Capacity Coaching: A New Strategy for Coaching Patients Living With Multimorbidity and Organizing Their Care

Abstract The prevalence of chronic conditions is growing; to date, 1 in 4 Americans lives with at least one chronic condition. In the population aged 65 years and older, most live with multiple chronic conditions, or multimorbidity. Coaching interventions have been widely touted as a potential way to prevent chronic illness and as a way to help patients better self‐manage their chronic illnesses. Health and Wellness Coaching (HWC) is now a respected discipline that offers certification, and HWC for patients with chronic conditions has demonstrated the potential to positively change behaviors and health outcomes. Yet, despite the enthusiasm and advancement of the discipline, the role of HWC has not been examined in light of the latest conceptual and theoretical work in the treatment of multimorbidity. In this article, we briefly describe HWC activities and the way in which they can be modified in alignment with the progress in the field of multimorbidity to form a new type of coaching, Capacity Coaching.

T he prevalence of chronic conditions is growing; to date, 1 in 4 Americans lives with at least one chronic condition. 1,2 Furthermore, more peopled75% of those older than 65 yearsdare living with multiple chronic conditions, also known as multimorbidity. 1,2 Coaching interventions have been widely touted as a potential way to prevent chronic illness and as a way to help patients better self-manage their chronic illnesses. [3][4][5] Generally, coaching describes a relationship between 2 people, one doing the coaching and the other receiving the coaching, and a process to uncover goals and work toward the achievement of those goals. Coaching draws from a range of strategies to tailor its response to the dynamic situation of patients and their families.
Coaching first emerged in human resource journals as early as 1937, and coaching in business was aimed at improving the functioning, specialization, productivity, and communication of personnel, organizational leadership, and employee relations. 6,7 The introduction of coaching coincided with a change in management approaches toward the cultivation of individuals' skills, expertise, and strengths within the context in which an employee or executive operates. Coaching's emphasis on the realization of the potential of a person made it applicable to diverse fields including sports, mentorship relationships, the armed forces, divinity, special needs education, rehabilitation practices, and eventually health care. 6 In health care specifically, coaching began to appear as a way to engage patients in selfmanagement when the notion of personal responsibility for one's health first emerged. 8 In 2010, a group of 14 industry leaders from government agencies, universities, and academic medical institutions convened to identify the knowledge, skills, and competencies of a Health and Wellness Coach, arriving at a national board certification process including a board examination by October 2017. 9,10 This work noted that coaches do not diagnose, interpret behavior or beliefs, or clinically advise patients on what to do. Instead, it requires coaches to follow specific procedures to elicit personally meaningful goals from the patient and to use evidence-based communication and learning techniques to aid the patient in selfdiscovery and generation of solutions. 9 Coinciding with the development of coaching certification, the health care literature aimed at examining coaching's effectiveness has expanded exponentially, particularly between 2009 and 2016. 5 This literature indicates some promising effects in changing health behaviors and patient health outcomes. Specifically, an integrative review on health coaching interventions revealed positive changes in health behaviors, 11 as did a systematic review of interventions to improve physical activity in patients with diabetes. 12 Furthermore, a recent systematic review summarizing randomized controlled trials and quasi-experimental studies testing coaching interventions across chronic conditions concluded that they had statistically significant positive impacts on physiologic, behavioral, psychological, and social outcomes of patients. 4 In the same time frame that the literature regarding Health and Wellness Coaching (HWC) was growing, literature in parallel began to point to a paradigm shift in the approach to care for patients living with multimorbidity. Namely, in 2009, Minimally Disruptive Medicine was named as a new philosophy of care to address a growing problemd "structural noncompliance"din the face of multimorbidity. 13 Briefly, structural noncompliance is the idea that patients were not simply choosing to disregard their treatments for chronic illness but rather that the way in which the health care system was organized simply placed too much work on patients with multiple conditions to practically enact that work. 13 In 2012, the cumulative complexity model (CuCoM), which served as the overarching conceptual model to guide the practice of Minimally Disruptive Medicine, was published. 14 The model described patient situations as ones in which there was workdboth the work of being a patient and the work of lifedbalanced by patients' capacity to enact that work. 14 A workload-capacity balance or imbalance affects patients' abilities and resources to access and use health care and enact self-care, which in turn affects their outcomes. 14 The cumulative nature of the model comes into play when health care responds to worsening patient outcomes by intensifying treatment, which increases the burden of treatment and overall workload of the patient while their capacity continually deteriorates because of the burden of illness. 14 The model is depicted in Figure 1. Since 2012, multiple middle-range theories have been applied or proposed to further describe concepts in the CuCoM, including the Normalization Process Theory applied to patient work, 15-18 the burden of treatment theory developed to describe patient and family treatment burden, 19 and the theory of patient capacity developed to describe the core components of patient capacity for life and self-care. 20 To date, while coaching in health care has grown as a discipline, including the development of certification and the expansion of its evidence base regarding the potential to impact behavior change and improve patient outcomes, the current practices of HWC have not been reconciled with the latest conceptual and theoretical progress in the field of living with and treating multimorbidity. In the one instance of using these new frameworks to analyze the impact of HWC on patient outcomes related to their capacity, it was noted that HWC impacted some areas of patient capacity but not others, suggesting value in using these new frameworks to better address the needs of patients living with chronic illness. 21 Therefore, the aim of this paper is to briefly summarize the current practice of HWC and offer a new form of coaching for this population, Capacity Coaching, which builds on HWC to date and the conceptual and theoretical foundations of Minimally Disruptive Medicine.

