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Research ArticleOriginal ResearchA

Health Coaching by Medical Assistants to Improve Control of Diabetes, Hypertension, and Hyperlipidemia in Low-Income Patients: A Randomized Controlled Trial

Rachel Willard-Grace, Ellen H. Chen, Danielle Hessler, Denise DeVore, Camille Prado, Thomas Bodenheimer and David H. Thom
The Annals of Family Medicine March 2015, 13 (2) 130-138; DOI: https://doi.org/10.1370/afm.1768
Rachel Willard-Grace
1Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
MPH
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  • For correspondence: willardr@fcm.ucsf.edu
Ellen H. Chen
1Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
2Silver Avenue Family Health Center, San Francisco Department of Public Health, San Francisco, California
MD
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Danielle Hessler
1Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
PhD, MS
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Denise DeVore
1Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
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Camille Prado
1Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
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Thomas Bodenheimer
1Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
MD, MPH
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David H. Thom
1Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
MD, PhD
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    Figure 1

    CONSORT diagram.

    appt = appointment; CONSORT = Consolidated Standards of Reporting Trials.

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    Table 1

    Training of Health Coaches: Topics and Skills

    Collaborative communication
    Eliciting patient knowledge and motivation
    Closing the loop (teach back)
    Setting the agenda
    Reviewing laboratory numbers
    Action plans
    Assessing patient motivations
    Exploring ambivalence
    Disease-specific knowledge
    Basics of study conditions
    Monitoring control
    Medication management
    Medication adherence
    Assessing patient knowledge and motivation
    Addressing barriers to adherence
    Working with primary care clinicians
    Taking notes during a visit
    Checking understanding
    Offering help
    Advocating for a patient’s agenda
    Community and clinic resources
    Behavior health
    Physical activity and healthy eating
    Smoking cessation
    Social determinants of health
    • View popup
    Table 2

    Characteristics of Participants, Overall and by Study Arm

    CharacteristicAll Participants (N = 441)Study Arm
    Usual Care (n = 217)Health Coaching (n = 224)
    Demographic characteristics
    Clinic site, % (No.)
     Clinic site A75.3 (332)76.0 (165)74.6 (167)
     Clinic site B24.7 (109)24.0 (52)25.4 (57)
    Age, mean (SD), y52.7 (11.1)52.9 (11.5)52.6 (10.7)
    Sex (female), % (No.)55.3 (244)52.2 (127)58.5 (117)
    Married/long-term relationship, % (No.)53.1 (234)57.1 (124)49.1 (110)
    Born in the United States, % (No.)25.6 (113)24.9 (54)26.3 (59)
    Years in United States, mean (SD)a18.2 (11.2)17.9 (11.9)18.5 (10.4)
    Primary language, % (No.)
     English27.7 (122)26.7 (58)28.6 (64)
     Spanish68.7 (303)69.5 (151)67.9 (152)
     Other3.6 (16)3.7 (8)3.6 (8)
    Race/ethnicity, % (No.)
     Asian4.1 (18)5.1 (11)3.1 (7)
     African American19.0 (84)18.4 (40)19.6 (44)
     Latino or Hispanic70.1 (309)71.0 (154)69.2 (155)
     White2.5 (11)2.3 (5)2.7 (6)
     Other4.3 (19)3.2 (7)5.4 (12)
    Working status, % (No.)
     Full time18.6 (82)16.1 (35)21.0 (47)
     Part time25.6 (113)26.3 (57)25.0 (56)
     Homemaker13.8 (61)17.1 (37)10.7 (24)
     Unemployed16.1 (71)16.1 (35)16.1 (36)
     Retired/disabled/SSI/other25.9 (114)24.3 (53)27.2 (61)
    Education, % (No.)
     ≤5th grade22.7 (100)23.1 (50)22.3 (50)
     6th to 8th grade21.1 (93)20.7 (45)21.4 (48)
     Some high school13.4 (59)12.4 (27)14.3 (32)
     High school graduate or GED17.7 (78)16.6 (36)18.8 (42)
     Some college15.6 (69)19.4 (42)12.1 (27)
     College graduate9.5 (42)7.8 (17)11.2 (25)
    Income, % (No.)
     ≤$5,00034.0 (150)31.3 (68)36.6 (82)
     $5,000–$10,00024.3 (107)25.3 (55)23.2 (52)
     $10,000–$20,00029.5 (130)29.0 (63)29.9 (67)
     ≥$20,00012.2 (54)14.2 (31)10.2 (23)
    Number of PCP visits in year before study, mean (SD)5.4 (3.9)5.5 (4.3)5.4 (4.1)
    Clinical characteristics
    BMI, mean (SD), kg/m231.4 (6.7)31.4 (6.3)31.5 (7.0)
    HbA1c, mean (SD), %b9.9 (1.5)10.0 (1.4)9.8 (1.5)
    LDL cholesterol, mean (SD), mg/dLb147.0 (35.6)147.8 (34.1)146.3 (36.9)
    SBP, mean (SD), mm Hgb159.4 (15.4)160.9 (16.8)157.7 (13.5)
    Uncontrolled at baseline, % (No.)
     For 1 condition72.6 (320)73.3 (159)71.9 (161)
     For 2 conditions23.6 (104)23.5 (51)23.7 (53)
     For 3 conditions3.9 (17)3.2 (7)4.5 (10)
     For HbA1c35.8 (158)33.6 (73)37.9 (85)
     For SBP43.5 (192)46.5 (101)40.6 (91)
     For cholesterol51.9 (229)49.8 (108)54.0 (121)
    • BMI = body mass index; GED = general equivalency diploma; HbA1c = hemoglobin A1c; LDL = low-density lipoprotein; PCP = primary care provider; SBP = systolic blood pressure; SSI = supplemental security income.

