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Veteran-Centered Primary Care Collaborative: Adding Health Coaches to Primary Care in the VA

Updated: May 13, 2020

Most everyone knows how much the veteran community means to me, and now that I'm a health coach, especially in the midst of a pandemic, I feel it's more necessary to advocate for them more than ever.

Recently, I wrote a letter to congress to explain why I believe Health Coaching should be added to the primary and preventive care teams in a primary care collaborative for the benefit of veteran patients in the VA medical healthcare system. Honestly, I believe health coaches should be in a primary care collaborative program all over the country, but I feel it's my dharma to push getting them in the VA.

It is well known that the cost of healthcare in the United States is poor value proposition. According to the CDC, nearly 78 million Americans are obese (2014), and the Veterans Affairs estimated nearly 80 percent of veterans are overweight and obese. One of the successful yet underutilized remedies for obesity-related disease is behavior change in the form of dietary and/or activity modifications. Health Coaching improves the management of chronic diseases as well as save cost.

Now, let's assess the potential benefits of adding a health coach to the primary care practice in the Veterans Affairs Healthcare System, both financial and clinical. Many provisions of the healthcare reform law, Patient Protection and Affordable Care Act (PPACA) of 2010, is to provide opportunities for healthcare organizations to provide or implement innovative programs that have a potential to improve the coordination of care, reduce cost, improve efficiency, reduce unnecessary hospitalization/readmission, and improve the quality of care (Goodson 2010; Holtrop and Jordan 2010).

These programs include Accountable Care Organizations, bundled payment, value-based purchasing, clinical integration, and the patient-centered medical home (Shoemaker 2010). Based on the enormous financial and societal costs that patients with chronic diseases impose on the U.S. economy (Partnership to Fight Chronic Disease 2008), a majority of researchers recommend that patients with chronic disease be treated at the primary care practice setting while developing effective and efficient patient-centered medical homes (Patient-Centered Primary Care Collaborative 2007). Recent studies showed that it requires 21.7 working hours per day to meet the chronic, preventive, and acute care needs of a panel of 2500 patients at a primary care practice (Ostbye et al. 2005). There is an urgent need of change in the health professional role managing patients with chronic illness (such as diabetes) toward personalized treatment strategies that should take into account patient preferences, readiness to change their lifestyle, and psychosocial variables (Wolever et al. 2010, Kahn and Anderson 2009).

A possible solution to remedy this situation is the development and implementation of a health coach function. Health coaches educate patients and help them build skills and confidence they need to reach their own health goals while providing emotional support and practical assistance that is needed among patients living with chronic illness (Palmer, Tibbs, and Whybrow 2003). The health coach is typically a nurse or other medical professional who supports the physician and the patient by meeting established care goals.

Health coaching works. A 2014 systematic literature review concluded that among adults with chronic diseases, health coaching leads to statistically significant improvements in weight management, physical activity, physical and mental health status. How is this accomplished? Well, a good health coach will take time to get to know a client and his/her goals and help formulate a plan to help reach those goals. The right coach will guide clients to make well defined, measurable goals, and will keep clients on track by holding them accountable for making forward progress. Health coaching that achieves lasting results uses a personalized approach that fits each individual’s unique life circumstances.

Physicians are not trained to help patients change behavior.  As doctors, we are primarily taught how to diagnose and treat disease. And although we are great at recommending patients lose weight, exercise more, or eat a healthy diet, we typically offer little advice on how to accomplish this beyond join a gym or see a nutritionist…

…know that some insurance companies offer health coaching as a covered benefit, so advise patients to check there first. Most health insurance, however, does not currently cover health coaching, in which case patients can expect to pay anywhere from $45 to $110 or more per session.” 

The results from this systematic review indicated that health coaching produced positive effects on patients’ behavioral, psychological, and physiological conditions on their social life. It also revealed statistically significant results in improved physical activity and better weight management that resulted in significant improvement in physical and mental health status (Kivela, Elo, Kyngas, and Kaarianinen 2014).