HEALTH AND WELLNESS COACHING
Recently, there has been considerable debate regarding the distinct naming of coaching in health and health care settings. 3 However, we adopt here the term Health and Wellness Coaching to describe activities by individuals who participate in coaching activities in health and health care settings, "typically in an effort to prevent or treat chronic illness by supporting sustainable change in health behaviors as well as adherence to complex medical regimens." This description is in alignment with recent efforts to promote consensus within the profession. 3,10 Furthermore, Wolever et al undertook considerable efforts to synthesize all definitions of HWC in the published medical literature and arrived at the following definition: "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." 22 However, beyond definitions and tasks undertaken, there is a spectrum of functions that coaches serve within organizations. These functions are all focused on engagement in behavior change, but coaching functions as described in the current literature differ in the patient-driven nature of their coaching goals. For example, Wolever et al 22 also found that 45% of coaching interventions described in the literature allowed patients to select their own goals vs 26% in which goals were partially patient driven and 29% in which goals were set externally from patient goals. Functions range from coaching patients toward prescribed, health careedetermined goals (eg, medication adherence, surrogate disease markers such as hemoglobin A 1c ) 23 to coaching patients toward pursuit of a broad range of health-promoting behaviors determined to be important by patients (eg, exercise, stress management, social activity). 22,24 The core tasks of coaching are illustrated in Table 1. Column 1 derives the 2 core domains from a recent job task analysis of HWC. 9, 25 Health and Wellness Coaches collaborate with clients to form and articulate a vision using appreciative inquiry, 26 develop goals to achieve that vision, and then begin to align the client's behaviors and values by using techniques such as motivational interviewing 27 to work toward realizing the specific and measurable goals. In order to progress, clients are encouraged to experiment with different plans of action to see how well they move them toward their goals. Through these experiments, clients learn and become aware of how they can best achieve their goals. A goal may be to exercise 3 times per week; an experiment could be to try biking to work once to explore if it is feasible and desirable. 28 Coach and client typically meet at the client's convenience, anywhere from quarterly to weekly, to discuss and plan experiments. Successful experiments, when continued to be acted upon, change the client's health behaviors, life, and appreciation of both.  Capacity Coaching is ideally integrated into the primary care team but can occur separately. When integrated into the care team, the coach-patient interaction drives the way other parts of care are arranged for the patient.

