Abstract
PURPOSE A randomized controlled trial found that patients with diabetes had lower HbA1c levels after 6 months of peer health coaching than patients who did not receive coaching. This paper explores whether the peer coaches in that trial, all low-income patients with diabetes, mastered and utilized an evidence-based health coaching training curriculum. The curriculum included 5 core features: ask-tell-ask, closing the loop, know your numbers, behavior-change action plans, and medication adherence counseling.
METHODS This paper includes the results of exams administered to trainees, exit surveys performed with peer coaches who completed the study and those who dropped out, observations of peer coaches meeting with patients, and analysis of in-depth interviews with peer coaches who completed the study.
RESULTS Of the 32 peer coach trainees who completed the training, 71.9% lacked a college degree; 25.0% did not graduate from high school. The 26 trainees who passed the exams attended 92.7% of training sessions compared with 80.6% for the 6 trainees who did not pass. Peer coaches who completed the study wanted to continue peer coaching work and had confidence in their abilities despite their not consistently employing the coaching techniques with their patients. Quotations describe coaches’ perceptions of the training.
CONCLUSIONS Of low-income patients with diabetes who completed the evidenced-based health coaching training, 81% passed written and oral exams and became effective peer health coaches, although they did not consistently use the techniques taught.
INTRODUCTION
Health coaching is the process of engaging patients with chronic conditions in their care by increasing their knowledge, skills, and confidence to the point that they become informed, active participants in the management of their conditions.1 Patients trained as peer health coaches can provide health coaching to other patients. A recent randomized controlled trial found that patients with poorly controlled diabetes had significantly reduced hemoglobin A1C (HbA1c) levels after 6 months of peer coaching compared with patients who did not receive peer coaching.2 This paper reports on the characteristics and training experiences of these peer coaches.
The peer coaches were low-income patients with diabetes who had backgrounds similar to those of the patients they coached. The process that transformed these ordinary patients into effective peer coaches was training and mentoring using the Evidence-Based Health Coaching curriculum developed by 2 of the authors (A.G. and T.B.).3 The core features of evidence-based health coaching are described in the Methods section.
This paper addresses the question, did the low-income patients with diabetes recruited to become peer coaches master and utilize the evidence-based health coaching curriculum?
METHODS
The peer coaches described in this paper were part of a randomized controlled trial comparing peer coaching to usual care for patients with poorly controlled diabetes, conducted in conjunction with the Peers for Progress World Health Organization (WHO) global initiative.4 The study protocol and results, showing that patients who received peer coaching had a significantly greater reduction in their HbA1c levels, are described elsewhere.2,5 Peer coaches were low-income English- and Spanish-speaking patients with diabetes whose HbA1c levels were 8.5% or lower and who were recommended by staff or clinicians from the clinic at which they received their care. Candidate peer coaches underwent a 36-hour training session in evidence-based health coaching followed by written and oral exams. Those who passed the course were paired with patients and met in monthly mentoring sessions with the program director to discuss their patient interactions and receive refresher training. Those who did not pass the exams were given a second chance, but they did not serve as peer coaches if they were unable to pass the written and oral exams the second time. The peer coaches were paid $25 per month up to 6 months for each patient coached. They were also paid $150 for the training whether or not they passed the exams. The coaches interacted with an average of 6 patients each.2
Evidence-based health coaching is based on 5 core principles. These principles were developed by compiling best practices from 5 years of experience in training patients, medical assistants, nurses, and physicians in health coaching and studying the literature on health coaching and self-management support.
