programs that include behavior change interventions serve as examples for how it can be done.
Health care reform discussions include an awareness of the need to support preventive services.
The Challenge Ahead
The challenge is how to deliver more effective and efficient behavior change interventions under the current restraints of primary care. Three steps are essential in this process:
First, physicians must take the lead, not only in advising patients that a change in behavior is needed, but also in assessing the practice and initiating changes in office systems and practice attitudes about behavior change interventions.
Second, office system enhancements are needed to support the interventions – identification of patients’ counseling and/or coaching needs, prompts for providers, staff roles, coaching and follow-up protocols, referral networks, and evaluation of outcomes.
Third, training in motivational interviewing for anyone who is going to be providing coaching. Without trained coaches, links to community programs are needed.
Steps to Initiate Practice Changes
A lot can be done with minimal change to the practice structure and systems.
Clinicians and coaching staff:
Learn communication skills, how to use a patient-centered approach
Use every visit as an opportunity to deliver brief advice on behavior change
Learn to use the 5A framework for addressing behavior change
Obtain some training in motivational interviewing, goal-setting, action-planning, and problem-solving strategies
Create a positive atmosphere in the office – from staff attitudes to office decor (e.g., inspirational pictures and messages, educational materials and messages)
Assign specific roles and responsibilities to staff
Develop a systematic protocol to follow-up on patients’ behavior change attempts
Develop a referral network in the local community to support behavior changes
Other practice changes:
Develop patient registries, group visits
Schedule visits specifically to address behavior change
Test the process with a "Teamlet” approach (a small team within the practice):
Requires a medical assistant trained in motivational interviewing
Assistant conducts a pre-visit to clarify needs and goals, a post-visit for counseling, and phone calls to follow-up
Try it a couple of days a week with patients whose issues are behavior related
Evaluate the impact on behaviors
Sample Office Visit for Behavior Counseling Using the 5A Format
The 5A counseling protocol is advocated by the USPSTF. It has been shown to be an effective approach to counseling for behavior change. The 5As are Assess, Advise, Agree, Assist, and Arrange.
Mail out questionnaire assessing current behaviors, goals, preferences
Greet patient, establish rapport
Review purpose of the visit, confirm with patient; identify issues to address
II. Assess current behaviors (review questionnaire)
III. Advise changesneeded in clear strong terms personalized to the patient’s health status
IV. Agree on a specific behaviorto target (may be several needs but need to identify what patient wants to work on)
Elicit patient’s thoughts on these to figure out what he/she can change.
Ask: "Is there any specific behavior you would like to begin working on this week to improve your health?” If so, what is that?
If yes, ask about the importance of the change: "On a scale of 0 to 10, with 0 being not important and 10 being very important, how important is it for you to ____ at this time?”
If the answer is 7 or more, he/she is ready; go to "V. Assist”
If the answer is < 7, it may not be important enough; Ask: "is there a behavior that you feel is more important to change at this time?”
If the answer is "no, not this week” then he/she is not ready; for the remainder of this visit, focus on reducing resistance to change -- discussing obstacles, reinforcing benefits and your belief in the patient’s ability to change. Provide some educational materials and affirm that maybe the next visit he/she will be ready to begin working on a behavior change.
V. Assist with planning the change
Provide brief counseling right now – goal setting and action planning
Introduce a staff assistant who will provide the counseling and follow-up
Refer the patient to an outside program for the behavioral intervention
Goal setting: Agree on long-term goal (e.g., lose 40 lbs in 8 months) and a specific short-term goal that is realistic and achievable (lose 5 lbs in 4 weeks); the short term goal will be the focus.
Action planning: Discuss a specific action to work on (e.g., substitute water for soft drinks, walk 20 min daily).
Assess confidence to achieve action: "On a scale of 0 to 10, with 0 being not confident and 10 being very confident, how confident are you that you can ____ at this time?”
If < 7, adjust the action plan until it is at least a 7.
VI. Arrange follow-up
Keep in mind the impact of personal behaviors on health, the influence that physicians have on patients, the number of physician visits made per year, and the potential impact of successful behavior change on individuals and the population.
Coaching has been used successfully in many areas to help people achieve goals that are important to them. It can be used similarly in primary care to encourage and empower patients to make lifestyle changes and to self manage their chronic conditions. But physicians and practices must be proactive. New skills, office systems and connections within the community are needed to overcome the barriers that are currently in place. With these changes, there is an opportunity to not only encourage more health behavior interventions, but also to strengthen relationships between patients and providers.
Supporting references and additional information:
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