Language Concordant Health Coaches Team with Residents to Help Improve Patients' Self Care Skills, Leading to Better Diabetes Management
Language Concordant Health Coaches Team with Residents to Help Improve Patients' Self Care Skills, Leading to Better Diabetes Management
San Francisco General Hospital's Family Health Center, a safety-net teaching clinic for family medicine residents, uses language-concordant health coaches (i.e., those who speak the patient's preferred language) to improve self-management support and quality of care for patients with diabetes who have limited English proficiency and health literacy. Coaches, who work in tandem with a resident, conduct a previsit meeting to help negotiate the visit's agenda and order routine tests and services; assist during the medical visit; immediately conduct a postvisit meeting to ensure patient understanding and to assist in establishing health goals and action plans; and follow up with the patient 1 to 2 weeks after the visit to offer additional support. The program improved the management, documentation, treatment, and outcomes of patients with diabetes.
Date First Implemented
Primary care clinicians often find themselves with limited time for indepth patient visits, leading to inadequate management and treatment of acute and chronic conditions,1 particularly for those with limited English proficiency.
- Limited time for chronic care visits: Clinicians have little time to properly manage patients with chronic conditions during the typical 15-minute visit.1 For a clinician with a panel of 2,500 patients, one study found that it would take 10.6 hours per day just to provide adequate management of common chronic conditions for these patients.2
- Leading to poor quality of care: Patients frequently leave office visits without understanding their clinician's advice or a clear plan for managing their condition(s).3 Many patients feel they have no time to ask and receive answers to questions about their conditions; one study found that 25 percent of patients felt unable to express their concerns at all during office visits.4
- Especially for patients with limited English proficiency: Communication barriers between providers and patients with limited English proficiency further exacerbate the problem. As a result, chronic care patients with limited English proficiency are less likely to understand and adhere to treatment plans, leading to greater risk of poor health outcomes. 5 , 6
Description of the Innovative Activity
The Family Health Center, a safety net teaching clinic for family medicine residents, uses language-concordant health coaches to improve self-management support and quality of care for diabetes patients with limited English proficiency and health literacy. Health coaches, who work in tandem with a resident, conduct a previsit meeting to help negotiate the visit's agenda and order routine tests and services; assist during the medical visit; immediately conduct a postvisit meeting to ensure patient understanding and to assist in establishing health goals and action plans; and follow up with the patient 1 to 2 weeks after the visit to offer additional support. Currently, patients always see the same health coach (with whom they are language concordant) and the same provider, although providers work with multiple coaches to meet the language needs of their patients. Key program elements include:
- Training of health coaches: Health coach trainees participate in 6- to 8-hour-long training sessions before starting their work with patients. Upon completion of the sessions, new coaches also receive mentoring; an experienced coach observes and provides feedback on coaching interactions. Additional training sessions are offered to discuss specific cases. Currently, all health coaches are health workers who have a background in health education and/or community work.
- Identification and matching of patients to health coach: The program currently targets patients with diabetes whose hemoglobin A1c levels designate them as being at high risk of poor health outcomes. The program identifies patients who meet this criteria and then assigns them to one of three health coaches. Because more than half of the Family Health Center's patients do not speak English as a primary language, all three health coaches are bilingual (two speak Spanish and one speaks Chinese and Vietnamese). The program matches each patient with a health coach who speaks the same language. Patients always have the same health coach and the same resident, although residents work with multiple health coaches to cover the language needs of all their patients.
- Health coaching before, during, and after visit: The health coach works in tandem with the patient's clinician (usually a resident) to expand the patient encounter, improve the patient's self-management skills, and promote fuller comprehension and compliance with medical advice. Typical support offered by the coach includes the following:
- Previsit meeting: The coach meets with the patient before the clinician enters the exam room. During this meeting, the coach encourages the patient to identify any agenda he or she wants to cover during the visit, checks the patient's medication use, orders any routine or standard services (e.g., a check of blood pressure and heart rate, a finger-stick to check glucose level), and takes and records the patient's basic history. These tasks help to make the visit patient centered and to reduce the physician's workload. The health coach shares the results of the previsit meeting with the clinician before he or she enters the room.
- During-visit support: The health coach may remain in the room during the examination, helping to navigate any patient/clinician language barriers and providing general assistance so that the clinician can focus on diagnosis, management, and building a relationship with the patient. General assistance tasks include documenting the clinician's physical findings, filling out forms, writing prescriptions for the clinician to sign, helping with medical procedures, and retrieving items or paperwork not in the examination room.
- Postvisit meeting: Immediately following the visit, the health coach remains in the examination room with the patient to “close the loop,” ensuring that the patient understood the visit and can repeat back the clinician's advice and instructions. The coach asks the patient about any outstanding questions he or she might have, engages the patient in collaborative goal setting, and helps the patient to establish an action plan for behavioral change around diet, exercise, taking medications, and other areas.
