Health Coaching: A Preliminary Report on the Effects in Traumatic Brain Injury/Polytrauma Patients

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1 ORIGINAL RESEARCH Helth Coching: A Preliminry Report on the Effects in Trumtic Brin Injury/Polytrum Ptients Esmerld Mdrigl, MSW; Mx Gry, BA; Molly A. Timmermn, DO; Ttin Orozco, PhD; Dine Cowper Ripley, PhD; Mheen Admson, PhD; Odette A. Hrris, MD, MPH Abstrct Bckground: Filure to dhere to tretment recommendtions hs significnt impct on the helth outcomes of the individul nd helth cre systems. Helth coching is promising cre model tht hs gined interest in the medicl field. This study focused on the impct of helth coching on helth behviors tht my hve direct impct on successful ptient outcomes. Primry Study Objective: The objective of this study ws to ssess the impct of helth coching dministered through the Polytrum Integrtive Medicine Inititive (PIMI). Methods/Design: This study ws qusiexperimentl cohort study. Setting: This study occurred t specilized polytrum rehbilittion center. Prticipnts: Prticipnts were divided into 3 cohorts: (1) 33 ptients who served through PIMI enrollment, (2) 22 ptients who declined PIMI, nd (3) control cohort of 30 rndom ptients who were not referred to PIMI. Ptients were primrily mle ctive duty or vetern militry personnel. Intervention: The intervention consisted of personlized helth coching by trined, certified personnel. Primry Outcome Mesures: Outcome mesures included the following (1) Self-ssessment: utilizing the Personl Helth Inventory (PHI) t enrollment nd t 3 mo; (2) tretment dherence: the percentge of scheduled ppointments fulfilled by ptients; nd (3) post hoc nlysis: for no-show nd cncelltion rtes; 2-tiled pired t tests for PHI dt nd post hoc within groups; 2-tiled independent smples t tests for tretment dherence percentges nd post hoc between groups. Results: There ws no significnt difference in tretment dherence rtes between the 3 cohorts (ll P >.45). PIMI ptients hd significntly higher cncelltion rtes thn no-show rtes for both clinicl, 20.8%/5%, nd coching ppointments, 17.3%/7.5%, (P <.05). PIMI ptients hd significntly lower no-show rtes, 5%, thn control ptients, 15.8% (P =.007). PHI dt suggest PIMI ptients believe they re mking improvements in mny res of helth coching focus. Conclusion: Low cohort numbers re concern. There ws no difference for tretment dherence rtes for helth coching compred with no helth coching. Select vribles such s cncelltion nd no-show ppointment rtes my better cpture the impct of helth coching on ptient behvior nd clinicl resource utiliztion. Esmerld Mdrigl, MSW, is progrm director t Polytrum Network Site VA Plo Alto Helth Cre System. Mx Gry, BA, is Reserch Associte t Defense nd Veterns Brin Injury Center (DVBIC). Molly A. Timmermn, DO, is clinicl instructor t Stnford University in Stnford, Cliforni. Ttin Orozco, PhD, is survey sttisticin for the Center of Innovtion on Disbility nd Rehbilittion Reserch in Ginesville, Florid. Dine Cowper Ripley, PhD, is cting co-director nd reserch helth scientist t the VA HSR&D Center of Innovtion on Disbility nd Rehbilittion Reserch nd n ffilite ssocite professor t the University of Florid in Ginesville, Florid. Mheen Admson, PhD, is senior scientific reserch director, Defense nd Veterns Brin Injury Center (DVBIC) nd clinicl ssocite professor (ffilited) of Neurosurgery & Psychitry & Behviorl Sciences, Stnford School of Medicine. Odette A. Hrris, MD, MPH, is n ssocite professor of neurosurgery t Stnford University School of Medicine. Corresponding uthor: Odette A. Hrris, MD, MPH E-mil ddress: ohrris@stnford.edu The burden of chronic disese on helth cre systems hs been well documented in pst decdes. 1,2 Filure to dhere to tretment recommendtions hs significnt impct on the helth outcomes of the individul nd helth cre systems. This highlights the need for enhnced helth cre models to go beyond the trditionl cre delivery to incorporte behviorl science s fctor in motivting behvior chnge. Helth coching is one such promising cre model tht hs gined interest in the medicl field Integrtive Medicine Vol. 16, No. 6 December 2017

