All aspects of the Health Coaches for Care Transition program, including informed consent documents obtained from the volunteer HCs and discharged HHS patients included in the study, were approved by the Clemson University Internal Review Board. A quasi-experimental design was used to evaluate the effectiveness of the pilot project. Process measures included: number of community members trained to be HCs; number of HCs who continued throughout the project period; number of referrals to the program from HHS RNs; number of referrals who agreed to participate in the program; and reasons why referred patients did not participate in the program. Impact measures included select OASIS (Outcome Assessment and Information Set-B1) measures used by HHS which were also administered by the HCs. These indicators included: level of physical activity; adherence to special or therapeutic diet; usual food intake pattern; grooming; ability to dress upper body; ability to dress lower body; bathing; toileting; transferring; ambulation/locomotion; feeding or eating; planning or preparing light meals; transportation; laundry; housekeeping; shopping; ability to use telephone; medication compliance/education; tobacco use; immunization received within the past 12 months; home modifications including structural barriers, safety hazards, and sanitation hazards; and ability to engage in self-management behaviors such as tracking health condition in Health Diary for at least two weeks. Outcome measures included; readmission to the hospital or ED for original diagnostic category of CVD, DM, or CHF; admission to hospital or ED for fall, flu, or pneumonia; and costs of admissions.
2.2. Health Coach Training
A training curriculum was developed to include chronic disease content, select CHW competencies, and health educator skills. It also incorporated communication strategies and adult learning principles, within an overall philosophy of self-determination where the patient defines their own vision of optimal health and works collaboratively with their health coach in a mutually respectful relationship to develop action plans for achieving their goals [39
]. As part of their training, HCs were certified by Clemson University research compliance staff in human subject protection since HCs obtained informed consent and collected data from study participants.
Skill development in CHW competencies such as accessing community resources and assisting in making healthcare appointments [33
], were included in the training since CHWs have proven to be a cost-effective strategy in facilitating individual’s adherence to recommended health behavior changes, self-management of health conditions, and access to health care [25
].Part of the success of CHWs is their cultural competence acquired through membership in the communities they serve [33
] which was considered in HC recruitment efforts.
HCs were trained in self-management best practices for cardiovascular diseases (CVD), hypertension, congestive heart failure (CHF), diabetes Type II (DM) and stroke. HCs were trained to teach and encourage their clients to monitor and record weight, blood pressure, pulse rate, and blood glucose, as indicated by the clients’ diagnoses; and to calibrate their relevant devices, all provided by the program, such as easy-to-read digital scale, BP monitor, and glucose monitor. HCs learned how to help clients maintain a log of their health status measures in their Personal Health Diary and how to use a “stop light” visual aid to recognize “red flag” symptoms such as shortness of breath, cough, and swelling of the feet by those with CHF, and how to conduct foot self-examinations to detect lesions by those with DM. By learning to recognize red flags of disease progression, clients were alerted to arrange early healthcare intervention to prevent an ED visit and/or hospitalization.
HCs were also trained in health education competencies so they could effectively mentor their clients to make lifestyle behavior changes. They developed skills in helping their clients build self-efficacy, develop behavior change goals, reward themselves for meeting goals, and prevent relapse to unhealthy behaviors. These skills helped HC clients improve their success in mastering self-management behaviors such as following dietary recommendations, creating a physical activity plan appropriate for their health status and fitness level, and selecting tobacco use cessation strategies. Additionally, HCs learned how to assist someone in conducting a home fall risk and safety assessment and how to secure community resources to make home repairs.
Consistent with the Chronic Care Model [37
], HCs were also trained to activate and prepare their clients to have more interactive medical visits with their primary care providers (PCP) through actions such as reporting disease symptoms; inquiring about medication use and side effects and reporting side effects; and bringing a list of concerns and questions for discussion during PCP visits. HC clients also regularly brought their Personal Health Diary to PCP visits, a practice which was well received by the PCP as it provided day-to-day data about their patient’s health and demonstrated that their patient was actively engaged in their own health management.
Finalized training curriculum modules included: (1) Parameter and Role of Health Coach; (2) Safety and Fall Prevention; (3) Adult Learning Principles and Communication Skills; (4) Psychosocial and Physical Aspects of Aging; (5) Cardiovascular System; (6) Heart Disease and Stroke; (7) Diabetes; (8) Pneumonia and Flu; (9) Medications and Self-management; (10) Chronic Disease Self-Management Behaviors (Nutrition, Physical Activity, Stress Management and Tobacco Use Cessation); (11) Changing and Maintaining Health Behaviors; (12) Identifying and Accessing Community Resources such as smoking cessation classes, free immunizations, utility bill waivers, and home modification assistance; and (13) Human Subjects Protection.
To pass the 30-h training and become certified, HC candidates were required to attend all sessions and to achieve a score of 80% or greater on the knowledge test. The Project Director and Community Coordinator conducted six separate training sessions over the four-year project period including 51 people with 43 meeting requirements to be certified as Health Coaches and accepting clients. Knowledge test scores for all 51 trainees averaged 61.2% at pretest and 80.0% at post-test. Of the 43 certified HCs, 38 were females and five were males with 25 Health Coaches (59.5%) continuing to serve clients through all four years of the project period. Some HCs preferred to work as teams and others worked alone.