One of the primary goals of the healthcare reform act is to reduce cost while improving healthcare quality. The long-term cost effects of health coaching have not yet been researched, but it is predicted to be cost-effective for the long-term due to the long-term lifestyle changes and the effectiveness of chronic disease practice implications. Most middle-class citizens cannot afford private health insurance without it being provided through their employer. Veterans that are not covered by their employer or disabled do not have health insurance other than the VA healthcare system and Tricare, neither of which provide health coaching services to veterans. Veterans nor civilians can afford private health coaching and it should not be limited to just the upper class. Health coaching should be taught as a basic course in schools (it is education our country lacks, much like basic life skills) but should especially be delivered to patients who are immunocompromised due to obesity related disease. Obesity, and most obesity related disease can be reversed. Studies have shown that coaches help identify barriers to behavior change, set health-related goals and make realistic plans for reaching these goals by listening, asking open question, supporting and providing feedback.

Obesity results from a combination of causes and contributing factors, including, but not limited to, individual factors such as behavior and genetics. Behaviors can include dietary patterns, physical activity or inactiviry, medication use, and exposures to various environmental factors. Additional contributing factor in America include physical activity environment, education skills, and food marketing promotion.

Obesity is a risk factor for heart disease, type 2 diabetes, stroke, and some types of cancer. In particular, diabetes and obesity have become very prevalent. According to the VA Office of Research and Development, over 165,000 veterans who receive health care from the VA Healthcare system have a BMI of 40 percent or more, which indicates morbid obesity. This can interfere with basic physical functions and significantly increase the risk of obesity-related conditions.

It was assessed by the VA Puget Sound Health Care System that obese people who followed a six-month diet program lost a significant amount of weight (2002). Research for gastric bypass was performed with the intention that it would decrease the stomach’s normal ghrelin secretion, but findings proved that ghrelin level return to close to normal in patients with gastric bypass in the long run. Other studies were performed to evaluate and assess episodic memory and fat cell metabolism. The new method of treating obesity with bariatric surgery proved to be helpful but did not benefit patients in the long-term. Rapamycin was another alternative to remedy obesity by targeting fat cells, allowing lean mass retention, but it was also not a long-term solution.

In that study, it was also brought to light that patients felt judged by their primary care provider, assuming physicians would see them as lazy and undisciplined. As a result, patients would not show for their follow-up appointments. The researchers believe that doctors should discuss weight issues, but in a less judgmental, more affirming way. Incentive programs were created and designed to increase weight loss, but the results did not prove effective.

A large majority of veterans seeking care through the VA Healthcare system have diabetes or obesity-related chronic illness. Michaeal E Debakey VA Medical Center in Houston presented preliminary findings of an ongoing clinical trial indicating that a healthier diet and exercise routine help older overweight adults with Type 2 diabetes improve their glucose control, body composition, and physical function, and bone density. They did this through record of all food and drink consumption, and weight counseling. At the six-month mark of a yearlong study, all patients preserved their lean body mass and their physical performance test and peak aerobic capacity improved more so than the gastric binding patients.

VA MOVE! Programs throughout the nation offer classes that include exercise and nutrition courses to help veterans develop weight management skills. This also proved helpful and positive results toward weight loss.

In Chicago, the Jesse Brown VA Medical Center found that regular thirty-minute phone calls from a trainer/coach resulted in significant weight loss for disabled patients. More than 100 participants with limited mobility received a web-based remote coaching tool. Of those who received the toolkit lost an average of 5 pounds. Whereas the participants who did not receive any coaching gained an average of 5-6 pounds. Half of the veterans in the study were give a PDA on which they recorded food/calorie intake, physical activity, mood, and pain intensity. This group also received regular telephone support every other week for six months. Weight loss among the group using PDAs was greater than the control group at three months, six months, nine months, and a year.