2 Severl studies hve documented the impct of helth coching for improvements of functionl helth outcomes in helth cre. A 10-month rndomized controlled tril demonstrted tht ptients who underwent helth coching hd significntly reduced risk of developing coronry hert disese. 3 Another clinicl tril of 28 ptients exmined the impct of helth coching on type 2 dibetes. Ptients who received 6 months of helth coching showed sttisticlly significnt improvement in outcomes relted to A 1c nd incresed dherence to mediction nd exercise plns thn the control group. 4 A 2010 systemtic review of quntittive nd qulittive methodologies found tht 6 of 15 studies demonstrted significnt improvements in nutrition, physicl ctivity, weight nd dibetes mngement, or mediction dherence fter helth coching intervention. 5 Although these studies serve to estblish helth coching s vible nd vlued tool in specific res of helth cre, severl fctors limit their generlizbility to other tretments or medicl disciplines. Specificlly, these studies lrgely focused on counseling for crdiovsculr disese nd dibetes, utilized helth coches from vried professionl bckgrounds nd eductions, nd did not employ stndrdized trining of helth coches. In ddition, the use of vrious definitions of helth coching, beyond the generlly ccepted ptient-centered nd ptient-driven process tht empowers client to chieve self-determined gols relted to helth nd wellness, 6 mke cross-study comprisons difficult. These limittions bring into question the relevnce of helth coching to the multidisciplinry rehbilittion field where dherence to prescribed clinicl tretment recommendtions is criticl to successful rehbilittion outcomes. To test the vibility of helth coching in specilized rehbilittion popultion, the VA Office of Ptient Centered Cre nd Culturl Trnsformtion (OPCC&CT) nd the VA Rehbilittion nd Prosthetic Service llocted resources in 2012 to implement pilot progrm to ssess the impct of helth coching for veterns utilizing the Polytrum System of Cre (PSC). Three polytrum sites: Plo Alto, Cliforni; Richmond, Virgini; nd Sn Antonio, Texs, were designted in the rollout of 3-yer pilot progrm, termed the Polytrum Integrtive Medicine Inititive (PIMI). Briefly, the PSC sites re multitiered lifetime tretment progrms estblished in 2005 to ddress the rehbilittion needs of those with multiple systemic injuries, of which trumtic brin injury (TBI) is often the primry dignosis driving rehbilittion nd mngement. There re 3 principl levels of PSC infrstructure serving significnt number of ptients ntionlly: (1) the Polytrum Rehbilittion Center, serving in-ptients through cute comprehensive interdisciplinry rehbilittion who experienced severe injuries to more thn 1 orgn system, often including brin injury; (2) the Polytrum Trnsitionl Rehbilittion Progrm, serving ptients in residentil setting with focus on successful community reintegrtion, with specilized trining to support return to work, school, or meningful ctivities; nd (3) the Polytrum Network Site (PNS), to serve outptient needs by providing polytrum nd mild TBI ssessment, tretment, nd