Health and Wellness Coaching: An Opportunity for Clinical Exercise Physiologists

Abstract

Over the past 30 years, medical knowledge and technology in the United States has advanced in an exponential fashion. A wealth of information has been provided to the public regarding the importance of physical activity, proper nutrition, and other wellness associated behaviors that prevent and minimize the effects of chronic diseases. Paradoxically, continued patterns of deconditioning, poor food choices, and socioeconomic circumstances have combined to create an increasing trend in morbidity due to such preventable health challenges as obesity, diabetes, high blood pressure, and numerous other chronic health conditions. This has led to a drop in the US worldwide life expectancy ranking from number 16 in 1960 to 26 in 2000 and 37 in 2011 (17). Data from the Centers for Disease Control and Prevention reveals that nearly half of all adults in the United States are living with at least one chronic condition and the associated cost is staggering (4,5). As a nation, 75% of healthcare dollars in the United States goes to the treatment of chronic diseases and current costs have escalated to a crisis point, approaching 3 trillion dollars in 2013. Annual per capita healthcare expenditures now exceed $8,400 per person in the United States, while costs are less than half this amount in countries such as Japan, the United Kingdom, and South Korea, where life expectancy is higher (5). Additionally, the aging US population and the growing shortage of primary care physicians add significant strain to the nation's challenged healthcare system. Because these trends are neither affordable nor sustainable, a dramatic shift in the focus and delivery of healthcare is evolving.The change in focus is in part due to the implementation of the US Affordable Care Act and partly because there is little choice. While the Affordable Care Act encourages preventive care, the primary focus to date has been on providing insurance coverage and opinions vary widely as to whether it will ultimately succeed at improving health and lowering costs.Frequently, persistent chronic health conditions leave in their wake lifelong disability, compromised quality of life, deaths that could have been prevented, and burgeoning healthcare costs. Current research suggests that many costly chronic conditions can be reduced or prevented through meaningful behavior change (1,12,13,16,25,30,32,34,35,38). Thus it is imperative that renewed efforts emphasize and focus on helping patients make the behavioral changes needed to prevent these adverse health conditions and minimize their costly effects.Due to the rise in preventable chronic conditions, many Americans receive stern advice from their primary care provider regarding health behavior changes that they should make but rarely succeed at undertaking. Allopathic (Western) medical training focuses on the analysis of presenting clinical signs and symptoms via a detailed history and selected medical tests to allow the formation of a diagnosis. From the diagnosis and test results, a treatment plan is developed, implemented, and directed to the patient by the medical practitioner, frequently without patient input into the plan. While effective in the acute and emergency settings, this “expert” approach has had minimal impact with creating lasting health behavior change. Patient compliance is frequently stifled and desired outcomes marginalized because the person's motivation for change has been undermined by a loss of perceived autonomy. It has been observed that “people often struggle to make and sustain health-related behavior changes, even when well informed and seemingly motivated” (33). Even when it is in their own best interest, human beings tend to resist directive advice with a flurry of excuses, denial, and a desire to be autonomous. Wellcoaches® founder Meg Moore gave a fitting illustration of this scenario during a presentation, stating that “even the fear of death is a bad motivator for change. Take a smoker, for example, the doctor tells them that it's going to kill them, yet most, if not all of them will continue to light up, often within just a few hours of the conversation” (22). This expert advice is an external motivator that is rarely converted into the required internal motivation that will successfully drive lasting behavior change. Thus, in America today, less than one in 20 adults engage in the key health behaviors of regular physical exercise, abstaining from tobacco use, adequate fruit and vegetable intake, no or moderate alcohol consumption, adequate sleep, and stress management (2). While most people yearn to be energetic, well, and in charge of their health, there is a huge gap between wanting to be well and the reality of committing daily to undertaking the appropriate behaviors that support wellness.This gap was emphasized by the Bipartisan Policy Center, which demonstrated the disconnect between what Americans spend on being healthy versus what truly makes a person healthy (see Figure 1). The key drivers to optimal health include healthy behaviors (50%), environment (20%), genetics (20%), and access to medical care (10%) (3).The rising cost and prevalence of chronic conditions make it clear that the traditional medical model is not effective and needs to be redesigned to achieve better long-term outcomes. Training clinicians and allied healthcare professionals, such as clinical exercise physiologists (CEPs), in the skills associated with health and wellness coaching may be an important step toward meeting this goal. Additionally, adequate insurance reimbursement for preventive services that empower people to take an active role in their own health and well-being is imperative (33).Health and wellness coaching (H/WC) has rapidly gained traction over the past 5 to 7 yr as a collaborative, patient-focused approach that enables people to take responsibility for their health and make meaningful and lasting behavior changes. While professional coaches have long been recognized for their skills in helping athletes and executives improve their performance, the use of professional wellness coaches within the heath care setting is just beginning to blossom.The terms health coach and wellness coach are frequently used interchangeably and currently lack a clear, concise, and widely accepted definition. Since the early 1990s, a variety of H/WC definitions have been published. While the concept of coaching as “one who instructs or trains” (20) has long been established, early definitions often confused the skills associated with H/WC to those of health education and teaching. Whitmore alluded