    • ↵a For the 328 participants born outside the United States.

    • ↵b Includes only patients qualifying for the study on this measure (158 for HbA1c, 218 for LDL, and 192 for SBP).

    • View popup
    Table 3

    Characteristics of Participants, Overall and by Clinic Site

    CharacteristicAll Participants (N = 441)Clinic Site
    Clinic Site A (n = 332)Clinic Site B (n = 109)P Value
    Demographic characteristics
    Age, mean (SD), y52.7 (11.1)52.3 (11.3)54.0 (10.5).18
    Sex (female), % (No.)55.3 (244)53.3 (177)61.5 (67).14
    Born in the United States, % (No.)25.6 (113)6.0 (20)85.3 (93)<.001
    Primary language, % (No.)<.001
     English27.7 (122)7.8 (26)88.1 (96)
     Spanish68.7 (303)89.5 (297)5.5 (6)
     Other3.6 (16)2.7 (9)6.4 (7)
    Race/ethnicity, % (No.)<.001
     Asian4.1 (18)3.3 (11)6.4 (7)
     African American19.0 (84)1.8 (6)71.6 (78)
     Latino or Hispanic70.1 (309)90.7 (30)7.3 (8)
     White2.5 (11)1.5 (5)5.5 (6)
     Other4.3 (19)2.7 (9)9.2 (10)
    Working status, % (No.)<.001
     Full time18.6 (82)22.0 (73)8.3 (9)
     Part time25.6 (113)28.0 (93)18.3 (20)
     Homemaker13.8 (61)16.9 (56)4.6 (5)
     Unemployed16.1 (71)13.6 (45)23.9 (26)
     Retired/disabled/SSI/other25.9 (114)19.5 (65)44.9 (49)
    Education, % (No.)<.001
     ≤5th grade22.7 (100)29.6 (98)1.8 (2)
     6th to 8th grade21.1 (93)27.1 (90)2.8 (3)
     Some high school13.4 (59)11.1 (37)20.2 (22)
     High school graduate or GED17.7 (78)14.2 (47)28.4 (31)
     Some college15.6 (69)9.9 (33)33.0 (36)
     College graduate9.5 (42)8.1 (27)13.8 (15)
    Income, % (No.).52
     ≤$5,00034.0 (150)33.7 (112)34.9 (38)
     $5,000–$10,00024.3 (107)23.8 (79)25.7 (28)
     $10,000–$20,00029.5 (130)31.0 (103)24.8 (27)
     ≥$20,00012.2 (54)11.4 (38)14.7 (16)
    Clinical characteristics
    BMI, mean (SD), kg/m231.4 (6.7)30.6 (4.7)34.0 (10.2)<.001
    HbA1c, mean (SD), %a9.9 (1.5)9.8 (1.4)10.3 (1.9).17
    LDL cholesterol, mean (SD), mg/dLa147.0 (35.6)147.3 (36.7)145.2 (28.9).75
    SBP, mean (SD), mm Hga159.4 (15.4)158.3 (13.5)160.9 (17.5).25
    Number of PCP visits in year before study, mean (SD)5.4 (4.1)5.2 (3.5)6.1 (5.5)<.05
    Number of coach interactions, mean (SD)12.4 (7.4)14.1 (6.7)7.6 (7.2)<.001
    Total time interaction, mean (SD), min540.8 (307.6)621.1 (281.1)305.5 (258.7)<.001
    Number of interactions by topic/activity addressed, mean (SD)
     Medications9.3 (6.0)11.0 (5.4)4.1 (4.6)<.001
     Reviewing clinical values and goals7.4 (4.6)8.4 (3.9)4.5 (5.2)<.001