ongoing ssistnce with community reintegrtion. The PNS lso serves s n nchor to broder outrech progrms such s the Community-Bsed Outptient Clinics nd Telehelth support. At our site, the outptient PNS Clinic ws designted to pilot the PIMI progrm in The overll gol of the PIMI progrm is to enhnce ptient-centered cre by integrting stndrdized helth coching within n interdisciplinry rehbilittion tem. An integrtive helth coch (IHC) prticiptes in interdisciplinry tem ctivities to help fcilitte nd promote helthy behviors in vrious domins of helth for the vetern popultion with TBI. The IHC focuses on the vetern s vision, vlues, nd helth gols. The IHC meets the vetern where they re to help guide nd support the vetern to chieve self-determined gols. The PIMI progrm uses the Personl Helth Inventory (PHI) to ssess ptient performnce nd stisfction in meeting identified gols. 7 The trgeted ptient popultion differs from previous studies on helth coching, which hve lrgely focused on persons with crdiovsculr risk fctors nd dibetes mellitus. In ddition, the PIMI progrm stndrdized helth coch trining nd definition of helth coching to minimize those bises nd limittions s estblished in the literture. The purpose of this report is to evlute the impct of this pilot PIMI progrm t the Plo Alto site. We sought to fully evlute the progrm with specific metric of interest within the designted progrms, tretment dherence. Within the rehbilittion field, the clinicl ppointments re the prescribed therpeutic sessions needed to fcilitte the ptients recovery. Rehbilittion services include physicl therpy, occuptionl therpy, speech therpy, recretionl therpy, nd neuropsychologicl therpy, mong others. We chose tretment dherence s functionl outcome vrible becuse it is best reflective of helth behviors tht hve direct impct on rehbilittion ptient s successful outcomes, the rte of clinicl tretment recommendtions fulfilled. We therefore propose to (1) exmine tretment dherence in ptients who were offered nd received IHC intervention (IHC+) compred with those who were offered nd declined to prticipte in IHC (IHC-) nd control group of PNS ptients (CPNS); nd (2) evlute ptient stisfction by nlyzing chnges in PHI rtings t 3 months for ptients who received IHC interventions. Our priori ssumption is for positive impct of helth coching on clinicl tretment dherence nd PHI. Methods The ptient cohort reported here consisted of PNS ptients served from initil PIMI enrollment in June 2013 through My 2014, t which time recruitment procedures for the PIMI progrm chnged. Potentil ptients who Integrtive Medicine Vol. 16, No. 6 December

3 might benefit from the PIMI progrm were identified by the PNS interdisciplinry tem nd discussed with the PNS ttending physicin who submitted pproprite referrls. Ptients identified nd considered for the progrm included those requiring ssistnce in setting pproprite helth nd wellness relted gols, those hving difficulty following PNS interdisciplinry tretment recommendtions, nd those hving difficulty mking progress towrd their tretment gols. Ptients were contcted for recruitment by n IHC following referrl. Ptients hd to opt-in to the PIMI progrm. Thus, 2 cohorts of referred ptients were identified, those referred who received IHC sessions (IHC+) nd those referred who declined to receive IHC sessions (IHC-). A third cohort, defined s those PNS ptients who were not referred to the PIMI progrm, served s the control (CPNS) group. The IHCs received stndrdized trining nd were certified by Duke University Integrtive Medicine. IHCs prticipte in foundtion course consisting of 3 onsite lerning