ON ROUNDS | FALL 2016
BY BRETT JAILLET
PHOTOS BY ZACH RIGGINS
Dr. Melanie Tucker has a patient who wants to make changes in her life: She gets very little physical activity, and she needs help starting an exercise routine.
Tucker can help her, but it will take baby steps, she says.
“We want her to walk from her front porch to her mailbox, and that’s it,” Tucker says. “She started off doing it once a day, and now it’s twice a day.”
It may not seem like much, Tucker says, but it’s a start.
“It starts with small changes,” she says. “It’s not as quick as we’d like, but that is not how behavior change works.”
That is what Tucker, assistant professor of Health Education in the College of Community Health Sciences’ Department of Family, Internal, and Rural Medicine, is working toward with her patients—behavior change.
Tucker is a certified health and wellness coach, and since February, she has provided clinical health coaching to patients with chronic diseases at University Medical Center, which the College operates. This is the first time UMC has offered health coaching to its patients.
According to the Annals of Family Medicine, cardiovascular disease is the leading cause of death in the US, and 50 percent of people with hypertension, 43 percent with diabetes and 80 percent with hyperlipidemia are not reaching their goals for blood pressure, glycemic control or lipids, respectively. This is due, in part, to a lack of patient understanding of their disease and needed treatment coupled with low confidence and motivation to make healthy choices.
In March, the College received a yearlong $50,000 grant from the Alabama Department of Public Health to address hypertension and diabetes and is using health coaching to tackle those diseases.
So three half days a week, Tucker works with patients on referral from UMC providers. She meets with the patients immediately after their exam to discuss their needs and lifestyle. Then, she helps them set goals.
Health coaching can be defined as “helping patients gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified health goals,” according the American Academy of Family Physicians. The five roles of a health coach are to provide self-management support, serve as the bridge between the clinician and the patient, help the patient navigate the healthcare system, provide emotional support and help establish continuity, according to the AAFP.
Tucker’s first objective when she meets with a patient is to understand his or her health literacy. So she asks questions about the disease to learn what the patient understands. The lack of knowledge is sometimes surprising, she says.
“We are finding patients who have been diagnosed with diabetes for 20 years and yet don’t know the symptoms of high blood sugar,” she says. “So we are really working to fill the gaps in knowledge.”
The next step is to assess the patient’s motivation.
“Some will say, ‘I’m just not interested in lowering my blood sugar,’” Tucker says. “We don’t want to push them if they aren’t ready to go there. But most of them are ready.”
If they are, Tucker sets small, attainable goals to start. It could be cutting out one soda a day, smoking one less cigarette a day or walking to and from the mailbox once a day. She then works with the patients for the next six months to get them started on achieving their goals.
“We hope to make some small changes that have a longer-term impact,” she says.
A key component of working with the patient is following up regularly. Tucker says it is important to call patients to ask about their progress and to laud their efforts. “It’s about praising them wherever they are and nudging them if they need it,” she says.
After Tucker meets with her patient, she sits down with the referring provider to work the health coaching into the patient’s health care plan. Often, the provider is a resident physician—the College operates The University of Alabama Family Medicine Residency, providing training for 48 physicians each year.
Dr. Catherine Scarbrough, associate director of the Residency, says that it has been a learning opportunity for the residents to work with Tucker.
“One of the issues we face today as doctors is that we’re just seeing our patients one visit at a time, and so it is great to collaborate with health coaches in helping our patients reach their goals—whether it’s their diabetes, weight loss or quitting smoking. A health coach can really supplement what you do in the office,” she says.
Residents learn the health coaching technique of motivational interviewing, or engaging with the patient in a way that encourages the patient’s autonomy to make the decision to change, versus the physician urging them to make the changes.
“That is a good technique for the residents to learn and take to their own private practices,” Scarbrough says. “And they’re learning how to set goals for their patients that are realistic. For example, you might have a patient with diabetes that is not under control. Maybe their A1C level is a nine or 10, and if you want that control, it’s not going to happen overnight. Sometimes we as physicians have trouble seeing those intermediate steps.”
Learning how to individualize each patient’s goals and treatment plan is an important component, too, Scarbrough says.
“Patients have different incomes. Some are able to afford certain foods or a gym membership. Others can’t,” she says. “Each patient is different, and the biggest thing is to individualize goals for that patient that make sense.”
Tucker says she feels like the residents are able to learn a lot about behavior change.
One prediabetic patient has been a learning opportunity for the residents, she says. “We set goals with her physical activity and on cutting back on drinking sweet tea.”
Three weeks later, she had lost four pounds and her blood pressure was normal. “She said, ‘I just did what those folks told me to do,’” Tucker says.
Other UA students learning from the health coaching program are from the UA College of Human and Environmental Sciences’ Health Education and Promotion program. The students join Tucker as health coaches: they visit with the patients immediately after their exams with physicians and then make follow-up phone calls. On the phone, they make sure the patients understand their goals and the doctor’s treatment plan, Tucker says.
“For example, if the patient agreed to walk 20 minutes per day, the coach would ask about their progress and if the patient was having any trouble. Then they would help brainstorm ways to meet their goals. Or they would check to see if the patient filled his or her medication and if he or she was taking it as prescribed.”
The students have also worked with Tucker in developing printed health education materials for patients. Most of the information focuses on hyper/hypoglycemia symptoms, physical activity and nutrition for patients with diabetes, Tucker says. Many of the materials that Tucker and her students found were written at a higher, technical reading level, and Tucker wants them to be more accessible for patients. So they have reworked the materials into a more digestible format.
Half of the patients who leave visits with their primary care physicians do not understand what was explained to them, and the average adherence rate for prescribed medications is at about 50 percent, according to the AAFP. For lifestyle changes, adherence rates are below 10 percent.
A study in the Annals of Family Medicine concluded that patients who received health coaching were more likely to reach at least one of their clinical goals and achieve control over their condition.
While research has indicated that health coaching can help patients take control of diseases such as hypertension, diabetes, hyperlipidemia and even asthma, Tucker is conducting her own research as part of the grant the College received from the Alabama Department of Public Health. About 75 patients with uncontrolled hypertension or diabetes are enrolled in her study, and she will be working with them intensely for six months to observe their clinical outcomes.
“A lot of folks dread coming to the doctor, getting on the scale, getting their blood pressure measured,” she says. “For some it’s really hard. But we want them to come back, and so we acknowledge any kind of effort. It’s about listening and hearing and picking up cues on what motivates them and what’s important to them.”
Tucker asked her patient—the one reaching her health goals by walking to and from her mailbox—what is important to her.
“She told me that it is playing with her grandkids. I told her, ‘The more you walk back and forth to your mailbox, you’ll live longer and get to enjoy your grandkids.”