CAPACITY COACHING
Capacity Coaching draws from a rich source of conceptual and theoretical work described previously. The CuCoM orients the way in which Capacity Coaching works within a health care team, whereas the theory of patient capacity most practically orients the coach-patient relationship because it identifies 5 factors from which patient capacity develops: Biography, Resources, Environment, Accomplishing Work, and Social (BREWS). 20 Briefly, how well a patient is able to incorporate their illness and its  (Figure 2) as a conversation starting point to facilitate asking how and to what extent illness and treatment are affecting the patient's lifedfor better or for worse. The ICAN Discussion Aid 29 helps structure the initial session and future interactions. In each instance, the discussion aid can  29 This approach provides an understanding of broader life demands and successes in which the patient understands and manages illness and treatment. Beginning from the practical consequences and demands of illness and treatment on diverse areas of a person's life, Capacity Coaching is oriented toward developing strategies for decreasing the burdens of illness and treatment, bolstering existing sources of capacity, and cultivating new capacities to bear and adapt to life with illness and treatment.
Patient-coach visits may occur as a single consultation or over a period of time, eg, 3 or 6 months. During this period, the Capacity Coach continues to explore with the patient to co-create an action plan that adapts prescribed health care to the patient's situation while supporting and growing patient capacity for self-care and quality of life. Like HWC, at the end of the coaching visit, the patient and coach set up one or more experiments for the coming week ahead. The coach and patient can follow-up to see how those experiments went at the next visit or asynchronously, eg, through e-mail. Although established relationships and continued follow-up are ideal in Capacity Coaching, the option for a single consultation may be the most practical option for overwhelmed patients. This factor differs from HWC, in which established relationships are considered a pillar of the practice. Following the visit, if integrated into the health care team, the Capacity Coach also documents the summary of the visit and subsequent actions needed in the electronic medical record and shares this summary with colleagues treating the patient. For example, if the coach identifies that the patient's 4 times per day insulin regimen is such a burden to the patient that she rarely can adhere more than 2 times per day, the coach would communicate this burden to the team member managing the patient's diabetes care (either her endocrinologist or her primary care clinician) for modification. Situation Joan has diabetes and high blood pressure. She has recently retired and enjoys spending time with her family and friends. She has an active social life and feels that she doesn't always keep up with the actions she knows she needs to take to maintain her current health and social life. She feels she has the time to manage her health now in her retirement but needs to figure out ways that align with her strengths and preferences. She also would like to manage her conditions as much as possible with little or no medication In a different scenario, Joan spends her Monday, Thursday, and Saturday mornings at dialysis. She feels a great loss because she used to spend Saturdays visiting with her girlfriends or playing with her grandchildren, but now she is too tired after dialysis. She takes multiple medications that must be taken 3 times a day on an empty stomach. Her husband of 45 years passed away last year, and she now feels lonely. She has since gotten a dog to keep her company. She enjoys walking the dog when she feels well but has been in too much pain to do so lately. She relies on her adult daughter, Judy, a great deal to take care of her dog and to get her to and from dialysis. Judy also has chronic conditions that now need her attention, and her ability to help her mom is becoming limited. Joan has become overwhelmed and begins missing some of her appointments Capacity Coaching begins in the practical issues of living with illness, which distinguishes it from HWC that may begin from more long-term visions of health or from clinically recommended treatment regimens. The emphasis on the day-to-day problemsd particularly the burden of illness and treatment and the work that they entaildmakes Capacity Coaching an approach that is particularly helpful for the growing population of patients with multiple chronic conditions. Table 2 describes patient stories about how traditional HWC activities are modified in Capacity Coaching practice.

Implications for Practice
Health and Wellness Coaching brings considerable strengths to the table in health care as a method for changing behaviors to prevent and treat chronic illness and in the physiologic, behavioral, psychological, and social outcomes for patients. However, the growing population of patients living with multimorbidity may need a slightly different approach to coachingdone that focuses on strengthening their capacity to adapt and thrive with chronic illness and that assists in orienting their health care teams' actions. Capacity Coaching brings to the same table a practice of coaching that incorporates the successful key elements of the HWC process but orients them in new ways with the conceptual and theoretical structures specifically developed to meet the challenges of living with and treating multimorbidity. The type of coaching used should be in line with the patient's situation at the time, as determined in conversation with the patient. Clinical policymakers and managers must consider the needs of their population before deciding to offer a specific type of coachingdHWC, Capacity Coaching, or both. Resources for practitioners can be found in Table 3.

Implications for Research
A notable difficulty in the HWC literature has been fairly unstandardized ways of delivering HWC, which may in the future be mitigated by the well-done job task analysis for HWC. Additionally, the measurement of patient outcomes in HWC studies has also been fairly heterogeneous (eg, different measures for quality of life, some studies measuring quality of life while others measure disease markers). There is considerable room in the research field to test HWC and Capacity Coaching in the care of patients with chronic conditions and multimorbidity. Our ongoing research focuses on the process of implementing Capacity Coaching within primary care teams and barriers and facilitators to that implementation. Building on this implementation work, future research should test Capacity Coaching's impact on outcomes such as patient quality of life, 38 treatment burden, 39,40 and health care team coordination 41-43 compared to usual primary care for chronic conditions and HWC. Researchers should carefully describe their interventions and monitor fidelity to the tasks prescribed by style of coaching, using standards such as the TIDieR (template for intervention description and replication) checklist for intervention reporting. 44

CONCLUSION
The literature on HWC has not yet considered the current state of the field in living with and treating multimorbidity, a growing population that coaching practices may be prescribed to serve. We have sought to briefly describe the practices of HWC and how those practices can be modified to create Capacity Coaching, a coaching strategy that specifically draws on the conceptual and theoretical foundations of Minimally Disruptive Medicine. Practitioners can use these working definitions to identify types of coaching needed for their patients, and policymakers can use them to consider the coaching style that needs to be made available to their patient populations. Furthermore, research should work to further test Capacity Coaching, as well as compare its utility and impact on patient outcomes with traditional HWC.