modules delivered in the course of severl months; ech module consists of 25 to 30 hours nd completion of pproximtely 2 to 3 hours of distnce lerning ech week. In ddition to the foundtion course, the certifiction course is distnce lerning delivered vi the Web nd teleconferencing in 6-month period. IHCs receive individul supervision for 9 coching sessions, complete 100 hours of professionl coching, nd complete both n orl nd written exm. 8 The IHC prtners with the vetern to support the development of personl helth pln. The IHC collected stndrdized bseline informtion from ll prticipnts during their initil PIMI coching session. Ptients completed self-ssessment utilizing the PHI, 19th revision, 7 developed by the OPCC&CT to help veterns nd clinicins work together nd estblish dilog to fcilitte development of personl helth pln. The PHI focuses on wht is importnt to the vetern nd included rting scles for the following: physicl, mentl/ emotionl, life, working the body, rechrge, food nd drink, personl development, fmily, friends nd coworkers, spirit nd soul, surroundings, power of the mind, professionl cre nd prevention, professionl cre, nd intervention. These were identified s key res of self-cre tht contribute to living helthy life. Ech prticipnt identified both current ssessment nd desired score in these res. Coching sessions were done t the convenience of the prticipnt. The frequency of coching intervention ws dependent on the needs of the prticipnt. Ptient gol ttinment ws ssessed with questionnire using the 13 PHI rtings dministered by the helth coch during follow-up coching sessions t 3 months. Ptient dt for tretment dherence nlysis nd demogrphics were extrcted through chrt review by licensed clinicl socil worker nd registered nurse. Tretment ppointments were tbulted for clinicl sessions scheduled by ech treting discipline, the number of cncelled sessions (CAs) nd the number of no shows (NSs). Due to the low number of ppointments for some disciplines, dt were collpsed cross disciplines, resulting in singulr vlues for the 3 importnt vribles of scheduled, CA nd NS clinicl ppointments for ech ptient. Agin, low numbers of CA nd NS ppointments prompted us to collpse the 2 vribles for the first nlysis of tretment dherence. For the clinicl tretment dherence mesure, rtes were clculted s 1 minus the percentge of totl NS nd CA clinicl ppointments divided by the totl of scheduled clinicl ppointments. IHC nonclinicl (PIMI) ppointments were ssessed seprtely becuse only the IHC+ ptients hd those ppointments. Two-tiled independent smples t tests were performed on the resulting tretment dherence percentges between IHC+, IHC-, nd CPNS groups using Microsoft Excel s built-in function (Microsoft, Redmond, WA, USA). Exmintion of the tretment dherence nlysis prompted post hoc nlysis of between- nd within-group CA/NS rtes. These post hoc mesures were clculted s the individul percentges for CA (CA/scheduled) nd NS (NS/scheduled) for clinicl (IHC+c) nd PIMI (IHC+p) ppointments. We performed 2-tiled independent smple t tests on percentges nd included only ptients with 1 or more ppointments using Microsoft Excel s built-in function. Personl Helth Inventory The Center of Innovtion on Disbility nd Rehbilittion Reserch (Ginesville, FL, USA) performed 2-tiled pired t tests to nlyze the PHI dt. IHC+ ptient gol ttinment ws ssessed by compring PHI t 3 months with their bseline PHI using SPSS, version 21 (IBM Corp, Armonk, NY, USA). They lso performed pproprite sttisticl tests on the demogrphic fctors of the 3 cohorts: for ge, 1-wy ANOVA with Bonferroni-corrected post hoc tests, nd