Patient coaching: results of a pilot project

The population in the Federal Republic is undergoing demographic change. The number of people in older age groups is increasing and is therefore becoming more important. With longer life expectancy, morbidity, multimorbidity and immobility are increasing - a development that increasingly poses challenges for those responsible for paying and providing services. Against the background of rising healthcare costs and with a view to better patient care, innovative and effective approaches to care management are increasingly coming into focus. One of these is patient coaching, which aims to promote the patient's health literacy in a targeted, needs-oriented manner as part of maintaining health and coping with illness.

>> In particular, the care management of chronically ill and multimorbid patients and the high non-compliance or non-adherence rate of these patients presents the healthcare system with a difficult task. With a share of around 20 to 30 % of all patients, chronic patients cause around 4/5 of total health expenditure (Bauer/Preuß 2009). Lack of adherence to therapy, which can be up to 50 % and more for some indications, burdens the healthcare system and the solidarity community in Germany with direct and indirect follow-up costs of 10 to 15 billion euros annually, 2.3 billion euros per year alone lost due to medication not being taken (Seemann/Kissling 2008; DGbG 2009). In view of these figures, it is clear that quality and cost-effectiveness in medical care are closely linked and do not solely depend on the quality of the medical-curative and rehabilitative process. According to the 2005 report by the Advisory Council for assessing developments in the healthcare system, the contribution that institutional medical care can make to improving the health situation amounts to only 10 to 40 %, depending on the general conditions. Much stronger effects - certainly also with regard to cost regulation - can therefore be expected from interventions that aim to influence lifestyles and consumption patterns and to promote compliance (Expert Council for the Assessment of Developments in the Health Care System 2005). In order to be able to use this potential for improved patient care, it is necessary to reassess and strengthen the position of the patient in the network of relationships in the healthcare system. What is no longer needed is the passive patient who has a paternalistic relationship with his therapist and uses medical services largely without thinking. Rather, the sick person should participate as an active participant in the care process and take responsibility for their health to the extent possible. This is where the concept of patient coaching comes in - to enable and motivate patients to deal responsibly with their health or illness in the sense of helping them help themselves. The aim of this article is to describe the requirements and success factors of targeted patient coaching and to present possible outcomes using the practical example of a pilot project in collaboration with a German health insurance company.
Patient coaching – what is it?
The patient coaching working group of the German Society for Citizen-Oriented Health Care (DGbG) eV defines patient coaching as follows: “Coaching is intended to enable patients to recognize and achieve their individual health goals in the long term by learning to develop their own abilities and skills for self-management of the disease and to select and use offers and structures in a targeted manner and thus increase their quality of life." Patient coaching does not mean treating people - this is and remains the task of the treating doctor and other therapeutic authorities. Nor does it necessarily mean advising him. Rather, the coach takes on the role of an appreciative companion who, in his groundbreaking role, understands and supports the patient holistically and in the context of his or her personal framework (settings). Each patient organizes themselves individually with their illness, wants to be perceived individually and needs individual approaches to support. Patient coaching must not be limited to setting- and context-independent interventions that are limited to mere information and education. Rather, it is about recognizing the patient as an important factor in treatment and recovery and enabling them to actively contribute, within their own means, to coping with their illness and to the success of the therapy. Numerous experiences and studies from the USA show: 65 to 80 % of all chronically ill people can largely manage their illness themselves - as part of ongoing medical care. However, before the patient can be a “manager” of his illness, he must become an “expert” of his illness: he needs support, advice, motivation and information that address his individual needs and accompany him in developing personal strategies for coping with the illness. The central task of patient coaching is to support the patient in his development from an affected patient to an informed and ultimately competent patient who complements medical action with active participation and a sense of responsibility on his own behalf and for his own benefit.
Core elements and process of targeted patient coaching
1. Analysis phase: Identification of suitable patient groups
Patient coaching measures are not useful or effective for every patient. In order to achieve a good cost-benefit ratio, it is crucial for success to attach the highest importance to the selection of possible participants with regard to patient- and disease-specific parameters and the desired outcomes. As a rule, the focus of the analysis phase is on identifying people with chronic, often multimorbid illnesses and patients with acute health risks (back pain, psychological suffering), for whom an optimization of the therapy and illness progression can be expected through targeted coaching. Based on existing, pseudonymized performance and master data and taking into account defined medical inclusion criteria, a personal risk profile is created for all insured persons. Based on these profiles, individual risk scores can be created using prediction models that predict the probability of costly medical events and a deterioration in overall health. This prospective approach makes it possible to address potentially eligible program participants at points in the course of the disease that occur before a high-cost phase occurs (e.g. due to inpatient admissions, secondary illnesses) and offers real opportunities for influence, including with regard to maintaining quality of life.

