Evaluation of a Health Coaching Course for Providers and Staff in Veterans Health Affairs Medical Facilities

Abstract

Background:The purpose of this study was to determine whether a health coaching (HC) course for providers and staff in Veterans Health Affairs medical facilities resulted in increased attitudes toward, intentions to use, and actual use of HC. Methods: A Whole Health Coaching Course was developed and implemented in national sites in 2014. A pre-post intervention group only design was used to assess changes in HC outcomes, including use of HC skills. Results: There were large pre- to posttest increases in preparedness and self-efficacy that were sustained at follow-up. Initial small increases in attitudes toward patient-centered care and intentions to use HC skills were not sustained at follow-up. There was a medium-sized increase in actual use of HC skills between pre-test and follow-up. Conclusions: Findings suggest that participation in the HC course is an effective means for providers and staff to increase preparedness, self-efficacy, and actual use of health coaching skills.

Keywords

health coaching VHA medical facilities patient-centeredness health promotion primary care program evaluation

Introduction

Preventable chronic diseases, including coronary heart disease, type 2 diabetes, and cancer, remain the costliest health care expenditures in the United States.¹ Much of the morbidity and mortality associated with preventable chronic disease is linked to 4 behaviors: low physical activity, poor nutrition, tobacco use, and excessive alcohol consumption.² Engaging patients in the care process to help them improve poor health behaviors has become an important target of clinical and public health interventions.³ Studies suggest that both patients and health care systems demonstrate improved outcomes when strategies including patient involvement in decision making and self-management are incorporated.⁴

Approaches to help providers engage patients in health decision making and behavioral change to prevent and manage chronic disease have proliferated, with the most well-studied example being motivational interviewing (MI).⁵ More recently health coaching (HC) has emerged as a viable strategy for supporting patients in managing their health and improving health behaviors⁶; there is general consensus that both MI and HC are effective and complementary approaches to behavioral change in health care.⁷ Studies have demonstrated that HC promotes positive health outcomes for patients with type 2 diabetes and heart disease, as well as healthy lifestyle behaviors, including improved physical activity, nutrition, weight management, and medication adherence.^8-10

The Veteran’s Health Administration (VHA), which has high rates of preventable chronic disease within its patient population,¹¹ established the Office of Patient Centered Care and Cultural Transformation (OPCC&CT) to spearhead patient-driven care efforts.¹² One of OPCC&CT’s initiatives has been to train providers and staff in patient-centered care. The Whole Health Coaching Course, which was based on a literature review of HC, MI, and other effective behavioral approaches and designed to meet the core competences set forth by the International Coach Federation,¹³ was developed to address this task. The course was developed through a contract from Department of Veterans Affairs to Pacific Institute for Research and Evaluation (PIRE).

Drawing from the tenets of patient-centered care,^14,15 the Whole Health Coaching Course was designed to teach diverse clinicians to (1) assist patients in developing a personalized health plan based on what matters most to them, (2) partner with patients to proactively take action toward present- and future-oriented behavioral goals, (3) recognize that health is broader than the absence of disease, and (4) support patients in achieving optimal health that takes into account mental, physical, and social well-being. The emphasis is on the patient as the person best able to decide what they need, while the expertise of the coach lies in guiding the change process.

The purpose of the current study was to determine whether the course was effective in improving attitudes toward, intentions to use, and actual use of HC among diverse providers and staff across eight VHA facilities. We also assessed changes in norms that could support integration of HC into VHA clinical services. PIRE’s Institutional Review Board reviewed the study protocols and deemed them exempt from human subjects review. The initial curriculum and evaluation measures were piloted at 2 VHA facilities in 2013 to assess preliminary effectiveness and identify needed modifications before course implementation on a wider scale. The team changed the course based on participant and OPCC&CT staff feedback, and the evaluation measures were refined. The course was implemented in 3 facilities in Fall 2013 during which time the evaluation measures were further modified. This study includes data from 8 VHA facilities (Phoenix, AZ; Atlanta, GA; Lovell, IL; Palo Alto, CA; Little Rock, AR; Nashville, TN; New Orleans, LA; and Sioux Falls, SD) where the course was implemented with finalized evaluation methods between January and July, 2014.

Methods

Procedure

The 6-day course included 42 contact hours and was conducted onsite at the VHA facilities in two 3-day modules, which were separated by approximately 5 weeks. Between the 2 modules trainees participated in three 90-minute practice coaching sessions in person or via telephone, at least one of which was mentored by the training staff. The training team included 2 facilitators who lead the didactic instruction, large and small group discussion, and live coaching demonstrations (modeling) and 2 to 3 mentors (depending on enrollment), who assisted with delivering course content as needed and helped trainers to provide structured feedback on triad practice sessions, where trainees alternated roles as patient, coach, and observer. Figure 1 presents key content areas of the 2 modules.

