According to the World Health Organization (WHO), “Without a system that addresses the determinants of adherence, advances in biomedical technology will fail to realize their potential to reduce the burden of chronic illness.”1 The WHO has recommended that adherence challenges are most effectively solved by individualized interventions addressing multiple factors impeding adherence.1 In its report, Adherence to Long-Term Therapies: Evidence for Action, the WHO has identified 5 interactive “dimensions” or factors affecting adherence, including1:
- Social/economic factors, such as unemployment, lack of health insurance, and limited social networks for support
- Health system factors, such as lack of provider clinical training in chronic disease management and followup systems
- Condition-related factors, which describe the inadequacy of our clinical systems to address the impact of disabilities (eg, memory impairment) and disease comorbidities (eg, depression associated with diabetes) on patient medication-taking persistency
- Therapy-related factors, which deal with problems such as complex medication regimens and side effects
- Patient-related factors, describing some of the more pernicious obstacles to treatment adherence, such as healthcare illiteracy, a lack of motivation for medication persistence, and wavering confidence or self-efficacy in one’s abilities to manage a chronic condition.
All these factors create powerful cognitive, emotional, and spiritual disincentives that sap the willpower of individuals to adhere to treatment recommendations.
Recognizing that successful behavior change is not simply a cognitive decision to get healthy, the WHO declared that, “information is a prerequisite for changing behavior, but in itself is insufficient to achieve this change. Motivation and behavioral skills are critical determinants.”1 Clearly, from the viewpoint of an organization that assists the most challenging health populations around the world, “information alone is not enough”1; motivating or inspiring the individual to change his or her behavior is also needed.
Research further confirms that improved medication adherence reduces the financial burden of illness.2 In their analysis of the costs of medication adherence, Sokol and colleagues have concluded that, “For some chronic conditions, increased drug utilization can provide a net economic return when it is driven by improved adherence with guidelines-based therapy.”2
RAND Health has called for programs that strike a balance between customized, patient-specific variables and population-based programs.3 Gellad and colleagues at RAND advocate the development of programs for large groups or classes of patients that identify “unique” barriers among patients as individuals and customized interventions for patients based on those barriers.3
Disease management programs have responded to this call for individualized, motivational interventions, and Geyman has commented on their emerging availability not only to patients served by commercial, employersponsored health plans but to patients served by Medicare and Medicaid plans as well.4 Interest in individualized, motivational change has grown to the extent that the Agency for Healthcare Research and Quality commissioned a report from RAND regarding patient self-management support programs.5 The report recommended that programs include “both supportive coaching interventions and educational interventions as part of the program content.”5 This is not surprising, because multiple studies have associated coaching with improved health behaviors.6-11
Coaching interventions address unhealthy behaviors associated with health and behavioral health disparities12; these can be employed across the plethora of healthcare delivery systems, such as disease management programs,13 medical care homes,14 home healthcare,15 pharmacy adherence programs,16,17 and peer coaching networks18 that have been promoted to enhance patient self-care, as described below.
The 2010 Patient Protection and Affordable Care Act (ACA) for healthcare reform also provides financial incentives for health coaching. Specifically, according to the ACA, health plans will be permitted to include expenditures for healthcare quality improvement, including those that “increase wellness and promote health,”19 such as coaching programs, in the calculations of their 2011 medical loss ratios.
Nevertheless, many clinicians still receive little, if any, training in coaching and motivational techniques for treatment adherence. RAND Health has commented on the lack of professional school training to support patient self-management5 and has called for coaching interventions that are “patient-centered and tailored to the needs and concerns defined by the patient and his or her situation.”5 Some clinicians have opined that not only professional clinicians but also paraprofessionals in networking or supervisory relationships with clinicians could benefit from coaching skills training.9,18 This article provides clinicians and paraprofessionals with some practical coaching suggestions to promote patient motivation for adherence improvement.
The article will focus on some leading-edge concepts such as connectedness, and will describe key coaching concepts that can be used when speaking with patients to promote motivation for medication adherence and to minimize other factors impinging on adherence.
Definitions: Coaching Concepts
For the purposes of this article, “coaching” is defined as “a collaborative process of self-discovery, support, inspiration, and confidence building. Coaching motivates participants to use information for realistic goal setting, to identify their motivations for change, and to develop and maintain personalized strategies based on individual strengths.”18 The coaching process may be applied in multiple contexts, including health, business, professional development, sports, and other life spheres. This article focuses on the application of coaching concepts to enhance medication and treatment adherence for health improvement.
Network Coaching integrates coaching with social networking concepts by recognizing that all individuals and families have complementary team and network participating strengths whose successful use is essential to personal values of self-worth.20
Clinicians seeking to enhance patient adherence through improved motivation may be helped by remembering the mnemonic COPE (Figure) that assists in the recall of these 4 significant coaching concepts that help inspire patients for medication persistence:
- Connectedness and collaboration
- Open-ended questions
- Positive attitude
- Encourage support.