     Discussing lifestyle changes7.4 (5.0)9.1 (4.3)2.1 (2.2)<.001
     Agenda setting5.7 (4.3)7.1 (4.1)1.7 (1.9)<.001
     Navigational support5.1 (5.1)6.4 (5.3)1.5 (1.8)<.001
     Action plans for behavior change4.2 (3.2)5.1 (2.9)1.6 (2.3)<.001
     Facilitating communication with PCP3.3 (3.8)4.0 (4.1)1.1 (1.5)<.001
     Closing the loop (teach back)5.3 (3.6)6.1 (3.3)2.8 (3.4)<.001
    Patient-reported quality of health-coaching interactions, mean (SD)b3.3 (0.7)3.4 (0.5)2.8 (0.9)<.001
    Patient-reported trust in health coach, mean (SD)c4.1 (0.5)4.1 (0.5)3.9 (0.7)<.005
    • BMI = body mass index; GED = general equivalency diploma; HbA1c = hemoglobin A1c; LDL = low-density lipoprotein; PCP = primary care physician; SBP = systolic blood pressure; SSI = supplemental security income.

    • ↵a Includes only patients qualifying for the study on this measure (158 for HbA1c, 218 for LDL cholesterol, and 192 for SBP).

    • ↵b On a scale of 1 to 5, where 5 = best.

    • ↵c On a scale of 1 to 5, where 5 = high.

    • View popup
    Table 4

    Primary Composite and Condition-Specific Outcomes by Study Arm, for Total Sample and by Clinic Site

    OutcomeHealth Coaching, % (No./n)Usual Care, % (No./n)Difference, % (95% CI)P Value
    Total sample
    Composite (primary)a46.4 (90/194)34.3 (57/166)12.1 (2 to 23).02
    Composite (secondary)b34.0 (66/194)24.7 (41/166)9.3 (1 to 19).05
    HbA1c goal achievedc48.6 (36/74)27.6 (16/58)21.0 (5 to 39).01
    Cholesterol goal achievedd42.7 (41/96)32.0 (24/75)10.7 (−4 to 25).15
    SBP goal achievede23.8 (19/80)28.9 (22/76)−5.1 (−9 to 19).46
    Clinic site A
    Composite (primary)a49.7 (73/147)32.8 (42/128)16.9 (5 to 29).01
    Composite (secondary)b36.1 (53/147)24.2 (31/128)11.9 (1 to 23).03
    HbA1c goal achievedc52.3 (34/65)29.4 (15/51)22.9 (5 to 41).01
    Cholesterol goal achievedd41.8 (33/79)25.4 (16/63)16.4 (1 to 32).04
    SBP goal achievede25.5 (12/47)31.9 (15/47)−6.4 (−11 to 25).49
    Clinic site B
    Composite (primary)a36.2 (17/47)39.5 (15/38)−3.3 (−17 to 24).76
    Composite (secondary)b27.7 (13/47)26.3 (10/38)1.4 (−18 to 20).89
    HbA1c goal achievedc22.2 (2/9)14.3 (1/7)7.9 (−31 to 46).69
    Cholesterol goal achievedd47.1 (8/17)66.7 (8/12)−19.6 (−18 to 56).29
    SBP goal achievede21.2 (7/33)24.1 (7/29)−2.9 (−18 to 24).78
    • HbA1c = hemoglobin A1c; HDL = high-density lipoprotein; LDL = low-density lipoprotein; SBP = systolic blood pressure.