to the difference between the process of health education/teaching and that of coaching when he described coaching as a facilitated approach that assists people in maximizing their own performance by “helping them to learn rather than teaching them” (37). Palmer et al. published a 2003 article in the International Journal of Health Promotion and Education that highlighted the possible role of coaching in helping people achieve health-related goals. The authors summarized their review of coaching definitions by proposing a tentative definition of H/WC as the following:In 2010, a group from the National Consortium for Credentialing Health & Wellness Coaches (NCCHWC) arrived at the following definition:Subsequently, Wolever et al. (39) concluded that despite operational and definitional disparities, there is an “emerging consensus in what is referred to as health and wellness coaching; namely, a patient-centered process that is based upon behavior change theory and is delivered by health professionals with diverse backgrounds.” They defined the conceptual and interventional components of health and wellness coaching as the following:Based on these definitions, H/WC significantly differs from the current healthcare model of prescription, education, case management, and, in some cases, psychotherapy. Building on 50 yr of neuroscience, behavioral change, positive psychology, and adult development research, H/WC translates a formable scientific foundation into meaningful relationships that are focused on facilitating a lasting change of mind-set and behavior. H/W coaches focus on accentuating possibilities rather than problems and causes and build on client strengths rather than “fixing” weaknesses. Coaching builds on a person's intrinsic resources and strengths and supports each individual through a process of self-discovery and identifying the prime motivators that are required to realize positive change. The utilization of H/WC in healthcare has tremendous potential to help people achieve the health and well-being that many desperately desire yet are unable to successfully reach.To summarize, H/WC is a patient-focused process undertaken by health professionals, such as CEPs, who are trained and skilled in the art of facilitating sustainable health-related behavior change. Despite the potential benefits of H/WC, the lack of a standardized definition, core competencies, and nationally accredited credentialing programs currently makes its effectiveness difficult to prove.Some H/W coaches are licensed healthcare professionals, while others have very diverse backgrounds in other allied health professions, counseling, and fitness. Most have undergone some form of additional education/training, which may include a certificate of achievement and/or culminate in a certification exam. Training in H/WC competencies may significantly augment the skills of CEPs, as their typical patient/client population is referred to them due to the need to successfully change their health-related behaviors.There are numerous organizations that offer H/WC certification exams that include a broad range of training (2 h to 2 yr) requirements. This has created a challenge similar to personal training in that the public cannot distinguish between the different certifications and their widely varying requirements. Currently, H/WC certification providers lack a set of nationally agreed-upon core competencies, educational standards, and training benchmarks that support a certification accreditation process. While data trends toward supporting H/WC as part of the healthcare continuum, this lack of standardization negatively impacts the credibility of the profession and, therefore, the support of the medical provider community.There is an emerging consensus in the literature that H/WC should be provided by health professionals who have undergone additional training in the skills/techniques of coaching and behavior change. This opens up a tremendous opportunity for CEPs to obtain additional training in coaching skills that will augment their clinical experience and exercise physiology training. The National Consortium for Credentialing of Health & Wellness Coaches continues to work on a universal set of certification standards. Once developed, these standards should encompass the required education, associated critical competencies, necessary training, and standardized practice guidelines that will support the H/WC profession. A few independent organizations have developed their own standards that will hopefully be integrated into the universal set (24).Currently, the only wellness coaching certification program endorsed by the American College of Sports Medicine is provided by Wellcoaches (36). As one of the most widely recognized and accepted certifications, Wellcoaches offers two primary levels of training and certification: the Core Coach and the Professional Coach. Certification at the Core Coach level requires the completion of an 18 wk intensive and interactive training program, passage of a written exam, practical skills assessment, and the submission and review of a client case summary. Certification as a Professional Coach requires certification at the Core Coach level, completion of an intensive 9 mo training program (including two residential weekends), skill demonstration by the submission of a recorded coaching session, and a 12,500 word coaching mastery journal.Duke Integrative Medicine offers an Integrative Health Coach Professional Training program—launched in August 2008—that consists of a Foundation Course and a Certification Course (7). The Foundation Course provides training in integrative health coaching core competencies and consists of three multiday on-site learning modules. Completion of the Foundation Course is required to enroll in the Certification Course, which is a 6 mo distance learning program that culminates in certification as an integrative health coach. Applicants must hold a minimum of a bachelor's degree.These are two excellent examples of the available training/certification programs that are currently offered. However, as previously mentioned, there are numerous certifications that lack the necessary development rigor and competencies to be credible credentials. Thus, it is imperative that the H/WC profession continues to work toward implementing a nationally accepted set of standards. This will increase the credibility of the professional and allow future research protocols to utilize interventions that incorporate the standardized coaching processes/techniques that will derive meaningful outcome measurements (31).A significant and growing body of peer-reviewed literature has been