ABSTRACT: Cardiovascular disease (CVD) is the leading cause of death globally, with costs expected to increase drastically over the next few decades. Health coaching has emerged as a potential adjunct treatment option for addressing CVD risk factors. Several studies show the positive impacts of health coaching on CVD risk factors. Health coaching, however, is an unregulated term leading to immense variability in its definition. The National Board for Health and Wellness Coaching provides a credential to standardize health coaching. Pharmacists, with their unique training and accessibility, can consider broadening their practice by obtaining additional training and then expanding their scope to include health-coaching services.
Cardiovascular disease (CVD) is the leading cause of death globally, with an estimated 17.9 million deaths in 2019. Of these deaths, 85% were due to heart attack or stroke.1 CVD is a broad term that encompasses an array of disorders affecting the heart and blood vessels. CVD disorders include coronary heart disease (CHD), cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, deep vein thrombosis, and pulmonary embolism.1 Risk factors for CVD are numerous and include diet, physical activity, dyslipidemia, prediabetes/diabetes, high blood pressure, obesity, age, race, sex, thrombosis history, kidney dysfunction, smoking status, and genetics.2
In 2020, one in three adults received care for a cardiovascular (CV) risk factor or condition. Healthcare costs of CV risk factors are projected to triple between 2020 and 2050—from $400 billion to $1,344 billion. For CV conditions, annual healthcare costs are projected to almost quadruple, from $393 billion to $1,490 billion, with stroke projected to account for the largest absolute increase in costs.3
Given these alarming statistics facing the future of healthcare, it is crucial to consider modifiable CV risk factors. At its core, a healthy lifestyle can make a significant impact on many of the CV risk factors. The challenge lies in how healthcare providers can effectively encourage their patients to adopt a healthy lifestyle. The World Health Organization states that simply giving information is unlikely to change behavior, implying that providers must go beyond traditional patient counseling. To achieve the sustainable health behavioral changes and outcomes, patients need support through behavioral change techniques that promote self-determination, autonomy, self-efficacy, and relatedness. Health coaching has emerged to fill the gap in care by using evidence-based health behavior change interventions, the Transtheoretical Model, and psychological principles to help patients transform from not wanting or knowing how to make to make behavioral changes to sustaining new healthy lifestyle practices.4
Health coaching, also referred to as life coaching, wellness coaching, or health and wellness coaching, has emerged as an intervention for individuals with chronic diseases or those who are seeking to prevent them. It aims to improve a patient’s quality of life and health outcomes.5 Health coaching goes beyond traditional patient counseling to encompass a more comprehensive and patient-centered approach. The definition of health coaching has evolved over time from “the practice of health education and health promotion within a coaching context, to enhance the well-being of individuals and to facilitate the achievement of their health-related goals” to “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.” A health coach is a healthcare professional who is trained in behavior change theory, motivational strategies, and communication techniques, which are used to assist patients to develop intrinsic motivation and obtain skills to create sustainable change for improved health and well-being.6
Despite its growing popularity, there is significant variability in the definitions of health coach and health coaching in the literature. In fact, the label “health coach” is an unregulated term, allowing for broad interpretations across various sources. To address this issue, the National Board for Health and Wellness Coaching (NBHWC) is striving to standardize health coaching by offering a pathway to a credible, recognizable credential that validates a coach’s training and expertise. The National Board Certified Health & Wellness Coach (NBC-HWC) credential is available to coaches who have met the eligibility requirements and have passed a rigorous examination. Eligibility criteria for examination include having a baseline associate’s degree or higher level of education, completion of one of 138 approved health and wellness coaching programs across the country, and completing 50 coaching sessions. To date, over 11,000 coaches possess the credential of NBC-HWC.7
Models of health coaching exhibit some variability as well; however, several common elements are typically present. Health coaching is patient centered, relying on patients determining their own health goals by taking an active learning role in the process through self-monitoring and acquiring health education.8 One type of health coaching, Integrative Health Coaching (IHC), is a standardized process developed at Duke Integrative Medicine and the University of Minnesota. IHC follows a structured process model that guides patients from envisioning their best self to the maintenance of achieved goals over time. This process involves self-identification of goals and action steps that reflect patients’ vision and values, aligning with their concept of their best self.8
Health coaching incorporates various skills that healthcare providers may already be familiar with, such as goal setting, effective questioning, overcoming setbacks, mindful awareness, motivational interviewing, appreciative inquiry, and stages of change theory, among others.6 What distinguishes health coaching is its comprehensive use of multiple health psychology and behavioral principles, combined with various skills from performance and development coaching. Health coaching is not serving as a mentor, educator, or expert. Instead, coaches create a nonjudgmental space by radiating compassion, expressing empathy, honoring silence, creative brainstorming, and providing the gift of positive affirmations. This integration allows health coaching to move beyond individual theories or skills and guides the patient through the process of change from beginning to end.8,9 Such an approach is particularly well-suited for the complex nature of CVD management, wherein long-term lifestyle modifications are often crucial for improved outcomes.
