Health and Wellness Coaching in Serving the Needs of Today’s Patients: A Primer for Healthcare Professionals

Abstract

The past six decades have been marked by leaps and bounds in medical advances, while concurrently clinical outcomes and the quality of life continued to lag or decline. There is a need for more comprehensive approaches to delivering healthcare to patients that address illness and wellness within and outside healthcare settings. Mounting evidence shows that making sustainable changes in healthcare requires approaching patients’/individuals’ care as a continuum—within and outside healthcare settings—while addressing their capacity (ie ability) and workload (ie demands) and incorporating their values and preferences. Health and Wellness Coaching (HWC) has been proposed as a solution to create partnerships to empower individuals to take ownership, leadership, and accountability of their well-being, using nondirective, empathic, and mindful conversations that employ motivational-interviewing and evidence-based approaches. Insufficient clarity exists among healthcare professionals in understanding the definition, roles, and types of HWC. This primer summarizes HWC concepts and history and compares HWC types and its potential role in promoting, supporting, and improving the well-being, clinical outcomes, and quality of life of the pertinent stakeholders. This primer also highlights current and potential areas of application of HWC within different subpopulations and healthcare-related settings.

The Past and Current State of Health and Wellness Affairs

Despite a steady increase in life expectancy and significant advances in medical discoveries in the United States for the past six decades, population health continues to show an overall lag or decline in comparison. The trends of increasing chronic conditions and associated worsening or disparities in quality of life have led to a diminished sense of well-being for many patients and their caregivers. ^{1 – 6} While patients still require cutting edge and advanced medicine, compassionate and thoughtful care remains the core of the mission of medicine—the art of healing.

Equally, public health is often threatened by misinformation, conflicting evidence, profit-driven practices, and/or lack of access to proper resources of education, information, promotion, and engagement,^7–9 thus creating a sense of confusion, misinformation, and/or mistrust. This reflects that more work is needed and that the needs of the patient are not being adequately addressed. Evidence shows that helping patients make sustainable, modifiable lifestyle changes is significant to both curtailing the epidemic of preventable diseases and improving the health and well-being of those living with chronic disease.^10,11 This requires approaching the care of the patients as a continuum: pre-, peri-, and postdiagnosis or care delivery. There is a need for care models that address a person’s capacity (ie resources and abilities) and workload (ie demands or necessary work) to promote intention, accountability, and sustainability of better healthcare delivery, improved outcomes, and promoted well-being.

Recognizing that medicine is always evolving, “Health and Wellness Coaching” (HWC) emerged as a practice model and approach to support the critical unmet need to addressing well-being/wellness, and life goals of the patients and their caregivers, when applicable, within and outside healthcare settings. There is paucity of knowledge about this field among healthcare professionals. This primer will summarize for healthcare professionals the evolution of HWC and outline its hypothesized and validated value, application, practice settings, and different approaches and strategies to support and improve the well-being, clinical outcomes, and/or quality of life goals. We also highlight known, novel, and potential areas of application of coaching to take on challenges certain subpopulations encounter.

HWC History and Evolution

Since the late 1990s, flourished by the tenants of Seligman’s theory of positive psychology,^12,13 the HWC concept has been proposed as an approach to support the mission of helping individuals, healthy or with health challenges, to achieve certain goals through the support of a coach. Despite its increased popularity and adaptation in various settings within the past two decades, the definition and applications of HWC remained vague.^12,14,15 A 2013 scoping review summarized the published evidence about HWC, its definitions, heterogeneity, application, methods of delivery, and outcomes assessment; ¹⁵ the most evidence extracted came from empirical studies (65%). The majority of these studies used patient-centered coaching (60.5%); were based on patient-driven goals (80%); and deployed self-discovery processes (63%), accountability (85%), and content education (91%) that was mostly related to condition- or disease-specific content (40%) in their approaches. The vast majority of persons delivering HWC were from various professional backgrounds with the highest being medical (53%) and allied health professionals (51%). Just over half of the studies reported adequate information about the length and ongoing relationship with HWC providers. Wolever et al., ¹⁵ concluded with proposing defining HWC as

a patient-centered approach wherein patients at least partially determine their goals, use self-discovery or active learning processes together with content education to work toward their goals, and self-monitor behaviors to increase accountability, all within the context of an interpersonal relationship with a coach. The coach is a healthcare professional trained in behavior change theory, motivational strategies, and communication techniques, which are used to assist patients to develop intrinsic motivation and obtain skills to create sustainable change for improved health and well-being.