for the remining ctegoricl vribles χ 2 tests, using Fisher s exct test whenever the dt did not meet ssumptions for χ 2 (ny tbles with expected cell counts <5). Alph ws set t.05 for significnce testing (in the cse of Bonferroni post hoc corrections, α =.05 is the fmily wise error rte cross ll possible pirwise comprisons). Results Demogrphics Of the 416 ptients served by the PNS during the report intervl, 55 were referred to the PIMI progrm. Of those, 33 opted to tke dvntge of the IHC provided by the PIMI progrm (IHC+) nd 22 declined (IHC-). To mintin similr sized comprison groups, 30 PNS ptients not referred to the PIMI progrm were rndomly selected to constitute the control cohort (CPNS). Demogrphics for the 3 cohorts re presented in Tble Integrtive Medicine Vol. 16, No. 6 December 2017

4 Tble 1. PIMI Demogrphic Summry for IHC+, IHC-, nd CPNS Cohorts Vrible IHC+ IHC- CPNS n = 33 n = 22 n = 30 Age, M (SD) 43.7 (12.9); rnge: 29 to (11.6); rnge: 24 to (13.0); rnge: 22 to 70 Gender Mle 26 (78.8%) 20 (90.9%) 26 (86.7%) Femle 7 (21.2%) 2 (9.1%) 4 (13.3%) Mritl Sttus Never mrried 6 (18.2%) 2 (9.1%) 7 (22.3%) Living with SO 1 (3.0%) 0 (0.0%) 0 (0.0%) Mrried 13 (39.4%) 12 (54.5%) 14 (46.7%) Seprted 1 (3.0%) 1 (4.5%) 1 (3.3%) Divorced 12 (36.4%) 7 (31.8%) 8 (26.7%) Widowed 0 (0.0%) 0 (0.0%) 0 (0.0%) Rce n = 31 n = 20 n = 24 Americn Indin/Pcific Islnder 1 (3.2%) 1 (5.0%) 2 (8.3%) Asin 3 (9.7%) 5 (25.0%) 3 (12.5%) Blck 2 (6.5%) 3 (15.0%) 2 (8.3%) Hispnic 5 (16.1%) 3 (15.0%) 0 (0.0%) White 17 (54.8%) 8 (40.0%) 17 (70.8%) Mixed Rce 3 (9.7%) 0 (0.0%) 0 (0.0%) SC Injured No 5 (15.2%) 3 (13.6%) 1 (3.3%) Yes 28 (84.8%) 19 (86.4%) 29 (96.7%) Period of Service OEF/OIF/OND 19 (57.6%) 16 (72.7%) 25 (83.3%) Gulf 2 (6.1%) 3 (13.6%) 2 (6.7%) Post-Vietnm 4 (12.1%) 1 (4.5%) 0 (0.0%) Vietnm 5 (15.2%) 1 (4.5%) 3 (10.0%) Other (includes multiple) 3 (9.1%) 1 (4.5%) 0 (0.0%) Eduction n = 33 n = 22 n = 27 Less thn high school 1 (3.0%) 0 (0.0%) 0 (0.0%) High school/ged 11 (33.3%) 6 (26.8%) 9 (33.3%) 1+ y of college, no degree 5 (15.2%) 5 (23.8%) 10 (37.0%) Associte s degree 5 (15.2%) 3 (14.3%) 1 (3.7%) Bchelor s degree 9 (27.3%) 4 (19.0%) 0 (0.0%) Mster s degree 2 (6.1%) 3 (14.3%) 4 (14.8%) Professionl/doctorte 0 (0.0%) 0 (0.0%) 1 (3.7%) Voctionl/technicl 0 (0.0%) 0 (0.0%) 2 (7.4%) Employed n = 33 n = 22 n = 29 Yes (%) 7 (21.2%) 5 (22.7%) 14 (48.3%) % Full-time 42.9% 40.0% 64.3% In School n = 33 n = 22 n = 29 Yes (%) 11 (33.3%) 5 (22.7%) 11 (37.9%) Full-time 54.5% 20.0% 45.5% Service Brnch 1. Air Force 3 (9.1%) 2 (9.1%) 1 (3.3%) 2. Army 21 (63.6%) 16 (72.7%) 20 (66.7%) 3. Mrines 6 (18.2%) 3 (13.6%) 5 (16.7%) 4. Nvy 3 (9.1%) 0 (0.0%) 4 (13.3%) 5. Other (includes multiple services) 0 (0.0%) 1 (4.5%) 0 (0.0%) Abbrevitions: PIMI, Polytrum Integrtive Medicine Inititive; IHC+, ptients with both PIMI nd clinicl tretment ppointments; IHC-, ptients who refused PIMI ppointments; CPNS, control group of PNS ptients; SD, stndrd devition; SO, significnt other; OEF/OIF/OND, Opertion Enduring Freedom/Opertion Irqi Freedom/Opertion New Dwn; GED, Generl Eduction Development. For ge, there ws mrginlly significnt difference between the 3 cohorts, F 2,82 = 3.05, P =.05. Bonferronicorrected post hoc comprisons indicted tht IHC+ ptients were significntly older, 43.7 yers (SD, 12.9), thn those in the CPNS cohort, 35.8 yers (SD, 13.0), with The IHC- cohort did not differ significntly in ge, 39.5 yers (SD, 11.6) from either of the other 2 cohorts. Fisher s exct test showed significnt ssocition between cohort nd eduction (P <.05). However, none of the stndrdized residuls in the contingency tble were significnt; in