Studies from the San Francisco VA Medical Center also found high rates of obesity among Iraqi and Afghanistan veterans- the highest rates being among veterans with PTSD and/or depression. They also found that veterans with PTSD and depression were at greater risk of being obese and being unable to lose weight.

Currently, the world is in the midst of the SARS-CoV-2 virus (the virus that causes COVID-19) crisis, holistic health is important as ever! According to CDC, based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19. The underlying medical conditions include:

  • People with chronic lung disease or moderate to severe asthma

  • People who have serious heart conditions

  • People who are immunocompromised

  • Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications

  • People with severe obesity (body mass index [BMI] of 40 or higher)

  • People with diabetes

  • People with chronic kidney disease undergoing dialysis

  • People with liver disease

In 2013, VA estimated that more than 165,000 Veterans who receive their health care from the department have a BMI of more than 40, which indicates morbid obesity. This interferes with basic physical functions and significantly increase the risk of obesity-related conditions (Health Services Research & Development). Our biggest defense is our immune systems and with an 80 percent veteran population with obesity related disease (all of the people that are affected by the Coronavirus according to the CDC), there is a need to change the way medicine is practiced within the VA. With a growing awareness of nutrigenomics- the potential for modifications of food or diet to support health and reduce risk of obesity-related diseases (Neeha and Kinth 2012), health coaches can support the efficiency and effectiveness of proper nutrition to reduce disease.

Modern medicine treats symptoms, prescribing medications, rarely treating the root cause of illness. Food is medicine! Not just the food we put on our plates, but also Primary foods. (Circle of Life)

In regard to the current state of America with the threat of the Coronavirus (COVID-19) as it spreads throughout Texas, it is recommended by the CDC to maintain good hygiene and improve and/or maintain healthy immunity. There is no better time to implement innovative programs such as health coaching to combat this pandemic, especially amongst our veteran community.

Chronic diseases, such as cardiovascular disease, diabetes, cancer and chronic respiratory disease, have a slow progression and last a long time. They account for more than 60% of all deaths in the world, and a large proportion of these account for people under 60 years of age. Economic transition, rapid urbanization and poor lifestyle choices such as tobacco use, poor diet, insufficient physical activity and excessive alcohol are among risk factors that contribute to chronic disease.

Health coaching is a single patient education method that can improve the quality and cost-effectiveness of chronic disease management for veterans. Health coaching can motivate and enhance the wellbeing of patients and facilitate the achievement of their health-related goals. The purpose of health coaching is to improve patients’ health and improve their quality of life. The role involves listening, understanding, facilitating, applauding, supporting, motivating and providing feedback to change their behavior.

Health coaching can be provided through virtual media such as telephone, internet, email, or face-to-face. It was proven to be most effective in a six-month program. Nurses were the most widely used source of health coaching, but were also provided by dieticians, psychologists, social workers, physical therapists, qualified fitness professionals, health lifestyle coaches, and education coaches.

In that systematic review, health coaching proved to improve areas of physiological outcomes, decreasing pain, reducing symptoms of medical diabetes, and decreasing dyspnea. The most significant behavioral outcomes were the readiness to change, smoking, and alcohol consumption. Type 2 diabetes patients self-care behaviors strengthened, diets improved, foot care increased, and there was a significant reduction in medication adherence. The psychological outcomes showed an improvement in vitality, mental health, and lowered depressive and stress symptoms. Social outcomes include physicians communicating more details about the patient’s health and referred them to a specialist more often. Health care teams gave more support over a 6-month program and provided more social resources compared to the control group.

The most significant of the outcomes were weight loss, improved physical health status and the reductions in weight were obtained in all of the studies in which it was measured. All of the results of the studies were encouraging and indicated that health coaching has positive effects on adults with chronic diseases. The findings supported the effectiveness of chronic disease management, weight management, physical health status, and indicated that health coaching improves patients’ behavior and self-efficacy and mental health status. Health coaches have demonstrated to play an important role in assessing treatment, identify barriers, set health-related goals, make realistic plans and goals by listening, asking high-mileage questions, supporting and providing feedback.