Connectedness and Collaboration
Connectedness, connectivity, or the quality of the personal relationship between patient and physician has been found to be an important determinate factor in the quality of care received by a patient.21 This study from Harvard researchers showed that people who felt connected to a specific doctor were more likely to complete recommended testing for prevention and care of chronic illness.21 In another recent study, Schoenthaler and colleagues found that collaborative communication between provider and patient was associated with improved medication adherence.22 These 2 studies suggest that connectivity and collaborative communication may indeed be connected.
Travaline and colleagues have written about the importance of collaboration in furthering connectivity or close physician–patient relationships.23 They cited a physician’s empathy and sensitivity to a patient’s nonverbal signals as key factors in encouraging a collaborative sense of teamwork in their care.23
EXAMPLE Noticing patients’ verbal and nonverbal cues of anxiety and inviting them to ask questions will encourage patients to seek information and reassurance about a new medication. An open invitation such as “What questions do you have about this medication?” affirms the importance of patients and their inquiries. An abrupt or dismissive “Any more questions?” will probably be perceived as perfunctory and uninviting.
In addition, Rollnick and colleagues indicate that the directive, authoritative communication style frequently practiced in healthcare may actually discourage patient–clinician collaboration.24 The authors advise that a collegial, inclusive style promotes patient participation. Patients respond more favorably when clinicians adopt a collaborative tone that conveys, “I’m here to assist you in solving your health-related problems.”24
EXAMPLE When a patient continually forgets to take his medication, some clinicians ask a mindful question such as, “When you take your pills, what helps you to remember to take them?” Prompting for helpful cues assists patients in identifying their own solutions and in increasing their feelings of inclusion as members of a collaborative team of problem solvers.
The patient motivation problems associated with adherence to care widen the treatment playing field to include not just the traditional clinical, multidisciplinary team but also patients and healthcare professionals and paraprofessionals, serving as coaches and participating team members. Research indicates that this inclusion strategically shifts the care to favor the importance of connectivity and collaboration.25,26
Open-ended questions inviting self-reflections as in the example above establish a more personal exchange of information conducive to furthering clinician–patient relationships.24 Frequently, these self-reflections will involve feelings that reveal personal incentives and avoidances. These patient reports on emotional states are useful in expediting the development of individualized interventions.
As diagnosticians, clinicians often use a criteria-driven, deductive approach as an efficient method for narrowing diagnostic possibilities. But efficiency may be gained at a price costly to the emotional nuances involved in individual motivation and treatment adherence. The medical criteria and processes used in making an accurate diagnosis are not the same as the personal information needed to coax a unique individual’s adherence to care. Open-ended questions help bridge the chasm between clinician and coach.
EXAMPLE Asking a patient with asthma a question such as “How do you feel when you forget your medicine?” helps the patient to identify his/her personal, intrinsic motivations for medication adherence. A question such as “How are you feeling since you began taking this medicine?” can open the door to discussing therapy-related factors, such as living with a particular medication’s side effects.
A positive attitude or a belief in one’s self and the confidence to make self-care decisions can greatly impact treatment efficacy.27 Philosopher coach Reginald Gant compared his management of 2 chronic, life-threatening conditions (diabetes and atherosclerosis) to “running a marathon—small strides are still steps in the right direction, pacing is more important than sprinting, expect setbacks with equanimity, and the water bottle is always half full.”28 Just as a positive mental attitude fosters optimal marathon performance,29 it can foster optimal condition self-management. Not surprisingly, Matthews found a correlation between positive patient attitude and glycemic control among adults with diabetes.30
Yet, the changes required for successful self-care can be daunting. Negative thoughts learned from childhood become formative in adulthood, stymieing a positive outlook. Psychologist coach Anthony Grant31 and colleague Jane Greene summarized more than 6000 research articles and concluded that performanceenhancing thoughts can effectively alter ingrained, negative thought patterns if they are short, specific, and simple. 31 They encourage readers to minimize doubts during problem planning and resolution stages by repeatedly substituting debilitating thoughts with simple, short, and specific positive thoughts.31
EXAMPLE When a patient with diabetes is discouraged, being mindful of short, specific, simple performance-enhancing thoughts, such as “I feel em powered when I exercise,” “With portion control I can still eat many foods I’ve previously enjoyed,” and “Insulin injections are not nearly as evil as they look,” can effectively counter negative, self-defeating thoughts.