As further evidence shows, the majority of these studies have ascertained the positive impact of HWC on various populations and outcomes, and within different settings, especially in primary care settings.^14,16 However, a recognizable challenge observed in implementing “coaching of patients” is that it has been often delivered by healthcare professionals (eg nurses, physicians, social workers) who are not trained HW coaches. Additionally, these healthcare professionals are often individuals who are already overwhelmed and experiencing burnout themselves. ¹⁷ An opportunity exists to develop innovative ways to address this continuum of patient’s needs before, during, and after health assessment through the utilization of HWC. ¹⁸

The Spectrum of HWC

Despite the remarkable innovation in medicine through surgical and other technologic advances, addressing the well-being crisis in this country requires us to remain high tech and high touch, hand in hand. Despite appropriate medical care, a significant challenge for patients struggling with a suboptimal quality of life or well-being is addressing barriers within as well as outside the clinical setting to provide equal and equitable healthcare,^19,20 with the goal of making sustainable changes to fit healthcare within their lives.^21–24

For example, eating better, getting regular exercise, sleeping better, managing stress, fostering social connection, and/or cultivating gratitude, although often considered the “softer side” of health, are clearly a major component of the evidence-based recommendation for what ails many of our patients—not to mention our physicians, staff, and society as a whole. Yet for so many, this elixir remains elusive. Supported by a growing body of literature,^{12,14–16,25} it is increasingly clear that properly trained Health and Wellness Coaches, as part of care team, can contribute to providing certain aspects of support needed by many of our patients.

A proper coaching process uses evidence-based interventions, including motivational interviewing, positive psychology, transtheoretical model of change, active listening, goal setting, aggregation, emotional intelligence, validated health outcome metrics, and/or methods of prevention.^12,15,26 With any HWC type, the foundation is creating partnerships that empower individuals to take ownership and leadership of their own well-being through nondirective motivational interviewing with an empathetic, respectful, mindful, and conversational approach. A potential confusion and lack of clarity exists among healthcare professionals in differentiating health, and wellness or well-being, and any other type of related coaching; the natural evolution and the differentiation between the two has led to defining a health coach to be more closely focused on the state of physical health, while wellness, well-being, or life coach is more focused on the expanded state of happiness and content about one’s being that encompasses various components, including physical, spiritual, emotional, financial, intellectual, environmental, and occupational wellness. ²⁷ Potentially adding to the confusion, Integrative Health Coaching, a term utilized by some organizations and programs, is more in alignment with the conceptual approach of well-being coaching. Wellness and well-being are used interchangeably and typically refer to the same type of coaching that serves their goals(s).

The Case for HWC

In efforts to clarify these challenges in the field of HWC, The International Consortium for Health & Wellness Coaching (ICHWC) ²⁸ (the previously designated as the National Consortium for Credentialing Health and Wellness Coaches or NCCHWC) has moved past the confusion about “wellness” versus “health” coaching and provides the same rigorous and standardized process of credentialing through the National Board for Health & Wellness Coaching (NBHWC) ²⁶ in collaboration with the National Board of Medical Examiners (NBME) in the United States. The goal of these organizations is to set minimum standard of reliability and integrity of education and training through standardized and accredited training programs to support the mission of effective and supportive HWC. While being a licensed Health and Wellness Coach is not a requirement as of the date of publishing this article, coaches who receive licensing credentials through these organizations showcase adherence to standards set by NBME, whose mission is to provide rigorous standards of assessment of health professionals. In the United States, the American Medical Association’s (AMA) has approved a new Category III Current Procedural Terminology (CPT®) Codes for health. ²⁹ While these are temporary codes for emerging technologies and practices, this provided a wider recognition to the importance and value of HWC, and potentially further future opportunities to propose and integrate HWC practices within various healthcare settings, especially in primary and preventive care.

