Diabetes Education, the Quadruple Aim and Health Coaching – a perfect match

Diabetes in the 21^st century

In population terms, diabetes is quite plainly, starting to get away from us. The worldwide prevalence of diabetes increased fourfold between 1980 and 2014². This paints a stark picture of the influence of lifestyle on human health and points to a future where worldwide healthcare systems will collapse under the weight of chronic NCDs.  The current state of affairs with NCD has been described as a “global emergency”³; however, emergencies, by definition, arise unexpectedly. This situation is better thought of as a “crisis” in which clear decisions must be made in order to avert further decline.

In recognition of this, diabetes-specific services and educational organisations have grown all over the world. In addition, medical and health support services must be equipped to work effectively and sustainably, well into the future.

The Quadruple Aim

The notion of the “Triple Aim”⁴ in health care – so called for its tripartite focus on enhancing client experience, improving population health and reducing cost, became quickly accepted as a roadmap for health care systems. However, it lacked a key component: the impact on the provider of the health care (and in this context not a systems provider like a health care system, but the individual providing the health service to another person). This led to the articulation of the “Quadruple Aim”⁵ which acknowledges the key component of improving and supporting provider wellbeing in maintaining a viable health care system.

While focusing on diabetes, meeting the demands of the Triple Aim was challenging in relation to improving population health. Once the fourth arm of ‘provider wellbeing’ in the “Quadruple Aim” is considered, the challenge is doubled down and outcomes for people living with diabetes have been shown to be negatively impacted by poor health provider wellbeing and burnout^5.

So if we are to honour the “Quadruple Aim” of health care in relation to diabetes support and treatment, a primary focus must be using approaches that will give a measurable and appreciable boost to population health over time, manage the costs of treatment,  respect the autonomy of the person with diabetes and support the psychological and physical wellbeing of those who provide these health services – largely diabetes educators.

What is health coaching and how can it help?

The exact origins of health coaching (or sometimes “health and wellness coaching”) are difficult to define. The notion of coaching has its origins about two centuries ago when Oxford University used the word to describe the idea of preparing a person for an examination or athletic contest or literally as someone who “conveys” a person from one point to another (before a test, to after a test).⁶

While there does not exist, to the best of my knowledge, a unified definition of health coaching, the working definition used by the US National Board of Health and Wellness Coaching (NBHWC) captures the elements of health coaching which speaks to its utility in health care:

“Health and Wellness Coaches partner with clients seeking self-directed, lasting changes, aligned with their values, which promote health and wellness and thereby, enhance wellbeing. In the course of their work, health and wellness coaches display unconditional positive regard for their clients and a belief in their capacity for change, and honoring that each client is an expert on his or her life, while ensuring that all interactions are respectful and non-judgmental.” ⁷

Does this mean that health coaching must stand apart from diabetes education? Not at all. In fact, ensuring that all 21^st century health providers are equipped with health coaching skills ensures that they are able to target sustained health behaviour change – the real challenge of non-pathogenic, NCD which accounts for the overwhelming proportion of our disease burden.

The notion embedded in the definition, that “each client is an expert on his or her life” does not preclude the judicious use of medical and health expertise. The two areas of expertise (diabetes and an individual’s personal values and understanding of their own capacity for change) work alongside each other.

Health coaching draws extensively on psychological science, in particular the Transtheoretical Model of Behaviour Change⁸, Motivational Interviewing⁹, Choice Theory¹⁰, Reality Therapy¹¹ and Solution-Oriented Brief Therapy¹², among others. The US NBHWC provides a credible and consistent means¹³ of certifying health coaches and ensuring that health coaching is undertaken by those who have studied and met evidence-based criteria for certification.

What does health coaching look like in practice?

In the context of diabetes education, health coaching is best thought of as a style of engagement, rather than a specific activity to be undertaken. A coaching approach emphasises particular aspects of the provider/client interaction including curiosity, an orientation towards Appreciative Inquiry¹⁴, a question and reflection style of interaction and a focus on supporting the individual to identify changes that have meaning and purpose for them (and which they will therefore be much more likely to sustain).