other words, no one cell on the cohort eduction contingency tble stood out s hving n unexpectedly high/low frequency. Fisher s exct test lso showed significnt ssocition between cohort nd employment (P <.05). The CPNS cohort s percentge of employment, 48.3%, ws more thn double the employment percentge in the other 2 cohorts (21.2% for IHC+, nd 22.7% for IHC-). There ws no significnt difference between cohorts for gender, mritl sttus, rce, service-connected injury, period of service, service brnch, or school enrollment (ll P >.17, Fisher s exct test). Tretment Adherence Tretment dherence refers to the totl percentge of scheduled clinicl ppointments fulfilled by ptient. Tretment dherence rtes for the IHC+ cohort rnged from 30% to 100%, with men of 73.09%. For the IHC- cohort, the rnge ws 22% to 100%, with men of 72.5%, nd for the CPNS cohort, the rnge ws 33% to 100%, with men of 71.56%. There ws no significnt difference in tretment dherence rtes between ny of the 3 cohorts (ll P >.45). Incidentlly, we observed tendency (P =.09, pired, 1-tiled) for the IHC+ ptients to hve lower tretment dherence rte for their PIMI ppointments (IHC+p, 72.02%) thn their clinicl ppointments (IHC+c, 75.61%) for those who hd both types of ppointments. Post Hoc Mesures Post hoc mesures re for the individul percentge rtes for CA nd NS ppointments. Integrtive Medicine Vol. 16, No. 6 December

5 Tble 2. Within-groups Dt Tble 3. Between-groups P Vlues IHC+c IHC+p IHC- CPNS Totl (n) Totl (n) w/ppts Men ppts Medin ppts % NS 7.5 (n = 14) % CA 17.3 (n = 20) 5.0 (n = 12) 20.8 (n = 28) 9.3 (n = 8) 18.5 (n = 9) 15.8 (n = 18) 13.7 (n = 18) P vlues (NS-CA) P Vlues IHC+p IHC- CPNS NS IHC+c NS IHC+p NS IHC- NS.197 CA IHC+c CA IHC+p CA IHC- CA.39 Abbrevitions: IHC+c, IHC+ ptients with clinicl tretment ppointments; IHC+p, IHC+ ptients with PIMI ppointments only; IHC-, ptients who refused PIMI ppointments; CPNS, control cohort from PNS; CA, cncelled ppointment; NS, no show. Within Groups. IHC+ ptients hd significntly higher CA rtes thn NS rtes for both clinicl (IHC+c) nd coching (IHC+p) ppointments (P <.05). IHC- nd CPNS ptients did not hve significnt differences in CA nd NS rtes (Tble 2). Between Groups. There ws significnt difference for NS rtes with IHC+p ptients hving lower rtes, 5%, thn CPNS ptients, 15.8% (P =.007). There ws nerly significnt difference for NS rtes with IHC+c ptients hving lower rtes, 7.5%, thn CPNS ptients, 15.8% (P =.052). There ws tendency for IHC+p ptients to hve greter CA rtes, 20.8%, thn CPNS ptients, 13.7% (P =.057). There were no other significnt differences for NS or CA rtes between ny of the 3 IHC groups nor between IHC- nd CPNS ptients (Tble 3). PHI dt re presented in Tble 4. Eighteen ptients who received 3-month follow-up reported significntly improved scores in 7 of 13 rtings including the lst 2 relted to tretment dherence. Discussion The purpose of this report ws to evlute the preliminry impct of the PIMI inititive mong our PNS outptients. The PIMI progrm t our site is ptient-centered pproch to helth cre with focus on behvior chnge through mindful wreness nd self-cre interventions. As pilot progrm initited in 2012, the PIMI progrm fced substntil hurdles to implementtion before ptient enrollment nd continued evlution nd revision. Chllenges included logistic nd dministrtive ctivities such s creting new clinics, templtes, implementing the referrl process, stff recruitment, nd trining. There ws lso lck of knowledge bout helth coching from clinicl stff, skepticism bout the vlue of helth coching, nd concerns bout redundncy of services in n Abbrevitions: IHC+c, IHC+ ptients with clinicl tretment ppointments; IHC+p, IHC+ ptients with PIMI ppointments only; IHC-, ptients who refused PIMI ppointments; CPNS, control cohort from PNS; CA, cncelled ppointment; NS, no show. Tble 4. 