Ask-tell-ask
Asking patients what they wish to learn and what they are willing to do is an effective way to involve patients in their care. Several studies demonstrate that active participation by patients—achieved by asking them what they think and what are their goals—is associated with better outcomes than telling patients what to do, which makes them passive bystanders in their care.6–10
Closing the loop
Fifty percent of patients leave the physician visit without understanding the physician’s recommendations. A method to assess patient understanding involves asking patients to state the physician’s recommendations in their own words; this is called “closing the loop” or “teach-back.” Physicians’ use of teach-back for patients with diabetes has been associated with improved glycemic control.11
Know your numbers
Most patients with diabetes do not know their actual HbA1c number or their HbA1c goal. A randomized controlled trial found that patients with diabetes who are taught their actual HbA1c level and their HbA1c goal improve their glycemic control more than a control group.12
Behavior-change action plans
In a study of patients in diabetes self-management support groups, patients were randomly assigned to traditional patient education or to goal setting with concrete behavior-change agreements called action plans.13 The group doing action plans had a significant reduction in HbA1c compared with the patient education group, whose HbA1c levels did not change.
Medication adherence counseling
Effective strategies for optimizing medication adherence are based on coaching techniques that include eliciting the patient’s feelings about taking the medication (ask-tell-ask), ensuring that the patient understands the instructions (closing the loop), and customizing the regimen in accordance with the patient’s wishes (ask-tell-ask and behavior-change action plans).14 Peer coaches were taught to engage patients in medication reconciliation, which included finding out whether patients were taking their medications as prescribed, eliciting the barriers to adherence, and suggesting strategies to overcome those barriers.
These 5 principles were taught to the peer coach trainees through scripted dialogs and role-playing performed by trainee dyads with feedback and discussion. Trainees also learned how to clearly explain the essentials of diabetes to patients, including the complications, the basics of healthy eating and physical activity, the common medications, medication reconciliation, and the essentials of managing depression and stress. Peer coach trainees were carefully instructed in patient confidentiality and in the limitations of their scope of activities.
The written and oral examinations were administered to the peer coach trainees at the end of the training. The written exam included basic questions about diabetes; for the oral exam, trainees had to demonstrate to a trainer that they knew how to close the loop and negotiate a behavior-change action plan with a patient.
The data for this paper comes from several sources: (1) demographic information on the peer coach trainees obtained at the beginning of the study; (2) the trainees’ attendance rates and the pass rates of the written and oral exams administered at the end of the training, (3) an exit survey of peer coaches who completed the study and of those who dropped out of the study, with questions using a Likert scale to measure satisfaction with training and the coaching experience, (4) a convenience sample of observations by the study team of 13 meetings between 13 different peer coaches and patients, using a checklist to assess implementation of coaching skills, and (5) in-depth semi-structured interviews with all 17 peer coaches active at the time, using iterative methods based on grounded theory (detailed elsewhere15), with examples focusing on the training experience.
RESULTS
Of the 37 peer coach trainees recruited to the study, 32 (86.5%) completed the training, and 26 of those (81.3%) passed the written and oral post-training examinations. Those who passed the exams had higher attendance at the training sessions than those who failed to pass (Table 1). Of the 26 who passed the exams and became peer coaches, 17 completed the study, 6 dropped out after starting to meet with patients, and 3 dropped out before meeting with patients. Only 28.1% of those completing the training had a college degree, and 25.0% did not graduate from high school (Table 2). Trainees who did not complete the study cited reasons such as being too stressed by their own diabetes (35.7%) and lacking confidence in their ability to coach (21.4%).
Training Experience of Peer Coach Trainees
Peer Coach Demographics
Survey responses from 15 of the 17 peer coaches who completed the study showed that coaches were generally satisfied with the training and mentoring they received and felt comfortable coaching the patients they worked with (Table 3).
Responses From 15 of 17 Coaches Who Completed the Study
Observations made by the study team of 13 different peer coaches meeting with patients found that the coaches did not regularly utilize the coaching principles taught during the training (Table 4). While coaches utilized most components of ask-tell-ask in most meetings, they utilized the procedures they had learned to engage patients in medication adherence counseling and in behavior-change action plans in only about 30% of meetings and closing the loop in 25%.