This approach must, by necessity, be integrated with expertise, to ensure that people living with diabetes have access to current knowledge and when required, can be advised to take a particular course of action. However, this “expert” style of intervention is used sparingly and only as required, rather than as a default means of engaging with clients.¹⁵

Thus, during the course of a consultation, a diabetes educator using a health coaching modality will likely spend time initially on supporting the person with diabetes to identify a “vision” for their health and wellbeing. This is the foundation of Appreciative Inquiry and seeks to engage the person in a “higher and wider” discussion about their health. Previous successes in managing aspects of health are identified, as are the strengths, supports and resources the person brings to their situation.  At this point, concrete goals are explored and the individual is supported to identify and create two to three specific behavioural health goals, with meaning and relevance to them and their health condition. These are formulated on the “SMART”¹⁶ principle to ensure accountability and practicality. Motivational interviewing techniques form part of the overarching framework of health coaching. These strategies may be used to support the individual to address ambivalence about health behaviour change.

Health coaching is best thought of as a framework for client support, rather than as a discreet service or treatment approach which must be sourced additionally with diabetes education. Practitioners who become certified in health coaching are able to adopt a coaching framework with its inherent focus on supporting client autonomy, the creation of a personally meaningful health vision, decision making, motivation, identification of strengths, goal setting, readiness and confidence to change. In summary, health coaching becomes a framework to support the client to implement specific evidence-based approaches to diabetes management.

It’s worth emphasising that goal setting is a small part of the entire process of health coaching and not its main focus. Personally-relevant and sustainable behavioural change goals flow from a vision. Without a clear vision in place, behavioural change goals often lack a purpose, or a response to the question “Why?”

The health benefits of coaching

There is a considerable body of peer-reviewed research demonstrating the efficacy of health coaching interventions as part of the management and treatment of a number of chronic diseases and lifestyle patterns including diabetes, prediabetes, cancer, hypertension, obesity, smoking cessation and fibromyalgia¹⁷.

For example, one study concluded that health coaching is a cost effective, and widely accepted intervention (by people with diabetes), that leads to increases in autonomy, independent care and management.¹⁸

In a 12 week study of 118 people with T2D pairing a smartphone app with lifestyle medicine education and fortnightly telephone health coaching, 57% of participants achieved a combined outcome of reduced HbA1c, reduced diabetic medication use, or both; 92% reported greater confidence in their ability to manage their diabetes compared to before the program, and 91% reported greater confidence in their ability to maintain a healthy dietary pattern.¹⁹  Health coaching interventions among individuals with prediabetes in primary care were shown to result in a significant reduction in HbA_1c and weight over two years²⁰ and there are indications that health coaching deployed in primary care settings is both cost and outcome effective.²¹

 In fact, there is a great deal of published literature attesting to the benefits of health coaching in diabetes management. For example, a coaching intervention focused on client values and sense of purpose likely augments diabetes education and leads to improved HbA_1c levels²² and diabetes self-management.^{23, 25} Health coaching has also been used effectively to support people with T2D to set healthy goals and minimise hospital admissions.²⁴ In a novel study using a diabetes app with in-app coaching by a diabetes educator, clinically meaningful reductions in HbA_1c were achieved.²⁶

The mechanism for health coaching appears self-evident but is worth re-stating. Chronic NCDs require lifestyle modification to achieve restoration of health. Health coaching is a person-centred intervention which seeks to support such change.

Improving the wellbeing of diabetes educators

With its focus on building positivity, identification of strengths and a generally “solution-oriented” mindset, being a provider of health coaching can provide a welcome change from the often problem-focused narratives and conversations that health providers routinely engage with. In turn this likely leads to a different personal experience of professional work – one in which anecdotally, health care providers report that they experience greater levels of satisfaction, energy, compassion and engagement. This in turn leads to better client outcomes^{27, 28}

With rising occupational burnout rates in healthcare²⁹, uncovering health interventions for improving provider experience, while simultaneously protecting outcomes for clients ensures two of the four aims of the Quadruple Aim are addressed and may also lead to longer term workforce retention of valuable professional skills and experience.