3-Month Follow-up Chnges in PHI 13 Rtings (n = 18) Domin Bseline Score Men (SD) Follow-up Score Men (SD) P Vlue Physicl Scle 4.81 (2.45) 6.39 (1.46).0205 Mentl/Emotionl Scle 5.33 (2.89) 6.67 (1.71).0223 Life Scle 5.39 (2.62) 6.67 (1.97).0513 Working the Body 4.94 (1.76) 6.44 (1.95).0171 Rechrge 4.78 (2.37) 5.06 (2.01).5623 Food nd Drink 5.41 (2.78) 6.44 (1.62).2126 Personl Development 5.44 (2.09) 7.61 (1.72).0001 Fmily, Friends, nd 5.39 (3.15) 6.61 (2.17).0585 Coworkers Spirit nd Soul 6.06 (2.80) 6.83 (2.75).1539 Surroundings 5.83 (2.64) 6.94 (2.75).1763 Power of the Mind 5.39 (2.64) 7.17 (2.55).0010 Professionl Cre, 7.50 (2.01) 9.28 (0.96).0018 Prevention Professionl Cre, Intervention 7.33 (1.94) 8.94 (1.35).0075 Abbrevitions: PHI, Personl Helth Inventory; SD, stndrd devition. interdisciplinry model tht required eductionl ctivities to help grner cceptnce. Given these chllenges, our site enrolled its first ptient during fiscl yer 2013, qurter 3. One of the gols of the PIMI progrm is to improve positive helth outcomes. Helth coches develop prtnerships with their ptients nd work in collbortion with the existing tretment tems to develop individulized wellness plns to help support ptients overll dherence 30 Integrtive Medicine Vol. 16, No. 6 December 2017

6 to tretment recommendtions. Therefore, we set out to ssess the efficcy of helth coching in this domin by ssessing the tretment dherence rtes of 3 cohorts of ptients served in our PNS clinic in the yer following enrollment of the first PIMI ptient. The cohorts were composed of PNS ptients referred to the PIMI progrm who ccepted helth coching (IHC+), or declined helth coching (IHC-), nd third control cohort of PNS ptients not referred to the PIMI progrm (CPNS). We hypothesized tht there would be positive impct of helth coching on tretment dherence nd PHI. We found no significnt difference in tretment dherence rtes between the 3 groups when mesured s the percentge of scheduled ppointments fulfilled by ptients. We observed tendency for IHC+ ptients to hve lower tretment dherence rte for their PIMI ppointments thn their clinicl ppointments. These findings prompted post hoc nlysis of individul CA nd NS rtes. The within-groups nlysis found IHC+ ptients hd significntly higher CA rtes thn NS rtes for both clinicl nd PIMI ppointments. IHC- nd CPNS ptients did not hve significnt differences in CA nd NS rtes. The between-groups nlysis found significnt difference for lower NS rtes for IHC+p ptients compred with CPNS ptients. There were trends for lower NS rtes for IHC+c ptients thn CPNS ptients nd for higher CA rte for IHC+p ptients thn CPNS ptients. These findings my be skewed by the low number of IHC- ptients nd ppointments, but they suggest potentil positive behviorl effect for helth coching. Given tht NS ppointments represent lost provider time nd CA ppointments offer the opportunity to recover provider time, the positive effect of helth coching on CA versus NS rtes represent potentil positive impct of helth coching on scheduling hospitl resources nd strtegic plnning. The PIMI progrm uses the self-report PHI s its efficcy ssessment instrument t initil enrollment nd fter 3 months of helth coching. Results from this dt suggest tht IHC+ ptients believe they re mking significnt improvements in mny of the identified res of helth coching focus, including the 2 relted to tretment dherence, professionl