Mapping out HWC

In this primer, we summarize and compare current coaching styles that are used within various healthcare settings, with the goal of enhancing clinical outcomes, quality of life, and/or any aspect of well-being. We also highlight known, novel, and potential areas of application of coaching to take on challenges certain subpopulations encounter. There are various examples of traditional and innovative programs incorporating HWC that exist within different healthcare settings. Some of these programs have been piloted and validated;^14–16,25 others have been proposed as a novel approach to incorporating HWC within different clinical settings, especially within primary and community care settings. ³⁰ Each of these programs may target one or more various populations and address strategic enterprise priorities, thus creating additional added value and positively contributing to a care that fits efficiently and effectively for the patients, caregivers, clinicians, and the health systems. It is not uncommon to find patients who seek or receive hybrid or incorporated forms of these types of coaching. An example of this would be patients working with a life coach to discuss their overall well-being goals while also receiving other health coaching techniques by the same coach, including smoking cessation (eg by registered nurses) or diabetes education (eg by licensed dieticians). Some individuals may receive health coaching with a focus on executive coaching by coaches who are also experienced and trained in effective leadership and other aspects of professional development. Our lives, goals, and preferences are dynamic, and evolution of these needs is part of the process of growth, support, and guidance that coaching provides; therefore, it is inevitable that many patients require one or more type of coaching. A coach may choose to practice or specialize in one or more areas of HWC. It is also important that, no matter what type of coaching is provided, it will involve partnering with the client/patient to support sustainable behavioral change to meet the needs of the patient and improve their quality of life, honoring that the patient/client is the expert and main driver of this process to achieve their best selves.

Table 1 shows summary and comparison of current and novel coaching styles that are used within various settings. Table 2 highlights current and potential areas of application of coaching to address various challenges within certain subpopulations.

Table 1.

Examples of HWC Types and Variations in the United States.