2. Admission phase: Development of a patient-specific care strategy
The active approach and recruitment of the insured persons selected in the analysis phase is carried out within the framework of data protection regulations by the cost bearer, i.e. the commissioning health insurance company, with the help of target group-specific information documents and, if necessary, telephone recruitment measures. By signing a program-specific declaration of consent and, optionally, a release from confidentiality for the treating doctors, the insured person in question declares their willingness to participate and agrees to an initial telephone conversation with a coach. For a stable, goal-oriented coaching relationship that allows the supervisor to have a value-adding and lasting influence on the behavior of the other person, it is necessary to establish a situation of trust between coach and patient as quickly as possible. This is ensured by the fact that the patient communicates with a permanent contact person, their personal coach, from the beginning and throughout the entire course of the coaching program. During the initial contact, the patient obtains a precise overview of the patient's individual illness situation as well as his or her personal conditions and resources. With the help of a structured assessment, the coach assesses the patient's level of knowledge about his illness and where there are deficits in understanding of the illness and therapy process. He asks targeted questions that concern the patient's personal environment and his possibilities, ability and willingness to behave in a way that supports therapy. From this basic information, the coach derives an individual needs profile and, together with the patient, develops a needs- and needs-oriented care concept that determines the frequency, type and intensity of the planned interventions as well as the focus of the medical content. If the patient wishes, the coach will contact the treating doctor in this phase to obtain further information relevant to the care and to coordinate the care concept with him.

3. Coaching phase: Information, support and motivation with the aim of sustainable self-management
The first phase of coaching is seen as a stabilization phase in which the patient, together with his carer, builds an understanding of his personal illness-related problems and develops individual solution strategies. In regular telephone contacts, the timing and frequency of which take into account the patient's needs, the coach identifies areas in which there is a need for lifestyle changes or improved therapy compliance. He gives practical recommendations with a view to the patient's overall personal situation and home environment, e.g. B. on exercise, nutrition, necessary doctor's visits, dealing with prescribed medication or emergency management, and deals with individual problems. Through conversation and with the help of appropriate information material, the coach imparts basic medical knowledge about the background of the disease and the treatment with the aim of making it clear to the patient the usefulness of the therapeutic measures as well as the necessity and possibilities of active participation. By agreeing on realistic behavioral and action goals that the patient can achieve with the means available to him, the patient's awareness is strengthened in the course of the coaching that he will benefit from his personal commitment and - assuming this - will be able to successfully manage his own illness and can have a positive influence. As soon as the patient's level of knowledge and inner attitude allow it, the coach leads him into the phase of accompanied self-management. It gives the patient the opportunity to experience and test how to deal with their own illness independently. The coach's job at this point is primarily to provide assistance with difficulties and crises and to motivate the patient to continue the changes they have begun. With targeted interventions to promote compliance and adherence and, if necessary, the resumption of relevant training content, the coach ensures that the patient internalizes health-promoting measures and treatment recommendations and implements them sustainably. The coaching ends with a final discussion.
The success of the coaching depends to a large extent on the qualifications of the accompanying consultant. The requirements for a patient coach are complex and their tasks are diverse. He needs a sound medical background and many years of professional experience in order to be able to understand the patient's individual health situation and to be able to influence the patient's needs and needs in the course of the care. However, coaching does not only take place on a professional level; in order to be effective, it must take place on the basis of a sustainable, trusting relationship characterized by mutual acceptance. The basic requirements for this are a coach's attitude that is free of prejudice and values, a cooperative, pedagogically sensitive leadership style and the ability to empathize. Only when the patient feels understood in the entirety of his needs and requirements will he gain trust, open up and become accessible to influence that promotes competence. This must be steered by the coach in particular towards the ability to make decisions in partnership (e.g. with the coach, doctor or therapist) or to make decisions independently. Personal commitment to a shared agreement or a self-made decision is the best guarantee for adherence to therapy, the sustainability of health-promoting behavior and the patient's willingness to self-manage.

4. Result evaluation: Determination of the outcomes achieved
Evaluation as the methodical recording and justified assessment of processes and results is a central method of quality management. In particular, areas that affect the health and quality of life of patients imply high demands on quality and responsibility and the need to control and analyze measurable effects and the processes involved with a view to goal-oriented implementation. The measurement of short- and long-term consequences of patient coaching serves to monitor success and legitimize the client and at the same time as a decision-making aid for continuous adjustment of the design and implementation of the measures carried out in the sense of quality assurance. Patient coaching is seen as a holistic concept that is intended to be beneficial for the patient, but also for the service providers and payers. Accordingly, the evaluation process includes clinical, psychological and economic effects.
Patient coaching in practice:
A pilot project
1. Framework conditions and process of the pilot project
The patient coaching pilot project was carried out by 4sigma GmbH in cooperation with a German company health insurance company between January 2008 and February 2009 (see Table 1). After the analysis phase (January 2008), 710 insured people were identified in the pilot region who met the defined section, inclusion and exclusion criteria. 44 patients with an average age of 64 years were included in the patient coaching pilot project, regardless of the main indication (February 2008). The telephone support from a personal coach lasted 12 months and was divided into a 5-month stabilization phase and a 7-month phase of accompanied self-management. In the admission phase and after 6 and 12 months, various parameters were collected that are important for the clinical course of the indications represented in the participant group and allow an assessment of the patients' compliance behavior, self-management skills and quality of life.