published on H/WC. This literature contains numerous case reports and H/WC studies that have focused on a variety of health conditions, such as obesity, diabetes, cancer, coronary artery disease, hypertension, chronic pain, depression, arthritis, fibromyalgia, and other diagnoses. While the published data appears to support the perception that H/WC is an effective approach to help people improve their health and wellness status, the results cannot be considered definitive (39). As identified by Wolever et al., the current scientific literature is compromised due to numerous methodological concerns and variations. In a recently published systematic review of H/WC, Wolever and colleagues identified a number of significant challenges that make the literature difficult to interpret. These challenges include the following (39):Despite the aforementioned methodological challenges identified, the vast majority of the published articles show beneficial trends toward improving health status. Thus, it appears that an H/WC model focused on the patient-centered self-discovery process of developing a specific wellness vision, along with associated actionable goals and supportive accountability, may have a significant impact on a person's future health status. However, as Wolever et al. concluded, “the lack of standardization in both the definition and the operationalization of health coaching makes it difficult, if not impossible, to determine whether health coaching is indeed an effective approach to improving health behaviors and reducing the global burden of chronic disease” (39).Consistent with other healthcare professionals, CEPs often channel their education, experience, and passion for wellness into an expert approach with their patients. Often, these patients have multiple chronic conditions, are depressed, are downtrodden, and lack the self-esteem or self-efficacy to move out of the pre-contemplative or contemplative stages of change toward actually making the change. All too frequently, a CEP's clinical approach of developing and directing an appropriate interventional prescription produces marginal long-term outcomes as patient adherence tends to wane over time and the desired healthy behaviors cease. However, CEPs who channel their wellness passion into more of a patient-centered coaching approach may be able to better derive significant and lasting health behavior outcomes in their patients.One advantage that CEPs have over physicians in utilizing H/WC is that CEPs can typically meet regularly and spend more one-on-one time with patients at each visit. This flexibility is conducive to the development of a trusting, accepting relationship between the coach and the patient. This is the fundamental environment in which the coaching techniques can be successfully delivered. CEPs also have advantages over other healthcare and fitness professionals due to their advanced training in clinical exercise physiology that covers a broad spectrum of health conditions. While many CEPs have a good understanding of the trans-theoretical model of behavior change and the application of motivational interviewing, there are many other beneficial H/WC skills that can add to the clinician toolbox when faced with patients reluctant to change (21,23,27,29). By learning and applying coaching techniques, the CEP can facilitate a process that will help clients move toward the more active stages of change and goal achievement.The Journey to Wellness Program (J2W) at the Summit Medical Fitness Center (SMFC) in Kalispell, Montana, provides a wellness coaching model for patients with chronic health conditions who have been referred by their physician. This program utilizes CEPs, physicians, and other health professionals who are trained and certified wellness coaches.Because the underlying modifiable factors that need to be addressed remain fundamentally similar regardless of the condition (dietary intake, physical activity, stress modulation, sleep, social interaction, pain perception, and spiritual wellbeing), numerous condition-focused programs are not necessary. Thus, the J2W program consists of a platform that is applicable across a wide variety of chronic conditions. Patients are referred by their physicians to the primarily self-pay program, although a number of self-insured plans are now covering J2W participation. The 4 mo program includes initial and final outcome assessments, weekly coaching, use of the SMFC, and a variety of other wellness enhancement opportunities (e.g., mindfulness-based stress reduction, cooking classes/nutrition instruction, etc.). Reduced program prices in the form of “scholarships” are available for low-income individuals with medical needs.The program utilizes patient-centered H/WC to stimulate health-related behavior changes. Facilitated by the H/W coach, participants create a wellness vision, identify their personal strengths and motivators, and develop SMART (Specific, Measureable, Attainable, Realistic, Timely) program goals. Coaches establish trust and rapport with clients and use a “guiding approach” based on the seminal work of Miller and Rollnick in Motivational This each encourages and self-efficacy through the process of self-discovery of into internal A variety of wellness coaching positive and behavior change are used to the and of physical and in other health-related data is at the and the of the 3 mo program for the following is with participants able to the test without of pain or other Since patients have information is in J2W is for some and many participants have underlying disease, the program is primarily focused on the numerous other chronic health conditions. While and J2W some and both programs utilize H/WC the of a wellness and goals. Most have to a where they to the as a regular of the rather than in an additional focused achievement is a process and at a as patients through the J2W program and that in participants their goals. The of this process is an important skill and an of H/WC. While analysis has not been it appears the J2W H/WC model has been at facilitating health behavior changes and associated in clinical and behavioral outcomes. In the experience, the key has been the utilization of a patient-focused H/WC process and clinical who are trained in H/WC and these coaching rising of chronic conditions that both and all in America toward a critical need for a dramatic shift in the traditional approach to from an approach to a patient-centered H/WC model may the necessary support for people to successfully make important health-related behavior changes. trends in the current published literature to support

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