Observations of Coaches During Meetings with Patients
In addition to observing whether the peer coaches were using the 5 evidence-based health coaching elements in their meetings with patients, the observer of these meetings also noted that coaches utilized other techniques learned in their training. Coaches almost always greeted the patient in a friendly manner, thereby building a relationship with the patient. They usually asked patients open-ended questions about how things were going, they almost always listened to patients in a respectful and non-judgmental manner, and they volunteered information and feelings about their own diabetes. It appeared from the observations that the patients appreciated not being told what to do about their diabetes, but being engaged in a collaborative process.
The in-depth interviews with 17 of the peer coaches who completed the study provide insights into how they felt about the training (Table 5). In general, they liked the training curriculum and methods but felt that the training did not truly prepare them for the surprises they encountered in coaching patients.
Peer Coaches’ Evaluation of Their Training
DISCUSSION
Many health professionals would doubt that patients with diabetes could effectively improve glycemic control in other diabetic patients. Yet the patients trained as peer coaches, many with low educational achievement, who are described in this paper were able to significantly reduce HbA1c levels in patients with diabetes compared with patients who did not receive peer health coaching.2 A previous article analyzed some characteristics of coaches whose patients had the greatest improvement in HbA1c. 16 These characteristics included the coach having a HbA1c below 7%, having lower levels of depression, and—interestingly—having personal challenges with their own self-confidence regarding the self-management of their diabetes. It may be that lower coach self-confidence might encourage empathy, approachability, and development of coping strategies useful for sharing with patients.
The peer coach trainees were a selected group, nominated by their care teams in their primary care clinic. Of this group, only 17 of 37 (45.9%) were able to complete the study as peer coaches. Yet 81.3% of those who completed the training passed the written and oral exams, showing that they were able to grasp the information and principles presented in the evidence-based health coaching training. Those who completed the study stated that they felt comfortable with what they had learned in training and responded positively to the training and mentoring sessions. Not all the coaches, however, utilized the evidence-based coaching principles with every patient. Thus some of the peer coaches’ success may have been related to their building trusting relationships with their patients as much as their imparting knowledge, skills, and confidence to their patients.
One study has reviewed some peer coach training examples but did not provide details on the trainees.17 Other researchers described a peer leader training program for diabetes and found that all 9 trainees, African-American patients with diabetes, were able to pass competency exams. Seventy-five percent of the trainees had a college degree or higher.18,19 Our study extends this latter work by recruiting 37 patients with diabetes, including 10 Hispanic patients, 9 of whom received their training in Spanish. Moreover, in our study, only 28.1% of the coach trainees had a college degree and 25.0% did not graduate from high school. Our study demonstrates that an evidenced-based curriculum can be mastered by the majority of low-income patients with limited education.
Limitations of our study include missing data, with not all coach trainees participating in the observations of their meetings with patients, the post-study survey, or the in-depth interviews. Only 13 observations of peer coach interactions with patients were conducted and these were chosen as a convenience sample, though they did involve 13 different coaches; thus analysis regarding the content of the coach-patient interactions is suggestive but not conclusive.
CONCLUSION
Of the 32 patients who completed peer coach training, nearly one-third of whom were Spanish speaking and a quarter of whom had less than a high school education, 81.3% were able to pass exams indicating that they understood the principles and information contained in an evidence-based health coaching curriculum. The 17 peer coaches who went on to coach patients over the course of the study were able to significantly improve the glycemic control of the patients they coached. These results show that diabetic patients from disadvantaged communities, including non–English-speaking patients and patients with limited education, can be trained to successfully serve as peer coaches for other patients with diabetes.
Footnotes
Conflicts of interest: authors report none.
Funding support: Funding for this research was provided by the American Academy of Family Physicians Foundation through the Peers for Progress program with support from the Eli Lilly and Company Foundation.
- Received for publication August 14, 2014.
- Revision received November 25, 2014.
- Accepted for publication December 16, 2014.
- © 2015 Annals of Family Medicine, Inc.
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