Another enhancement to positive or confident thinking is devising personalized, problem-surmounting strategies that emphasize and use our personal strengths.32 In a study of care management recipients, Brun and Rapp found that reinforcing what patients believed were their personal strengths contributed to positive care-management relationships.33 Although many clinicians report a methodological dissonance in reconciling an emphasis on patient strengths when their formal training dwells on human pathologies, they are gradually recognizing the coaching logic of using personal strengths to reinforce the confidence of patients in sustaining healthy changes.
EXAMPLE A grandmother who has infinite patience with her grandchildren can be encouraged to use that strength when coping with chronic illness; an accountant can use his attention to detail for better medication tracking; and an imaginative writer can devise novel ways to remind herself to take her medication regularly.
Encourage Support: Social Support Networks
There is strong evidence that when clinicians focus on issues of patient support they and their patients are rewarded with improved outcomes. Several studies have suggested that social and support networks have significant impact on healthy behaviors.34-36 The experience of chronic disease often includes traumatic experiences for the patient and the family, and research indicates that network support is one of the key factors in motivating growth and resilient coping.37
Interventions to change unhealthy behaviors, such as overeating, smoking, and alcohol abuse, are more successful when they offer peer support.35,38-40 When patients adopt healthier habits, their untreated family members often emulate them and improve as well.34 Data culled from studies such as the Framingham Heart Study suggest that healthy and unhealthy behaviors pass like contagions among networks of peers.41 Furthermore, Christakis and Fowler found that these contagions or behaviors may even spread among people who have no contact with each other.42
When patients lose weight, their weight loss may positively influence the weight of their spouse, their spouse’s friend, and their friend’s coworker.41 The authors conclude that this kind of behavioral change typically has 3 degrees of influence, including people unknown to the initial subject of change.41 Additional analyses have shown subtle factors, such as type of behavior problem and type of relationship (eg, friend or spouse), influencing the spread of behavioral contagions. For example, men in the Framingham Heart Study doubled their risks for obesity if a male friend became obese, but their risk increased only 37% if their wives became obese.41 Smoking cessation by one spouse decreased the other spouse’s chance of smoking by an impressive 67%, whereas smoking cessation by a friend only decreased smoking by 36%.42
Social Networking Research
Social networking research introduces novel approaches to notions of disease and population management in healthcare. In the future, clinicians who understand the subtle interplay of social networks may find innovative ways of seeding a patient’s support network with beneficial influences; pair the treatment of patients with either spouses, family, friends, or selected unknowns; and weigh how cultural and psychosocial factors beyond the interpersonal differentially reinforce the success or failure of behavioral change.
For example, Excel Venture Management is investing in the future of social networking to improve health. They recently bankrolled MedNetworks, a startup firm offering services derived from Nicholas Christakis’ work.43 The company intends to sell its services to entities such as health plans, disease management companies, and wellness programs. They will use MedNetworks’ services and software to identify key connectors within networks who may potentially promote behavior change for healthier lifestyles within individuals and populations.43
EXAMPLE One day a clinician may have data regarding whether a large condition-management class that offers more potential network influences is more effective than a much smaller conditionmanagement class that offers more personal time with the instructor.
COPE represents just some of the elements from the coaching “playbook” that facilitate adherence to clinical care and medication management. At its highest and most visible levels in professional and collegiate sports, coaches routinely exact the highest levels of motivation and performance from their athletes. As we launch this era of healthcare reform, there has never been a more promising time for healthcare professionals and paraprofessionals to adopt coaching methods that inspire effective performances from patients facing challenges with care and medication adherence.
Author Disclosure Statement
Dr Hennessey and Dr Heryer have reported no conflicts of interest in relation to this article.
- World Health Organization. Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization. 2003. www.who.int/chp/ knowledge/publications/adherence_full_report.pdf. Accessed February 1, 2010.
- Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43:521-530.
- Gellad WF, Grenard J, McGlynn EA. A Review of Barriers to Medication Adherence: A Framework for Driving Policy Options. Santa Monica, CA: RAND Corporation; 2009. www.rand.org/pubs/technical_reports/TR765/. Accessed September 12, 2010.
- Geyman JP. Disease management: panacea, another false hope, or something in between? Ann Fam Med. 2007;5:257-260.
- Pearson ML, Mattke S, Shaw R, et al. Patient Self-Management Support Programs: An Evaluation. Final Contract Report. Prepared by RAND Health under Contract No. 282-00-0005. Rockville, MD: Agency for Healthcare Research and Quality; November 2007. AHRQ Publication No. 08-0011. www.ahrq.gov/qual/ptmgmt/ ptmgmt.pdf. Accessed September 12, 2010.
- Oliver JW, Kravitz RL, Kaplan SH, Meyers FJ. Individualized patient education and coaching to improve pain control among cancer outpatients. J Clin Oncol. 2001;19:2206-2212.
- Vale MJ, Jelinek MV, Best JD, et al. Coaching Patients On Achieving Cardiovas - cular Health (COACH): a multicenter randomized trial in patients with coronary heart disease. Arch Intern Med. 2003;163:2775-2783.