2.4. Health Coach Activities
On the first visit to the patient’s home after HHS discharge, the HC provided an overview of the HC program including a clear explanation of the limitation of their role and the time they would spend with the client which did not exceed four months in most cases. If the patient had a caregiver, this person was also invited to attend the initial session and all those which followed. The HC explained that the goal was for the client to be able to follow their self-care plan developed during HHS. If the client was still interested in the program, the HC then read through an informed consent document, provided two copies of the form to the patient, and asked him/her to sign one copy which was sent in to the Project Director. The HC transferred relevant information from the patient’s HHS self-care plan such as their parameters for acceptable glucose levels to a simpler Personal Health Diary that was then used by the patient to log their health status. At the first or second home visit, the Health Coach also collected selected Outcome and Assessment Information Set (OASIS) data such as edema, drainage, shortness of breath, cough, chest pain, dizziness, cramping, pain or temperature change in lower extremities, dietary behavior, physical activity, smoking levels, ability to engage in ADLs and IADLs, medication compliance behaviors, immunizations and residential hazards or structural barriers which might increase risk for falls.
The HC met with their assigned discharged HHS patient for a total of approximately 3.5 h per week in month 1 (two home visits and three phone calls); 3 h per week in month 2 (one home visit and four phone calls); 2.5 h per week in month 3 (no home visits with four phone calls; and 2 h per week in month 4 (four phone calls). The number of contact hours were tapered from the beginning to the end of HC services in order to promote independence from the HC. If by the end of the 4th month of HC support, self-care did not seem probable, with client permission, the HC placed the client’s name on the Community Long Term Care waiting list or contacted the HHS RN about the possibility of recertification for HHS. Six months after the end of Health Coaching (month 10), the Health Coach made one final home visit to collect OASIS data.
During the first home visit, the HC provided their client with a notebook of materials relevant to their chronic disease including a “stoplight” of disease symptoms and recommended actions. They also provided a digital blood pressure cuff, digital scales or digital glucose monitor, according to client needs, and instructed them in how to use the equipment. When the client demonstrated he/she could properly use their equipment, they recorded their baseline health status indicators such as BP, glucose levels or weight in their Personal Health Diary. On subsequent home visits, the Health Coach reviewed with the client their daily entries in the Personal Health Diary. Twenty-one out of the 33 Health Coach clients regularly tracked their conditions in their Health Dairies for a range of days from 21 to 224. With those clients not regularly tracking their condition, Health Coaches discussed ways to add this task to their daily activities. For those clients who were successfully tracking, the Health Coach complemented them on their commitment to monitoring their health, celebrated successes and discussed any trends which may be problematic. If, for example, the client was not staying within their recommended glucose parameters, the HC discussed any difficulties the client may be having with diet and physical activity or with taking diabetes medications. In this same example, if glucose levels were above those recorded on the “stoplight” of red flag symptoms, the HC helped the client follow through with the recommended action.
During the four months of home visits and phone calls, the HC tailored activities to the needs of the client and/or their caregivers. These activities included: improving chronic disease self-management skills; coordinating health care services and provider referrals; collaborating with community organizations to obtain resources such free immunizations, utility bill waivers, food stamp applications, home repairs, and meal deliveries; helping clients develop a medication management plan; arranging and reminding clients about appointment schedules and treatment regimens; making transportation arrangements for medical appointments and pharmacy visits, food shopping or physical activity programs; facilitating communication between client, family, caregivers, and service providers; and acting as an advocate with the PCP or HHS RN.
In addition to contacts with their clients, HCs attended monthly meetings as a group and made weekly contact via phone or e-mail with the Project Director during the time they were serving clients. At the monthly meetings, HCs submitted a client contact log and travel log if they were requesting reimbursement of travel expenses. They reported on their client’s progress in reaching self-management goals and their ability to collect and record their health information in their Personal Health Diary. They also shared challenges and solutions related to working with the clients and their families. The HCs, most of whom were retired, anonymously reported through an open-ended question survey administered in year 3 and 4 of the project that they experienced positive impacts from the program such as role satisfaction and fulfillment of their desire to help others in a meaningful way (quotations from HCs are included in Results section). The HCs also enjoyed getting acquainted and making new friends with their peer HCs.
The HCs submitted data collected with the OASIS and the client’s Personal Health Diary to the Project Director. The Project Director assigned a random number to each HC client which was linked with the client’s OASIS and Personal Health Diary information. A data analyst then entered, managed and analyzed the data. The Project Director worked with the HHS Director to match HHS patients who chose not to participate in the HC program on gender, age, health condition, and period of HHS services with those HHS patients who received HC assistance. Those HHS patients who served as the comparison group were also assigned random numbers. The HHS Director then provided information about hospital readmission, ED use and related costs of both the treatment and comparison group members to the Project Director. Data were then analyzed in the aggregate using assigned random numbers to determine differences in readmissions, ED use and costs between the treatment and comparison groups. See Table 1
for activities of HHS RN, HCs, and Project Director.