2. Results of the patient coaching pilot project
2.1 Patient satisfaction and quality of life
The intention of patient coaching is to offer targeted support that addresses individual needs and takes personal circumstances into account. The patient's satisfaction with the care and his commitment to the coaching are essential prerequisites for the training and self-help measures to show long-term success and become habitual. Regular patient satisfaction surveys during the course of the pilot project showed that participants' acceptance of the coach's telephone support is very high and that the effects on personal quality of life and care are assessed as predominantly positive (Fig. 2).

2.2 Behavioral patterns and clinical parameters
The task of patient coaching is to uncover the patient's personal illness risks and, together with the patient, to develop and implement behavioral strategies that serve to improve the risk profile and positively influence the course of the disease. In this pilot study, the basis for this was in particular the motivation for a health-promoting lifestyle in the areas of nutrition, exercise behavior and weight control - with the aim of also improving disease-relevant clinical parameters (e.g. obesity, high blood pressure) by influencing these behavioral factors. The outcome measurements in this area showed that:
57 % of the program participants had positively changed their eating and exercise behavior after the coaching phase. 45 % patients lost weight, 29 %'s abdominal circumference decreased, and the proportion of program participants whose blood pressure was permanently below the guideline value of 135/80 mmHg increased by around 10 percentage points (Fig. 3).

2.3 Self-management and compliance
During the course of the coaching, the number of patients within the pilot group who regularly used self-management strategies and measures increased significantly (increase by 24 percentage points to 71 %). Likewise, as a result of the support, significantly more participants felt more confident in dealing with emergency situations (increase by 29 percentage points to 62 %). In addition to enabling disease self-management, improving compliance or adherence is a central focus of patient coaching. In particular, taking the prescribed medication regularly is of crucial importance, on the one hand, to ensure the success of the therapy for the patient and, on the other hand, to limit the economic damage to the health and community caused by a lack of adherence to therapy, which runs into billions of euros annually. As part of the patient coaching pilot project, the proportion of participants who were adherent to medication was increased by 24 percentage points. Another aspect of compliance is regular follow-up checks by the treating family doctor or specialist. The data collected showed that the behavior of the program participants with regard to medical care did not change and that the existing fears of competition on the part of the service providers towards non-medical care offers are unfounded (Fig. 4).

2.4 Hospitalization rate and cost savings
The focus of patient coaching is on the quality of care and the well-being of the patient. At the same time, it is also suitable as a cost control tool by promoting the targeted use of existing, but often underused, resources in the areas of prevention and curation. In particular, the high number of avoidable inpatient stays is a cost driver in the German healthcare system. According to the Federal Statistical Office, hospital costs in Germany in 2007 amounted to 64.6 billion euros, which corresponds to around a quarter of total expenditure (Federal Statistical Office 2009). The goal-oriented interventions of patient coaching made it possible to reduce the hospitalization rate by over 60 % compared to the previous year. This and the avoidance of cost-intensive disease progression resulted in service expenditure in the inpatient area falling by more than two thirds and the total costs per patient by 63 % or 3,365 euros (Fig. 5).
discussion
The results of the pilot project described by 4sigma GmbH make it clear that goal-oriented, quality-assured coaching is a suitable instrument for creating a win-win situation for everyone involved in the care process for chronically ill people. The intensive, individual coaching helps the patient to live better with the disease and to improve their personal health situation and quality of life through the targeted use of their own resources. By promoting competence, compliance and self-management, the conditions are also created for patients to better understand and implement medical recommendations and to be able to maintain a cooperative, supportive relationship with their therapists. The work of the doctor and that of the coach complement each other beneficially in the sense of holistic care, which gives the service provider more space for his core medical competencies. As an effective tool for cost containment, especially in the inpatient care sector, patient coaching is also proving to be a worthwhile investment from the perspective of payers - quite apart from the fact that offers for better care for insured people are increasingly becoming an important factor in competitiveness and customer loyalty in the changing health insurance landscape become. The measurable successes of the pilot project prompted the commissioning company health insurance company to offer the structured coaching nationwide to all potential insured persons. The first experiences of the comprehensive implementation confirm the trends and outcomes of the pilot project. <<