- Followup support: One to 2 weeks after the office visit, the health coach contacts the patient by telephone to see how he or she is doing, help with health-related problem solving, reinforce the patient's action plan, and serve as a liaison between the patient and the clinician.
- Ongoing communication between coach and physician: The health coach and physician maintain regular communication regarding their shared patients through notes in the patients' electronic medical records, paper forms, and e-mail. Health coaches and physicians also participate in scheduled huddles as time permits, which allow for discussion of the day's patients, shared identification of possible focus areas, and prioritization of patient needs and concerns.
- Regular meetings to monitor progress: According to information provided in June 2011, the health coaches now hold monthly meetings where they review reports that display a list of their patients and tracked processes and outcomes for these patients. These reports allow the health coaches to identify issues with patient cases [e.g., low-density lipoprotein (LDL) levels over 100, medication dosage issues] and algorithms have been developed to target certain outcomes. Both individual reports and reports that combine data for all health coaches are available to help monitor the program's progress and performance over time.
Context of the Innovation
San Francisco General Hospital's Family Health Center is a safety net primary care clinic serving 10,000 patients, more than half of whom speak a primary language other than English. The clinic is staffed by faculty, residents, and family nurse practitioners from the University of California San Francisco Department of Family and Community Medicine. The clinic's health coaching program originated with Dr. Thomas Bodenheimer, who conceived of using a physician and health coach team to expand the 15-minute physician visit into a more patient-centered chronic care experience focusing on self-management support (see Planning and Development Process for more details). Noting that patients with limited English proficiency, particularly those living with diabetes, experienced significant health disparities, Drs. Hali Hammer and Ellen Chen modified and refocused the model to provide language-concordant health coaches to this population.
Both the original program and a revised version (see Planning and Development Process section for more details) improved the management, documentation, treatment, and outcomes of patients with diabetes.7
- Better management and documentation: Both models show increases in the percentage of patients receiving a regular hemoglobin A1c and LDL test. Between 2008 and 2009 (when the revised version of the program was in place), the percentage of patients who had a self-management plan more than doubled (from 31.8 to 66.7 percent) and the percentage who had smoking status documented in their file doubled (from 42.8 to 84.8 percent). Between 2007 and 2008 (when the original program was in place), the percentage of patients who had their body mass index measured rose significantly.
- More appropriate treatment: Between 2008 and 2009, the percentage of patients on appropriate medicines increased, including those taking aspirin (which rose from 67.6 to 85.5 percent), statins (which nearly doubled, rising from 44.3 to 78.3 percent), and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (which also nearly doubled, from 41.5 to 79.7 percent).
- Better diabetes-related outcomes: Between 2008 and 2009, the percentage of patients with a hemoglobin A1c level below 8 percent (indicating good control) rose by 7.4 percent, while the percentage with blood pressure below 130/80 mm Hg (indicating normal blood pressure) rose by 8 percent, and the percentage with LDL below 100 (indicating healthy levels of cholesterol) rose by 14 percent.
According to information provided in June 2011, the Center of Excellence in Primary Care is currently conducting a randomized control trial of the health coaching program within a San Francisco primary care community clinic. Results of this trial will relate to the effects of this model on chronic care outcomes, provider satisfaction and patient experience.
Planning and Development Process
Key elements in the planning and development process included the following:
- Conducting initial pilot test: In 2006, Dr. Bodenheimer launched a pilot to test his original model, in which four clinic employees were retrained to serve as health coaches working in dyads with a small group of residents and nurse practitioners. Each employee served as a health coach for 1 half day per week, in addition to performing his or her other job responsibilities.
- Training clinic staff: To prepare for a larger pilot test of the model, program leaders led six 1-hour training sessions for the entire Family Health Center staff. Training focused on basic information about cardiovascular risk factors, the collaborative care process, promoting patient self-management, negotiating patient agendas, and helping patients understand clinician instructions. First-year residents and faculty mentors also received training in the model. After this training, 11 health workers and medical assistants expressed interest in becoming health coaches. Health coaches received additional training, including role playing, observed interaction with patients, and mentoring.
- Expanding pilot: From 2007 to 2008, the clinic implemented the program with the entire class of 13 residents. Each resident paired with a health coach to make a language-concordant team in one of four languages: English, Spanish, Cantonese, or Mandarin. Each team worked together as a stable unit whenever possible, serving a panel of language-concordant patients with at least two cardiovascular risk factors.
- Reworking model: In 2008, having found it difficult to schedule consistently paired teams within a residency clinic setting, the program consolidated around a smaller group of health workers who dedicated a greater portion of their time to coaching. Under this new model, health coaches still pair with residents; however, each health coach may pair with any of a number of different residents during the course of a week, rather than being consistently teamed with the same clinician. Each patient is still paired with a language-concordant coach, but may or may not see a language-concordant clinician.