Type of coaching	Definition and examples	Examples of accrediting bodies
Health and wellness or well-being coaching	This broader spectrum of coaching has a broader emphasis on the principles of positive psychology13; the state of living one’s best self and explore any and all aspects of well-being, including physical, economic social, development and activity, emotional, psychological, life satisfaction, and/or professional aspects of well-being. Health and Wellness Coaches often employ multiple aspects of well-being and support client/patient integration of evidence-based interventions to improve those aspects. 15 HWC is often confused with physical health coaching (ie emphasis on fitness, free-of-disease status, and/or dealing with physical well-being). Wellness Coaches are typically able to provide Health Coaching as well. Coaches who are trained by ICHWC-approved educational programs are eligible to take the national boards and become designated as National Board Certified Health & Wellness Coach or NBC-HWC. Examples of the patient populations these coaches may work with include patients with chronic care in primary subspecialty clinics, veterans care, medical learners in medical education and training programs, and employer wellness program participants (physician and allied health professionals), or healthy patients seeking primary and preventative care.	• ICHWC • CCE31
Health Coaching	This is a form of coaching that involves providing strategies and approaches that target physical health-related goals. Health Coaching programs tend to focus on physical health assessment, management, and prevention approaches for healthy or at-risk individuals, or patients with specific health conditions. 27 Health coaches can be professionals from various background and qualifications in health-related professions, including nurses, nationally-certified exercise trainers, dieticians, nutritionists, and social workers. Health Coaching exists with various forms. Here are some of the most common ones: • LEAN model • Diabetes-Education coaching • Smoking cessation coaching • Weight management coaching	• ICHWC • ICF32 • CCE31
Life Coaches	We argue that Life Coaching falls within the spectrum of HWC and has been often interchangeably used to reflect the same mission of helping people explore and envision how to improve their well-being within the context of their lives, with emphasis on relationships, financial, and career-oriented goals while often using directive-style coaching approaches. The major body for accreditation is the ICF32 or the CCE. 31	• ICF • CCE
Holistic Health Coaching (HHC)	This is an integrative approach that emphasizes on the mind–body wholesome image and interaction and using diet and lifestyle changes to improve health in general.	• The American Naturopathic Medical Accreditation Board (ANMAB)33
Leadership/Executive HWC	This is a specialized type of HWC that emphasizes the challenges especially encountered by individuals who are in leadership roles and potentially specific challenges experienced and goals envisioned within that context. This may provide a specific focus on one or more aspects of a person’s well-being but typically more focused on coaching and specific skills related to leadership acumen and success.	• AHNCC • ICF • CCE
Capacity Coaching	This model of coaching has been proposed as “subspecialized or a modified” type of HWC when providing coaching to patients with chronic conditions or multimorbidity. 30 Capacity Coaching builds its model on the work of Minimally Disruptive Medicine or MDM and describes patient healthcare and daily life situations as ones in which there was work—both the work of being a patient and the work of life—balanced by patients’ capacity to enact that work.21,34,35 A workload-capacity balance or imbalance affects patients’ abilities and resources to access and use healthcare and enact self-care, which in turn affects their outcomes. 21 This model of HWC provides high potential of partnership and application, especially in primary care settings.	• Certified Wellness Coaches (eg NBC-HWC) can receive special training to understand and address the needs of this subpopulation. This training is currently available through Mayo Clinic in the United States. 36
Integrative Health Coaching	A hybrid form of HWC. It is generally provided within healthcare settings for individuals or groups to bridge the gap between medical recommendations and patient’s goals of well-being to assess and implement those recommendations into daily lives.	• ICHWC • AHNCC

Abbreviations: AHNCC, American Holistic Nurses Credentialing Corporation; CCE, Center for Credentialing and Education; HWC, Health and Wellness Coaching; ICF, International Coach Federation; ICHWC, International Consortium for Health & Wellness Coaching; LEAN, Lifestyle, Exercise, Attitude, Nutrition.

Table 2.

Examples of Settings for HWC Integration.