Figure 1.

Whole Health Coaching Course key content areas. SMART = Specific, Measurable, Action Oriented, Realistic, Timed.

Participants were identified based on responses to an email solicitation about the course (maximum enrollment was 45). Sites selected participants to maximize clinical implementation and diversity of representation across provider types and services. Physicians, social workers, dieticians, nurses, pharmacists, peer support specialists, medical assistants, and other allied health professionals were encouraged to participate. While most participants volunteered to attend, 15% enrolled because a manager required them to do so.

Measures and Instruments

The 5 primary outcomes in this study were (1) preparedness for HC, (2) self-efficacy to use HC skills, (3) attitudes toward patient-centered care, (4) intentions to use HC skills, and (5) past month use of HC skills. Two secondary outcomes were perceived norms in respondents’ facilities about patient-centered care and HC. While we did not expect the course would directly affect secondary outcomes, we considered them important to integration of patient-centered care and HC given the literature that demonstrates organizational support as critical to advancing patient-centered care.¹⁶ We developed items based on course content, except for seven of the ten items we used to compute the outcome of attitudes toward patient-centered care; these were adapted from items in the Patient-Practitioner Orientation Scale by Krupat et al.¹⁷ Cronbach’s α at baseline for all 7 outcomes demonstrated internal consistencies for all outcomes greater than .76 (see Table 1 for details on these multiple-item scales). Pretest instruments included demographic items and the seven outcome measures, while the posttests and follow-up surveys included the 7 outcome measures.

Table 1.

Outcome Measures and Their Reliability in the Current Study.^a

Outcome	No. of Items	Range	α
Preparedness for Whole Health Coaching (WHC)	5	1-5	.92
(Example: “How would you rate your current preparedness to . . .” “use whole health coaching skills effectively?”)	5	1-5	.92
Self-efficacy to use WHC skills	4	1-4	.90
(Example: “I feel confident in my ability to implement whole health coaching skills effectively with Veterans.”)	4	1-4	.90
Attitudes toward patient-centered care	10	1-4	.81
(Example: “All staff play an equally important role in manifesting patient centered care within the VA.”)
(Example adapted from Patient-Practitioner Orientation Scale (17): “Patients should be treated as if they were partners with the health care provider, equal in power and status.”)
Intentions to use WHC skills	5	1-4	.94
(Example: “In the next month how likely are you to . . .” “Assist Veterans in developing a personal mission that can support their short- and long-term objectives?”)	5	1-4	.94
Past month use of WHC skills	5	1-4	.88
(Example: “In the past month, how often did you . . .” “Assist Veterans in developing a personal mission that can support their short and long term objectives”)	5	1-4	.88
Perceived norms about patient-centered care	5	1-4	.77
(Example: “Please indicate the extent to which you agree with the following statements about the facility where you work . . .” “Patient centered care is a primary emphasis in this facility”)	5	1-4	.77
Perceived norms about WHC	5	1-4	.84
(Example: “Overall the staff in my facility is supportive of the use of whole health coaching.”	5	1-4	.84

Response categories were as follows: Preparedness—(1) very low to (5) very high; Self-efficacy, Attitudes toward patient-centered care, and Perceived Norms—(1) “strongly disagree” to (4) “strongly agree”; Intentions—(1) “very unlikely” to (4) “very likely”, Past month use of skills—(1) “none of the time” to (4) “all of the time.”

Data Collection

Participants were sent emails with links to a Web-based pretest survey prior to the course. Staff of OPCC&CT informed participants prior to the start of the course that they would be asked to take part in the evaluation, and the OPCC&CT staff provided the evaluators with the names and email addresses of those who signed up for the course. Those who did not complete the web-based pretest were asked to complete a survey onsite before module 1. Across the 8 sites, approximately 85% of participants completed the Web-based pretest. An evaluation team member checked for Web-based survey noncompleters just prior to the start of the course, and noncompleters were asked to complete paper versions of the pretest. Participants completed posttests onsite on the final day of module 1, on completion of course delivery. Two months after module 2, participants were sent a link via email to a follow-up survey. The evaluators also sent nonrespondents email reminders. Of those who completed a pretest (258), 163 provided usable data at follow-up (response rate of 63.2%).