- Holland SK, Greenberg J, Tidwell L, et al. Community-based health coaching, exercise, and health service utilization. J Aging Health. 2005;17:697-716.
- Sacco WP, Morrison AD, Malone JI. A brief, regular, proactive telephone “coaching” intervention for diabetes: rationale, description, and preliminary results. J Diabetes Complications. 2004;18:113-118.
- Whittemore R, Melkus GD, Sullivan A, Grey M. A nurse-coaching intervention for women with type 2 diabetes. Diabetes Educ. 2004;30:795-804.
- Wolever RQ, Dreusicke, M, Fikkan J, et al. Integrative health coaching for patients with type 2 diabetes: a randomized clinical trial. Diabetes Educ. 2010;36:629- 639. Epub 2010 Jun 9.
- Brondolo E, Gallo LC, Myers HF. Race, racism and health: disparities, mechanisms, and interventions. J Behav Med. 2009;32:1-8. Epub 2008 Dec 17.
- Gillespie JL, Rossiter LF. Medicaid disease management programs: findings from three leading US state programs. Dis Manage Health Outcomes. 2003;11:345-361.
- Ginsburg PB, Maxfield M, O’Malley AS, et al. Making Medical Homes Work: Moving from Concept to Practice. Washington, DC: Center for Studying Health System Change; December 2008. www.hschange.com/CONTENT/1030/. Accessed September 12, 2010.
- Huffman M. Health coaching: a new and exciting technique to enhance patient self-management and improve outcomes. Home Healthc Nurse. 2007;25:271-274; erratum 2007;25:398.
- Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial. JAMA. 2006;296:2563-2571. Epub 2006 Nov 13.
- Herborg H, Haugbølle LS, Sørensen L, et al. Developing a generic, individualised adherence programme for chronic medication users. Pharm Pract. 2008;6:148-157.
- Hennessey M, Hunt M, Heryer JW. Filling the nonadherence and lifestyle matters gap: the roles of coaching and mindfulness in our 21st-century healthcare delivery system. Grand Rounds Presentation, University of Missouri-Kansas City, School of Medicine; December 18, 2008.
- Regulation for uniform definitions and standardized methodologies for calculation of the medical loss ratio for plan years 2011, 2012, and 2013 per section 2718 (b) of the Public Health Service Act. Washington, DC: National Association of Insurance Commissioners; October 2010:190-1-190-42. www.naic.org/documents/ committees_ex_mlr_reg_asadopted.pdf. Accessed November 25, 2010.
- Hennessey M. The Choice Revolution. White paper prepared as an unpublished manuscript for the Gardener Study Group, November 2009.
- Atlas SJ, Grant RW, Ferris TG, et al. Patient-physician connectedness and quality of primary care. Ann Intern Med. 2009;150:325-335.
- Schoenthaler A, Chaplin WF, Allegrante JP, et al. Provider communication effects medication adherence in hypertensive African Americans. Patient Educ Couns. 2009;75:185-191. Epub 2008 Nov 14.
- Travaline JM, Ruchinskas R, D’Alonzo GE Jr. Patient-physician communication: why and how. J Am Osteopath Assoc. 2005;105:13-18.
- Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care. New York, NY: Guilford Press; 2008:17-18, 45-49.
- Joseph D, Griffin M, Hall R, et al. Peer coaching: an intervention for individuals struggling with diabetes. Diabetes Educ. 2001;27:703-710.
- Heisler M, Vijan S, Makki F, et al. Diabetes control with reciprocal peer support versus nurse care management. Ann Intern Med. 2010;153:507-515.
- Wang L, Dong J, Gan H, Wang T. Empowerment of patients in the process of rehabilitation. Perit Dial Int. 2007;27(suppl 2):S32-S34.
- Personal communication with Reginald Gant, philosopher coach. January 28, 2010.
- Medical News Today. Mental attitude crucial for marathon running. April 17, 2004. www.medicalnewstoday.com/articles/7356.php. Accessed February 4, 2010.
- Matthews SM. The effect of individual attitudes toward diabetes on glycemic control. Presented at the 18th International Nursing Research Congress Focusing on Evidence-Based Practice. July 11-14, 2007. http://stti.confex.com/stti/congrs07/tech program/paper_35186.htm. Accessed January 28, 2010.
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- McBride R. MedNetworks, co-founded by Harvard’s Nicholas Christakis, aims to tap healthcare’s hidden social networks. Xconomy: Boston; October 27, 2010. http://www.xconomy.com/boston/2010/10/27/mednetworks-co-founded-by-harvards-nicholas-christakis-aims-to-tap-healthcares-hidden-social-networks/. Accessed January 11, 2011.