    • Note: Analyses used missing-at-random (nonimputed) data. See statistical analysis in Methods section for details.

    • ↵a Achieved target for control of 1 or more of specific conditions for which patient was uncontrolled at baseline.

    • ↵b Achieved target for control of all conditions for which patient was uncontrolled at baseline.

    • ↵c Goal was <8.0%.

    • ↵d Goal for diabetic patients was LDL cholesterol <100 mg/dL or non–HDL cholesterol <130 mg/dL if triglycerides >400 mg/dL, and for nondiabetic patients was LDL cholesterol l<130 mg/dL or non–HDL cholesterol <160 mg/dL if triglycerides >400 mg/dL.

    • ↵e Goal was <130 mm Hg for diabetic patients and <40 mm Hg for nondiabetic patients.

    • View popup
    Table 5

    Secondary Condition-Specific Outcomes by Study Arm, for Total Sample and by Clinic Site

    OutcomeHealth Coaching Usual Care Difference Between Arms (95% CI)P Value
    nBaseline, Mean (SD)12 Months, Mean (SD)DIMnBaseline, Mean (SD)12 Months, Mean (SD)DIM
    Total sample
    HbA1c, %749.8 (1.5)8.6 (2.0)−1.2589.9 (1.4)9.4 (2.0)−0.5−0.7 (−1.4 to 0.0).06
    LDL, mg/dL95147.2 (36.3)119.3 (52.8)−27.973143.4 (33.2)125.4 (39.1)−18.1−9.8 (−21.6 to 2.0).10
    SBP, mm Hg80157.3 (13.8)148.7 (16.5)−8.676160.5 (16.4)150.3 (18.2)−10.21.6 (−7.6 to 4.4).59
    Clinic site A
    HbA1c, %659.8 (1.5)8.5 (2.0)−1.3519.8 (1.4)9.3 (2.0)−0.6−0.7 (−1.4 to −0.0).04
    LDL, mg/dL79148.2 (38.3)122.6 (55.1)−25.662145.0 (35.0)130.5 (37.6)−14.5−11.1 (−23.9 to 1.7).09
    SBP, mm Hg47154.9 (10.5)144.8 (12.5)−10.047160.5 (15.1)148.5 (18.9)−12.02.0 (−5.1 to 9.0).59
    Clinic site B
    HbA1c, %910.2 (1.4)9.5 (2.1)−0.7710.5 (1.5)10.1 (1.7)−0.5−0.2 (−2.9 to 2.5).89
    LDL, mg/dL16142.8 (29.4)103.6 (37.8)−39.211136.9 (29.2)98.6 (36.9)−38.4−0.8 (−31.3 to 29.6).96
    SBP, mm Hg33160.7 (15.8)154.1 (19.9)−6.629160.6 (19.2)153.2 (17.0)−7.40.8 (−10.0 to 11.6).88
    • DIM = difference in means; HbA1c = hemoglobin A1c; LDL = low-density lipoprotein; SBP = systolic blood pressure.

    • Note: Analyses used missing-at-random (nonimputed) data. See statistical analysis in Methods section for details.