Setting or care model	Description
Transplant Health	The integration of Health and Well-being Coaches into the Transplant Department could target several populations. As of 2019, it is estimated that 112,970 people will need a lifesaving organ transplant (total waiting list candidates). Of those, 73,729 people are active waiting list candidates (pretransplant), and 26,448 transplants have been performed. 37 Pretransplant patients receive medical care within their local communities while waiting potentially years to be eligible and receive a transplant. Despite that medical management, they often struggle with multiple quality of life issues, while their health typically declines, sometimes dramatically, during that waiting period. A pretransplant health and well-being enhancement program, utilizing integrative health and well-being coaches in addition to the care provided by healthcare teams, can provide a significant opportunity that leads these patients to healthier potential and become better surgical candidates for transplantation. For patients fortunate enough to undergo a transplant, posttransplant life is often complex and challenging—multiple lifetime medications, side effects, risk of infection or organ rejections, psychological challenges (anxiety, fear of reintegration in society), caregiver support challenges, dietary restrictions, and resuming life roles, to name a few of the challenges. Several studies have shown that implementing interventions that support patient capacity may lead to improvement of various patient-centric outcomes.14,38 Using models of health coaching (eg Trained Coaches, Care Coordinators, Social Workers, or others trained as health coaches) during the transplant admission hospital stay (when caregivers/family could also be engaged), as well as posttransplant when the patient returns to their local community, holds the potential to minimize readmissions, better clinical outcomes, medication adherence, improved patient experience, and overall well-being.
Chronic Pain	Chronic pain patients are often seen in multiple or various settings, including, but not limited to, primary care settings, pain rehabilitation program, fibromyalgia clinic, and/or specialty-pain clinics. The intention with these programs is largely for the patient to graduate and no longer be a chronic user. However, after “graduating,” most of these patients have ongoing needs related to not only chronic pain but also anxiety of fully reintegrating into their life roles and maximizing their quality of life and well-being while striving to take their lives back. A program utilizing health coaches, and other clinicians as necessary, who could work with those patients personally and/or remotely, holds the promise of better long-term clinical outcomes, better overall patient quality of life, and more appropriate return visits, as well as enhanced patient experience and satisfaction. It will also allow for less frequent follow-up visits to especially access challenged pain clinic specialists, thus facilitating access for new patients.
Patients with Complex Care or Multimorbidity	The life of patients with complex care or multimorbidity is often associated with high levels of healthcare workload (ie demands) for the patients and their caregivers (eg attending multiple appointments, insurance claims, polypharmacy); this is in addition to their roles and responsibilities they take on daily. 3 9 To take on life and healthcare roles and challenges, these patients’ capacity (eg personal, physical, psychological, financial, and/or social resources and ability) needs to match these roles’ needs and challenges. Capacity Coaching, a novel model of coaching, has been recently proposed as “subspecialized” type of HWC that provides coaching to patients with chronic conditions or multimorbidity. 30 Capacity Coaching builds its model on the work of MDM and aims to understand workload-capacity balance or imbalance that affects patients’ abilities. It also explores resources to access and use healthcare and enact self-care, which in turn affects their outcomes.
Physician–HealthCoach–Patient Triad Model	Proposed examples of this clinical model aim to create an opportunity for an initial Internal or Integrative and Complementary Medicine Evaluation & management (E&M) visit with a physician. A certified HW coach with additional training in Integrative and Complementary Medicine will be present for this visit and may assist as a scribe. During the visit, a comprehensive assessment and subsequent plan will be developed utilizing a triad dynamic. This triad model will create a partnership between the physician, health coach, and patient. All three will be focused on the needs of the patient but seeking to support those needs beyond addressing the disease state or potential pathophysiology with immediate feedback between the triad. Such model would be best integrated early on during medical education and training years for medical learners to learn and consider adapting into future practices.
Employer Wellness Programs	HW coaches could be further integrated into existing strategies and could become a component of new programs to enhance the well-being of any healthcare professionals. 40 –42 Those programs, once scaled and validated, could be brought to the employer and corporate well-being space, bringing additional potential revenue streams to support their sustainability.
Other settings	Multiple opportunities exist to use a similar model of integrating HW coaches, often supported by telehealth, to enhance the care provided to a number of patient-population settings, including, but not limited to, cancer, genetic conditions, caregivers of patients in advanced or palliative care, and international patient populations.

Abbreviations: HWC, Health and Wellness Coaching; MDM, Minimally Disruptive Medicine.

Summary

As we look to the future, continuing to explore the best approaches to delivering thoughtful, comprehensive, and supportive healthcare that serves the needs of all patients, it is also clear that finding innovative ways of supporting patients and their need for enhanced quality of life and well-being, within and outside of the formal healthcare setting, should also be an integrated part and a priority of our healthcare models. HWC is a promising, cost-effective approach of this mission commitment to address that priority. It is not unusual to integrate or incorporate different or specialized forms of these types of coaching.

In the United States, the recent recommendations by the AMA for approval of new Category III CPT® Codes for health marked a leap forward in recognizing the valuable application and integration of HWC within healthcare settings. ²⁹ This also lays out the foundation to move toward potential future implementation of Category II (supplementary practices) and I (contemporary practices) codes for reimbursement. The NBHWC and The National Commission for Health Education Credentialing (NCHEC) continue to develop and outline guidelines on use of these codes. Opportunities exist across various settings to integrate HWC and strengthen our overall approach to illness, health, and well-being care for patients, clinicians, and all allied health professionals and supporting staff. A true commitment to this priority will lead to healthier, more engaged, loyal, and content patients and healthcare-providing community.