Resources Used and Skills Needed
- Staffing: One full-time and two part-time (60 percent) bilingual health coaches staff the program. During initial implementation, the development, testing, and continual maintenance of the health coaching program was carried out by an interdisciplinary team of physician champions, a medical director, the residency director, the associate residency director, a nurse manager, a data analyst, and several University of California San Francisco Center for Excellence in Primary Care staff members. Currently, the support staff includes only a physician champion, lead health coach, and data analyst (updated June 2011).
- Costs: Data on program costs are not available, as expenses are absorbed as a part of regular clinic operating expenses.
The program is primarily funded internally; grants from the California Healthcare Foundation and Kaiser Permanente Preventing Heart Attacks and Strokes Everyday, although not specifically allocated to the health coaching program, have helped to support and maintain the program. (For example, some support for the data analyst staff position comes from the California Healthcare Foundation.) During the program's early stages, funding from the California Academic Chronic Care Collaborative supported a modest amount of faculty involvement in the program. The Gordon and Betty Moore Foundation is funding a current evaluation of the program that is being conducted by the Center of Excellence in Primary Care (updated June 2011).
Getting Started with This Innovation
- Identify motivated, qualified staff to serve as health coaches: Health coaches need strong interpersonal skills to engage patients, adequate attention to detail to allow tracking of chronic care processes, and the language skills to communicate effectively with patients who have limited English proficiency.
- Invest in training: To create a solid foundation for growth, focus on training, observing, and mentoring health coaches during the program & rsquo;s early stages.
- Start small: To avoid early burnout, allow new health coaches to begin by assisting one provider with one patient, or by conducting only one health coaching task (e.g., agenda setting before the clinician visit, or creating behavioral change action plans following the visit) with multiple patients.
Sustaining This Innovation
- Continually promote internal buy-in: Sustained leadership support is needed to ensure that adequate resources (e.g., meeting time, protected staff time, registry tools) remain dedicated to the program on an ongoing basis.
- Cultivate champions: A staff champion and a provider champion both play important roles in spreading this program and in building momentum over time.
- Keep focus on patient: Approach health coaching from the patient's perspective, allowing and encouraging patients to play a significant role in managing their own medical care, which is central to promoting positive long-term health outcomes.
Contact the Innovator
Note: Innovator contact information is no longer being updated and may not be current.
Hali Hammer, MD
Family Health Center
San Francisco General Hospital
Professor of Clinical Family and Community Medicine UCSF/SFGH Department of Family and Community Medicine
995 Potrero Ave., Ward 83
San Francisco, CA 94110
Phone: (415) 206-5122
Fax: (415) 206-8387
Dr. Hammer has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
Excerpts from the University of California San Francisco health coach training curriculum are available at: http://cepc.ucsf.edu/health-coaching.
Chen EH, Thom DH, Hessler DM, et al. Using the teamlet model to improve chronic care in an academic primary care clinic. J Gen Intern Med. 2010 May ;25(4):610. [PubMed]
Laing BY, Ward L, Yeh T, et al. Introducing the “teamlet”: initiating a primary care innovation at San Francisco General Hospital. Perm J. 2008 Spring;12(2):4-9. [PubMed]
Bennett HD, Coleman EA, Parry C, et al. Health coaching for patients with chronic illness. Fam Pract Manag. 2010 Sept-Oct;17(5):24-9. [PubMed]
Saba G, Tache S, Ward L, et al. Building teams in primary care: what do non-licensed, allied health workers want? Perm J. In press, 2011.
Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med. 2007;5:457-61. [PubMed]
Ostbye T, Yarnall KS, Krause KM, et al. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3(3):209-14. [PubMed]
Roter DL, Hall JA. Studies of doctor-patient interaction. Annu Rev Public Health. 1989;10:163-80. [PubMed]
Marvel MK, Epstein RM, Flowers K, et al. Soliciting the patient's agenda: have we improved? JAMA. 1999;281(3):283-7. [PubMed]
Ku L. How race/ethnicity, immigration status and language affect health insurance coverage, access to care and quality of care among the low-income population. Washington, DC: Kaiser Family Foundation; August 2003.
Ngo-Metzger Q, Telfair J, Sorkin DH, et al. Cultural competency and quality of care: obtaining the patient's perspective. The Commonwealth Fund, October 18, 2006. Available at: http://www.commonwealthfund.org/~/media/files/publications/fund-report/2006/oct/cultural-competency-and-quality-of-care–obtaining-the-patients-perspective/ngo-metzger_cultcompqualitycareobtainpatientperspect_963-pdf.pdf
Chen E, Thom D, Hessler D, et al. Using the teamlet model to improve chronic care in an academic primary care clinic. J Gen Intern Med. 2010 Sep;25 Suppl 4:S610-4. [PubMed]