Additional Files

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  • The Article in Brief

    Health Coaching by Medical Assistants to Improve Control of Diabetes, Hypertension, and Hyperlipidemia in Low-Income Patients: A Randomized Controlled Trial

    Rachel Willard-Grace , and colleagues

    Background Health coaching can give people with chronic illnesses the knowledge, skills, and confidence to manage their conditions. This study tests the effectiveness of health coaching by medical assistants to improve indicators of health among low-income patients with uncontrolled diabetes, high blood pressure, and high cholesterol levels.

    What This Study Found Health coaching by medical assistants is a promising way to improve indicators of health for people with common chronic conditions. In this study, almost twice as many patients who received health coaching achieved their diabetes goals. At the larger study site, health coached patients were more likely to achieve their cholesterol goals. There was no significant difference in the proportion of patients meeting their blood pressure goals.

    Implications

    • Medical assistants can successfully serve as health coaches to improve health indicators for some common chronic conditions.
    • The medical assistant health coaching model may help solve barriers of time, resources and cultural concordance faced by many primary care practices seeking to implement self-management support.
  • Annals Journal Club

    Mar/Apr: Impact of Medical Assistants as Health Coaches


    The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1

    HOW IT WORKS

    In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Discussion: Submit a comment.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/site/AJC/.

    CURRENT SELECTION

    Article for Discussion

    • Willard-Grace R, Chen EH, Hessler D, et al. Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial. Ann Fam Med. 2015;13(2):130-138.

    Discussion Tips

    This article investigates the impact of in-clinic health coaching by medical assistants using data from a randomized controlled trial of low-income patients in safety net primary care clinics in San Francisco. The study considers the effectiveness of this model on control of hemoglobin A1c, systolic blood pressure, and LDL cholesterol and explores potential factors in implementation.

    Discussion Questions

    • What question is asked by this study and why does it matter?
    • How does this study advance beyond previous research and clinical practice on this topic?
    • How strong is the study design for answering the question?
    • How well does the study follow the CONSORT guidelines? (www.consort-statement.org)
    • To what degree can the findings be accounted for by:
      1. How patients were selected, excluded, or lost to follow-up?
      2. How the main variables were measured?
      3. Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
      4. Chance?
      5. How the findings were interpreted?
      6. "Contamination" between intervention and control groups? How might this possibility be avoided in the study design?
    • What are the main study findings?
    • How comparable is the study sample to similar patients in your practice? What is your judgment about the transportability of the findings?
    • What contextual factors are important for interpreting the findings? How strong are the methods for assessing contextual factors affecting implementation?
    • How might this study change your practice? Policy? Education? Research?
    • What might be the financial impact of implementing a similar model? At what level do the costs accrue? At what level are the benefits likely to appear over time? (eg patient, practice, health care system, community?)
    • What other in-clinic interventions may lead to similar results?
    • Who the constituencies are for the findings, and how they might be engaged in interpreting or using the findings?
    • What are the next steps in interpreting or applying the findings?
    • What researchable questions remain?

    References

    1. Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197 http://annfammed.org/content/4/3/196.full.

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The Annals of Family Medicine: 13 (2)
The Annals of Family Medicine: 13 (2)
Vol. 13, Issue 2
March/April 2015
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Health Coaching by Medical Assistants to Improve Control of Diabetes, Hypertension, and Hyperlipidemia in Low-Income Patients: A Randomized Controlled Trial
Rachel Willard-Grace, Ellen H. Chen, Danielle Hessler, Denise DeVore, Camille Prado, Thomas Bodenheimer, David H. Thom
The Annals of Family Medicine Mar 2015, 13 (2) 130-138; DOI: 10.1370/afm.1768

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Health Coaching by Medical Assistants to Improve Control of Diabetes, Hypertension, and Hyperlipidemia in Low-Income Patients: A Randomized Controlled Trial
Rachel Willard-Grace, Ellen H. Chen, Danielle Hessler, Denise DeVore, Camille Prado, Thomas Bodenheimer, David H. Thom
The Annals of Family Medicine Mar 2015, 13 (2) 130-138; DOI: 10.1370/afm.1768
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