Analyses

We examined change over time in each outcome. Historical artifacts serve as one possible alternative explanation without a control group, but we do not suspect this. We still found robust changes from pretest using data collected from sites implementing at disparate time periods and we used an analysis strategy that statistically controlled for variability among sites on outcomes. Study attrition serves as another inferential threat. A Heckman selectivity analysis was used to statistically control for this possibility.¹⁸ Only missing background characteristic data (mentioned later in our sample description) were imputed using the expectation maximization algorithm only for our examination of selectivity. Imputing data without error for this analysis was less problematic than the inferential risk of omitting entire cases from inferential analyses due to minimal missing data on background characteristics. The first step model examined background characteristics as predictors of attrition at post-test and follow-up using probit regression models. The model only marginally predicted attrition at posttest, χ²(6) = 11.80, P = .07, where only that those for which the training was mandatory were more likely to drop out, χ²(1) = 7.08, P = .008. The model did significantly predict attrition at follow-up, χ²(6) = 23.47, P = .001, suggesting males, χ²(1) = 10.84, P = .001, and those with less positive patient-centered care attitudes at baseline, χ²(1) = 7.00, P = .008, were less likely to participate at follow-up. Therefore, we proceeded to the next step of the Heckman analysis and created an inverse Mill’s ratio to statistically mitigate selectivity biases.

We used random intercept regressions (referred to as hierarchical linear models) to examine whether changes over time occurred as a result of the course.¹⁹ All analyses assumed that variability arises in the outcomes due to repeated measurements and variability among the sites. We also calculated the intraclass correlation coefficient and the effect size r.²⁰ Calculating the effect size allows us to interpret effects as small (r = 0.10), medium (r = 0.30), and large (r = 0.50) according to the thresholds suggested by Cohen²⁰ in typical behavioral science research. The analyses regressed the 6 attitudinal and behavioral outcomes on our correction for selectivity and a dummy variable representing time (pre- vs posttest and pretest vs follow-up in separate analyses).

Results

Sample Characteristics

Sample sizes were 258 at pretest, 253 at posttest (representing 98% of those who completed pretests), and 163 at follow-up (representing 63% of those who completed pretests). Of the 238 to 255 participants at pretest who provided valid background information, the average age was 47 years and 81% were females. Most reported White (67%) as their race, 22% reported Black, 6% reported Asian, and 5% reported “other.” Twenty-one percent were Veterans. Occupational roles reported included the following: nurses (38%), social workers (13%), physicians (9%), psychologists (6%), and dietitians (6%). Other roles included health coaches, pharmacists, peer specialists, nurse practitioners, patient advocates, physical therapists, and occupational therapists; 9% reported “other.” The average number of years worked in the VHA was more than 9 years.

Change in Outcomes

There were large increases in preparedness and self-efficacy between pre- and posttest (P < .001) that were sustained at follow-up (P < .001) (Table 2). There were initial small gains in attitudes toward patient-centered care (P = .003) and intentions to use HC skills (P = .012) that were not sustained at follow-up; intentions showed a small decrease at follow-up (P = .008). Nonetheless, there was a medium-sized increase in use of HC skills between pretest and follow-up (P = .003). The training seemed to have decreased participants’ perceptions of HC norms between pretest and posttest (P = .033) and this effect was maintained at follow-up (P = .045).

Table 2.

Change Over Time on Outcomes From Baseline With Means (Standard Deviations).

	Pre vs Post				Pre vs Follow-up				Means (Standard Deviations)
	t(238-248)	P	r	ICC	t(139-156)	P	r	ICC	Pre (258)	Post (253)	Follow-up (163)
Preparedness	17.04	<.001	0.73	0.020	13.87	<.001	0.74	<0.001	3.03 (0.84)	3.93 (0.60)	4.01 (0.67)
Self-efficacy	14.00	<.001	0.67	0.016	13.31	<.001	0.73	0.001	2.64 (0.61)	3.26 (0.42)	3.33 (0.46)
Attitudes toward patient-centered care	3.05	.003	0.19	0.017	1.10	.275	0.09	0.007	3.42 (0.36)	3.49 (0.32)	3.49 (0.40)
Intentions to use health coaching skills	2.54	.012	0.16	0.005	–2.68	.008	–0.22	<0.001	3.19 (0.70)	3.30 (0.59)	3.06 (0.69)
Past month use of health coaching skills	—	—	—	—	3.06	.003	0.25	0.033	2.22 (0.75)	—	2.42 (0.70)
Perceived norms patient-centered care	0.19	.846	0.01	0.009	–1.19	.235	–0.10	<0.001	3.03 (0.43)	3.04 (0.42)	3.00 (0.48)
Perceived norms health coaching	–2.15	.033	–0.14	0.009	–2.02	.045	–0.17	0.007	2.92 (0.48)	2.85 (0.50)	2.83 (0.55)

Pretest data refer to data collected prior to module 1 of the course, posttest data refer to data collected immediately after module 1 of the course, and follow-up data refer to data collected 2 months following module 2 of the course.