cre: prevention nd intervention. This seems to be in contrst to our findings of no significnt difference in tretment dherence rtes between tretment groups. Results bsed on the PHI instrument must be viewed with cution, s it ws not designed s reserch instrument nd hs not been evluted for vlidity or relibility. As self-report mesure it is lso susceptible to subjective bis nd performnce demnds. In ddition, the 3-month follow-up instrument vried in formt from the initil PHI form nd gin hs not been vlidted in ny wy. However, we do not discount the benefit of perceived gin to the subjective wellbeing of ptients. This perceived gin in ptient stisfction my represent n dditionl positive impct of helth coching. There were some significnt differences in demogrphic fctors for the 3 PNS cohorts including ge, eduction, nd employment. Given tht our primry nlysis of tretment dherence rtes found no indiction of positive impct for helth coching between the groups, ny potentil reltionship between demogrphic fctors nd tretment dherence rtes need to be exmined crefully in lrger cohort. We temper these observtions with the cknowledgment tht this is preliminry report of reltively smll smple nd from period during which implementtion nd revision of new services my skew the results. Future nlyses will focus on the much lrger cohort from the subsequent period, where PIMI progrm protocols re more stble nd ll PNS ptients were offered helth coching. Conclusions Although helth coching hs shown positive impct in severl specific res of helth cre such s dibetic A 1c mngement, weight mngement, nd mediction complince, we did not find significntly incresed tretment dherence rtes for PNS ptients receiving helth coching compred with PNS ptients who received no helth coching. It is importnt to focus on select vribles such s CA versus NS ppointments to fully cpture the impct of ny progrms such s helth coching on ptient behvior nd clinicl resource utiliztion. Our report on PHI nd tretment dherence provides n exmple of the potentil pitflls of objective versus subjective dt collection instruments, especilly self-report subjective bis nd potentil performnce demnds. Although subjective input my be vluble, we believe the PIMI progrm would benefit from development of objective mesures of efficcy to ssess its future internl progrmmtic success. References 1. Wolever R, Simmons L, Sforzo G, et l. A systemtic review of the literture on helth nd wellness coching: Defining key behviorl intervention in helthcre. Glob Advn Helth Med. 2013;2(4): Murry C, Lopez A. Evidence-bsed helth policy: Lessons from the Globl Burden of Disese Study. Science. 1996;274(1): Edelmn D, Oddone E, Liebowitz R, et l. A multidimensionl integrtive medicine intervention to improve crdiovsculr risk. J Gen Internl Med. 2006;21(7): Wolever R, Dreusicke M, Fikkn J, et l. Integrtive helth coching for ptients with type 2 dibetes: A rndomized clinicl tril. Dibetes Eductor. 2010;36(4): Olsen J, Nesbitt B. Helth coching to improve helthy lifestyle behviors: An integrtive review. Am J Helth Promotion. 2010;25(1):e1-e Ntionl Consortium for Credentiling of Helth & Wellness Coches. Progress Report. Well Coches Web site. imges/pdf/progressreport-ntionltem-jul-2011.pdf. Published July Accessed September 9, Cornis-Pop M. Polytrum Integrtive Medicine Inititive: Finl Report. Ginesville, FL: Center of Innovtion on Disbility nd Rehbilittion Reserch; Duke Integrtive Medicine (DIM). Integrtive helth coch trining. DIM Web site. Accessed September 9, Integrtive Medicine Vol. 16, No. 6 December

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