Coaching to support patients in making decisions

An essential component of high quality clinical care is an informed and engaged patient.1 Although some patients have the necessary confidence and skills to participate in their care, others or their families need coaching to develop their skills. Over the past 15 years, health coaching has been evaluated in research interventions and is now provided mostly in call centres or management programmes for chronic conditions in North America, Europe, and Australia.

Coaching develops patients’ skills in preparing for a consultation, deliberating about options, and implementing change. Trained facilitators, who are supportive but do not make decisions for the patient, coach patients before or after an encounter with a clinician. Coaches are often nurses, but they may also be other health professionals or trained patients. Coaching is provided face to face between individuals or groups, or over the telephone, email, or internet. Human interaction is usually involved, but automated coaching using telephone or e-tools is evolving.

Coaching can be used for chronic conditions where the challenge lies in finding common ground between clinical and personal priorities and implementing changes. It is also useful for preference sensitive decisions (such as treatments for prostate and breast cancer, back pain, benign prostatic hyperplasia, benign uterine bleeding, and osteoarthritis), where the challenge lies in choosing the option that matches the patient’s informed values.

The figure⇓ illustrates the coach’s potential role in supporting the clinical encounter. The clinician and patient work together to reach informed decisions about the plan of care, on the basis of the patient’s clinical needs, priorities, and values. The clinician’s expertise lies in diagnosing and identifying treatment options according to clinical priorities, whereas the patient’s role is to identify and communicate their informed values and priorities shaped by social circumstances. Coaches are involved when the patient’s confidence and skills in preparing for consultations, deliberating about options, or implementing changes need to be developed.123

Roles of coaches in collaborative care and shared decision making

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What is the evidence that coaching is effective in these three domains? A recent review of seven systematic reviews of coaching and question prompts that are designed to prepare patients for consultations showed that these interventions had positive effects on patients’ knowledge, information recall, and participation in decision making.1 The effects on satisfaction and treatment outcomes were inconsistent, however.

In terms of deliberation about options, the review included 10 systematic reviews of “patient decision aids,” which explain options, clarify values, and provide structured guidance or coaching in deliberation and communication. Decision aids improved patients’ participation, increased knowledge of their treatment options and probable outcomes, and improved agreement between patients’ values and subsequent treatment decisions. The use of discretionary surgery decreased without apparent adverse effects on health outcomes. However, the intensity of structured guidance or coaching in decision aids varied widely.4 One trial evaluated the separate contribution of coaching relative to a video decision aid alone or usual care for menorrhagia.5 Women who had additional coaching to help them express their preferences had greater satisfaction and reduced hysterectomy rates; service costs were also lower.

Another systematic review assessed the evidence on implementing change. The combined effects of 72 trials of motivational interviewing in patients with various diseases showed no effect on cigarette smoking or glycated haemoglobin values, but significant positive effects were found for body mass index, total blood cholesterol, systolic blood pressure, blood alcohol concentration, and standard ethanol content.3 Single encounters of 15 minutes’ duration were effective in 64% of studies, but more than one encounter had a greater likelihood of positive effects. Interventions by doctors were effective more often (80% of studies) than interventions by other healthcare providers (46%).

So how can coaching be implemented in practice? Health coaches are most commonly found in call centres or peer support programmes. This improves access and coverage but usually lacks continuity or linkage with primary care or specialty care practices. Linkage to care may make it easier to identify and document cases, to tailor the coaching to the patient’s clinical needs, and to have the patient’s own doctor reinforce the skills patients acquire through coaching.

Some centres have embedded coaching into clinical care processes. In California, trained volunteers provide a consultation planning programme, which includes coaching in raising questions and concerns and in communicating and negotiating with doctors.6 In the United Kingdom, nurse specialists are trained to administer decision aids and provide coaching for patients having difficulty deciding about treatment for prostate cancer and benign prostatic hyperplasia.7 At the Dartmouth Hitchcock Medical Center in the United States, patients receive decision support using automated computerised methods8; highly distressed patients are automatically referred to support personnel. Patients view decision aids and are prompted by computers to elicit their knowledge, values, preferences, and unresolved decisional needs. Decisional needs are summarised electronically and sent to the doctors to “close the loop” on decision making with each patient. Also, the clinical service and the public receive aggregated quality reports on decision making.9 10

Although many healthcare providers are being trained in motivational interviewing, its use in daily clinical practice is limited.3 The future of coaching lies in a blend of human and electronic interfaces based on people’s specific needs. Patients’ electronic self reports of their clinical and decisional needs, which are completed at health centres or via the internet, could serve as prompts for planning consultations and trigger access to coaching.

Coaching in preparing for consultations can improve patients’ participation and inform their decisions. In turn, motivational interviewing can improve some health outcomes. However, many operational barriers need to be overcome before there is widespread implementation of coaching that is linked to clinical care and tailored to patients needs.11