Evidence for Health Coaching
The Coaching patients On Achieving Cardiovascular Health (COACH) study explored the outcomes associated with health coaching in patients with established CHD. The COACH study was designed to determine if dieticians or nurses, who could not prescribe medications, could effectively coach patients with CHD to work with physicians to achieve target cholesterol levels and other CVD risk factors. The trial was conducted as a multicenter randomized, controlled trial involving 792 patients across six university teaching hospitals in Australia. Eligible patients needed to have been hospitalized for coronary artery bypass graft surgery, percutaneous coronary intervention, acute myocardial infarction, unstable angina on medication therapy, or coronary angiography with planned elective revascularization. The coaches underwent a part-time training program for 2 weeks prior to the start of the study. Initial coaching visits had a median duration of 30 minutes, with subsequent calls at 6-week intervals averaging 20 minutes. For the primary outcome of mean reduction in total cholesterol (TC) from baseline to 6 months after randomization, there was a statistically significant difference of 21 mg/dL in the COACH group compared with 7 mg/dL in the usual-care group.
The limitation of these results is the composite influence of other factors that can impact TC changes, including the medication prescribed by the physician, baseline TC level, baseline fasting glucose level, reduction in saturated fat intake, and reduction in body weight. For secondary outcomes, the COACH program showed a significant impact on a reduction of calculated LDL cholesterol, body weight, BMI, anxiety level, and changes to dietary patterns, including decreased intake of total fat, saturated fat, and cholesterol and an increase in fiber consumption. There was no impact of the COACH program on fasting glucose, smoking behavior, depression, triglycerides, or HDL cholesterol.10
In a follow-up study, the COACH program demonstrated that the changes in coronary risk factors achieved at 6 months were sustained for at least 18 months after the program’s completion.11 The COACH program utilized in this study demonstrated the substantial potential for improving health outcomes in patients with CHD, making it a valuable strategy to bridge the treatment gap between usual patient counseling and a health-based coaching program. While the COACH study focused specifically on CHD, the broader application of health coaching extends to patients with various CV risk factors.
The application of health coaching to patients with or at risk of CVD can target various endpoints. A meta-analysis examined the impact of health coaching on patients with CVD risk factors across various outcomes. The review included 15 studies published between 2003 and 2018, involving 4,254 patients aged older than 18 years with established CV risk factors. Outcomes focused on specific cardiac health behaviors, including physical activity (11 studies), dietary behaviors (nine studies), health responsibilities (four studies), stress management (five studies), and smoking behaviors (three studies). The studies showed significant variation among the clinical background of the health coaches, the delivery method of the coaching, and the duration and frequency of the coaching sessions. Overall pooled analysis revealed that health coaching had a small but statistical impact on physical activity, dietary behaviors, health responsibility, and stress management; however, there was no statistical significance between the use of health coaching and usual care on smoking status in this review.12 These findings suggest that health coaching has the potential to impact multiple CVD risk factors in patients with established CVD risk factors. Weighing the potential benefit to the minimal risk health coaching carries, it is reasonable to consider a treatment approach that includes health coaching for overall CVD risk reduction.
The potential impact of health coaching extends beyond direct CVD management and can address various conditions that serve as risk factors for CVD. Numerous studies in the literature highlight the effectiveness of health coaching on chronic disease states that significantly contribute to CV risk. By targeting these underlying risk factors, health coaching offers a comprehensive approach to CVD prevention and management, potentially reducing the overall burden of CVD.
