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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.
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.
Sforzo GA, Kaye MP, Todorova I, et al. Compendium of the health and wellness coaching literature [published online May 19, 2017]. Am J Lifestyle Med. https://doi.org/10.1177/1559827617708562.
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.
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.
In health care specifically, coaching began to appear as a way to engage patients in self-management when the notion of personal responsibility for one’s health first emerged.
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.
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 self-discovery and generation of solutions.
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.
Sforzo GA, Kaye MP, Todorova I, et al. Compendium of the health and wellness coaching literature [published online May 19, 2017]. Am J Lifestyle Med. https://doi.org/10.1177/1559827617708562.
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,
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.
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 problem—“structural noncompliance”—in the face of multimorbidity.
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.
In 2012, the cumulative complexity model (CuCoM), which served as the overarching conceptual model to guide the practice of Minimally Disruptive Medicine, was published.
The model described patient situations as ones in which there was work—both the work of being a patient and the work of life—balanced by patients’ capacity to enact that work.
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.
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.
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,
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.
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.
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.
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.”
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
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 care–determined goals (eg, medication adherence, surrogate disease markers such as hemoglobin A1c)
What do health coaches do? direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers.
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).
International Consortium for Health & Wellness Coaching Health and wellness coaching job task analysis findings. International Consortium for Health & Wellness Coaching website.
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.
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.
Table 1Health and Wellness Coaching (HWC) Tasks and Their Modifications for Capacity Coaching
Adapted with permission from the International Consortium for Health & Wellness Coaching.
International Consortium for Health & Wellness Coaching Health and wellness coaching job task analysis findings. International Consortium for Health & Wellness Coaching website.
Assist the client in creating a description of their ideal vision of the future
Use ICAN Discussion Aid to assess life (biography) and treatment plan fit. Assist patient in describing areas of challenge and success with fit
Establish or identify the present situation, past history, previous successes and challenges, resources, etc associated with the client’s vision
Use ICAN Discussion Aid to identify the present situation, past history, previous successes and challenges, resources, etc associated with good or poor fit between life and care
Explore and evaluate the client’s readiness to progress toward the vision
Explore and evaluate areas in which patient’s capacity can be increased and readiness to progress in that direction. Explore and evaluate areas in which patient’s care team can reduce treatment burden. Communicate those to appropriate team members
Invite the client to identify and explore patterns, perspectives, and beliefs that may be limiting lasting change
Invite the patient to identify and explore patterns, perspectives, and beliefs found within their own biography, environment, and social networks that may be limiting lasting change
Work with the client to establish goals that will lead to the vision
Work with the patient to establish “experiments” that will lead toward better treatment/life fit
Work with the client to develop a series of steps that will lead to the achievement of client-selected goals
Work with the patient to break down experiments into smaller steps if needed
Elicit the client’s commitment to and accountability for specific steps
Support and develop patient capacity to undertake experiments. Work with health care team toward commitment to reducing areas of patient treatment burden
Collaborate as the client evaluates success in taking steps and achieving goals
Collaborate with patient and health care team to evaluate success in taking steps toward achieving life/treatment fit and increasing patient’s capacity for self-care
Work with the client to maintain progress and changes
Work with the patient and the health care team to maintain progress and changes
Collaborate as the client reassesses goals and makes modifications based on personal decisions and progress made
Collaborate as the patient reassesses fit and makes modifications based on personal decisions and progress made. Collaborate with the health care team to incorporate these changes as well
Assist the client in articulating learning and insights gained in the change process
Assist the patient in articulating learning and insights gained in the Capacity Coaching process (patient and team changes)
Work with the client to develop a postcoaching plan to sustain change that promotes health and wellness
Work with the patient and their care team to develop a postcoaching plan to sustain changes that achieve treatment-life fit
HWC = health and wellness coaching; ICAN = Instrument for Patient Capacity Assessment.
Capacity Coaching, a novel coaching approach, draws on the practices of the completely patient-driven spectrum of HWC and Minimally Disruptive Medicine to focus specifically on developing the capacity within patients to adapt, endure, and function optimally in their lives along with illness and treatment. It is designed to help patients facing complexity coming from life, health, health care, and their interplay. 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 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).
Briefly, how well a patient is able to incorporate their illness and its treatment into their personal biography, who they are in the world, and how they author their story, colors how they experience and organize self-care. Patients’ capacity also rests on the resources available and their ability to draw on those resources. Patients’ environment in their home, neighborhood, and health care system can enhance or deteriorate capacity. Patients’ ability to accomplish the work required to care for their health and pursue meaning in life affects their capacity; the experiential “wins” from accomplishing these tasks perpetuate capacity, while tasks too great in scope or number overwhelm the patient and impede experiences of success. Finally, the patients’ social support can hinder or improve patient capacity.
Capacity Coaching tasks are illustrated in column 2 of Table 1, next to their related HWC tasks in column 1. Capacity Coaches, who may be health care professionals or trained peers, collaborate with patients using means such as the ICAN (Instrument for Patient Capacity Assessment) Discussion Aid
(Figure 2) as a conversation starting point to facilitate asking how and to what extent illness and treatment are affecting the patient’s life—for better or for worse. The ICAN Discussion Aid
helps structure the initial session and future interactions. In each instance, the discussion aid can generate conversation about how health care and life are working together, including what is helping the patient and what is burdensome and how these factors manifest in different aspects of the patient’s life.
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.
Figure 2ICAN (Instrument for Patient Capacity Assessment) Discussion Aid.
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.
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 problems—particularly the burden of illness and treatment and the work that they entail—makes 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.
Table 2Coaching Situations and Actions for “Joan”
Health and Wellness Coaching
Capacity Coaching
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
Coaching actions
Joan works with a Health and Wellness Coach, affirms the biometrics she and her health care team are working to change. The Health and Wellness Coach asks questions to learn more about Joan’s strengths and values and then helps her create a vision of optimal health followed by a realistic plan to track changes on a daily and weekly basis while managing inevitable challenges along the way
Joan’s Capacity Coach helps her work with her health care team to evaluate treatment/life fit, including treatment burdens she may be able to decrease or eliminate, set experiments in which she can increase the activities that bring her joy and manage her pain, and connect her with community resources that can overcome her social isolation
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 coaching—one 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 coaching—HWC, Capacity Coaching, or both. Resources for practitioners can be found in Table 3.
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,
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.
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.
Sforzo GA, Kaye MP, Todorova I, et al. Compendium of the health and wellness coaching literature [published online May 19, 2017]. Am J Lifestyle Med. https://doi.org/10.1177/1559827617708562.
What do health coaches do? direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers.
Grant Support: This publication was supported by CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Science. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.
Potential Competing Interests: The authors report no competing interests.
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