Discussion

This study demonstrates that the Whole Health Coaching Course improved preparedness, self-efficacy, and use of HC skills among participants. Attitudes toward patient-centered care^14-17 showed a significant increase at posttest. Patient-centered care has become a primary focus not only of VHA efforts, but nationwide, as health care systems and providers strive to improve quality and reduce the negative effects of high rates of chronic disease.²¹ The literature demonstrates that a core component of effective patient self-management is a strong provider-patient relationship, where patients’ needs, values, and preferences are central to decision making.^22,23 A core feature of HC is to elicit from patients what is most important to them and to utilize this information in developing health behavior goals.⁶ Thus, our finding demonstrates that professionals who participate in a course designed to place patients at the center of health decision making develop appreciable attitudes toward patient-centered approaches to care. This finding, however, was not sustained at follow-up. This could be partially explained by the fact that a main feature of the course involved teaching participants how to integrate HC skills into their VHA roles. As integration increased, participants may not have readily identified their shifting attitudes toward patient-centered care.

The finding that participants’ perceptions of the degree to which their facilities were supportive of HC decreased over time was unexpected given efforts system-wide to promote patient-centered care. However, this finding suggests a need for increased facility-level organizational support for HC use; this is consistent with literature showing the importance of a culture supportive of change as efforts are made to transform VHA facilities to be more patient centered.¹⁶

One limitation is that our study did not include patient outcomes. Another limitation is that most participants self-selected into the training (since a large majority volunteered to participate), reducing the findings’ generalizability. While prior studies have demonstrated the utility of HC for various lifestyle behaviors and chronic diseases,^8-10 this is one of the first studies to document the effectiveness of training health care professionals to utilize HC skills.²⁴

Conclusion

This study evaluated the effectiveness of a new Whole Health Coaching Course for VHA providers and staff in developing specific skills to implement HC with Veterans. Using an intervention-group-only design, the study found that participants reported improvements in preparedness and self-efficacy to use HC skills, as well as increased use of the skills over time. This study also found significant decreases in perceived norms within facilities toward use of HC with Veteran patients. This unanticipated result raises questions warranting further investigation, including how system-level support influences provider and staff behaviors and the degree to which attitudinal changes regarding models of care and practice change must be approached for both leadership and front line staff. Despite this finding, our study is among the first to suggest that training health care professionals in HC can support patient-centered care initiatives and practices.

Footnotes

Acknowledgements

The authors wish to express their appreciation to Kelly Howard and Janet Vertrees of the Department of Veterans Affairs for their collaboration and review of this article, Ann Mason of Pacific Institute for Research and Evaluation (PIRE) for her assistance with the onsite course implementation, Chris Bayer of PIRE for his word processing assistance, and the providers and staff of the VHA facilities for their participation in this investigation.

Authors’ Note

The study sponsor did not prepare the study design, and did not participate in the data collection, analysis, or in the decision to submit the paper for publication; the study sponsor did, however, review the study design and provided input through regular meetings that informed interpretation of results especially regarding the context of the VA. The study sponsor reviewed a final report that this article is based on, and representatives of the study sponsor have reviewed the article.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: All of the authors’ work was supported by VA Education Contract #VA777-12-C-0002 from the Department of Veteran Affairs to Pacific Institute for Research and Evaluation.

Author Biographies

David A. Collins is a research scientist at the Pacific Institute for Research and Evaluation’s Louisville Center. His main research interests include evaluation of substance abuse prevention programs and strategies and other health related research.

Stephen R. Shamblen is a research scientist at the Pacific Institute for Research and Evaluation’s Louisville Center. His main interests include research methodology and statistics.

Katharine A. Atwood is a research scientist at the Pacific Institute for Research and Evaluation’s Louisville Center. Her main research interests include evaluation of substance abuse and HIV prevention programs and other health related research.

David L. Rychener was recently the project director for PIRE’s Educational Contract with the VHA. He has been developing behavioral health training programs for more than 30 years.

William H. Scarbrough is a senior research scientist and director of the Louisville Center at the Pacific Institute for Research and Evaluation. His main research interests include health care services research and evaluation of training and technical assistance programs.

Melissa H. Abadi is a research scientist at the Pacific Institute for Research and Evaluation. Her research interests focus on the development and evaluation of applied behavioral health interventions, especially among at-risk and underserved populations.

Leigh Ann Simmons is an associate professor in the Duke University School of Nursing and a practicing health coach. Her clinical and research interests focus on the design, implementation, and dissemination of personalized behavioral interventions for the prevention and management of chronic disease, especially among vulnerable and underserved populations.

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