Cost
With healthcare costs projected to rise significantly between 2020 and 2050, health coaching shows potential to positively impact the bottom line, though results vary across studies. In Australia, the COACH program demonstrated promising outcomes when implemented in a health benefits organization with 4 million members nationwide. The study evaluated the long-term impact of the COACH program on survival, hospital utilization, and costs in patients with CVD between those who received coaching with the COACH program and those who did not. The study included 1,024 patients total, with 512 matched patients in each group. The results showed a statistically significant absolute reduction in all-cause mortality of 5.08% in the COACH group, with 86 deaths in the COACH group compared with 112 deaths in the control group.
While there was no difference in hospital utilization, the average program cost per COACH participant was $592. Over the mean follow-up period, the healthcare costs to the insurer per COACH participant were $12,707 lower than the control group; however, this was not considered statistically significant (P = .078). After accounting for program costs, the average net cost savings were $12,115 per person. Further subgroup analyses revealed a statistically significant cost difference for patients receiving four or more coaching sessions (COACH: $42,307 vs. usual care: $61,725; difference: $19,418 per person, P = .006) and for male participants (COACH: $47,680 vs. usual care: $66,627; difference: $18,947 per person, P = .029).13 This study depicts the cost impact of a specific health coaching program, demonstrating its potential to reduce healthcare expenses and improve patient outcomes specifically in patients who were male and received more coaching sessions; however, it is important to note that while overall cost savings were considerable, they were not statistically significant in this study population.
Although the COACH study found cost benefits, not all studies show a cost benefit with health coaching. The Health Coaching in Primary Care study was a randomized, controlled trial testing the efficacy of health coaching versus usual care in low-income patients with CVD risk factors including diabetes, hypertension, and hyperlipidemia. At 12 months, the health coaching group was more likely to control one or more health conditions.14 Although there was a clinical benefit, this did not transfer to a net cost savings. The study found that the costs associated with health coaching provided by a medical assistant salaried at $19 per hour plus benefits did not translate to a difference in average 1-year healthcare costs. The final results of the study showed that the average 1-year healthcare costs for patients in the coaching group were $3,207 compared with $3,276 for the control group. The study notes that the time cost analysis only covered a 1-year period, and it may have failed to account for downstream savings that take a longer period of time to manifest. It was also a smaller study including 441 total patients and three health coaches.14
A larger study, with 1,161 high-risk health enrollees participating in health coaching for at least 4 weeks, showed a decrease in inpatient, emergency department, outpatient, and prescription claims. The results showed that there was a decrease in outpatient costs in the health coaching group while there was an increase in these costs in the control group. The predicted average monthly outpatient savings were determined to be $286 per person with a total cost savings of $412 per person participating in health coaching.15
As a whole, these cost savings studies demonstrate that health coaching provides clinical benefits in CVD; however, there are conflicting data on cost savings to justify the inclusion of the program. It is important to note that these studies occurred prior to approval of Current Procedural Terminology (CPT) codes in January 2020. To finance health and wellness coaching, various payment models can be considered, including medical practices billing patients directly for services, medical practices receiving monthly value-based care payments, payment based on utilization of CPT codes, negotiations with payers directly, and utilization of funds from health savings accounts or flexible spending accounts.16 With a variety of payment models available to sustain health-coaching initiatives, the clinical benefits that health coaching have demonstrated, and the rising costs associated with CVD, health coaching is a promising approach to achieve sustainable health behavioral changes to reduce CVD risk.
Application to Pharmacy Practice
For health coaching to meet its maximum potential, qualified individuals need to provide the coaching. Pharmacists should not exclude themselves from offering this valuable service, as they are uniquely positioned to excel as health coaches due to their extensive knowledge of medications, disease states, and communication skills. Their unique blend of expertise is ideally suited to bridge the gap between traditional patient counseling and personalized health coaching. The accessibility of community pharmacists acts as a strength for health coaching and allows for regular follow-up and consistent support, which are crucial elements of effective health coaching. In ambulatory care settings, pharmacists are already working with patients to reach specific healthcare goals through patient medication management. Adding health coaching to their practice is an ideal fit to complete a comprehensive and patient-centered approach to health management. By leveraging their expertise, accessibility, and patient rapport, pharmacists can take the next steps to becoming health coaches, with a final result of contributing to improved CV health outcomes and reduced healthcare costs.
