Why Health Coaching in the Clinical Setting Has Become a Powerful Force in Transforming Healthcare

By William K. Appelgate, PhD, CPC

Prompting improved behaviors, building self-care skills and inspiring individual accountability for health promises the greatest opportunity for lifting health outcomes and reducing the high cost of American healthcare.

Healthcare reform comes in part from changing the system – quality, delivery and payment. True reform also arises from how individuals access the system and demonstrate health promoting behaviors. Between 70-80 percent of healthcare costs are driven by personal behaviors. Hence, powerful opportunity springs from the capacity of individuals in a population to build self-care skills, improve their health behaviors and accept accountability for health. For healthcare professionals, it is not about giving motivation for behavior change, but inspiring it.

This inspiration comes more easily for some than others. Lifting health status and reducing health risks in a population can be dramatically influenced by the culture of health. However, inspiring those at most risk is the nut of achieving real clinical and cost reduction outcomes. Some individuals at higher risk will be motivated by knowledge of their condition and interest in better well-being; others will be the “drinkin, smokin, carrying-on types.” Each must be reached.

The Clinical Health Coach® training was developed several years ago by the Iowa Chronic Care Consortium specifically to drive better outcomes in population health – clinical, quality of life, patient experience and cost. It is a highly performance oriented program designed for members of a healthcare provider team. The intent is to develop a very particular set of skills to enable patients to build self-care skills, prompt improved health behaviors and inspire accountability in individuals. It was designed to address the needs of individuals requiring active care management; it serves well those benefiting from health promotion and maintenance.

This innovative training strategy was created to address three gems of evidence based knowledge: 1) 98% of healthcare decisions take place outside of a provider office or clinic; 2) most care is self-care, from health promotion to care of chronic conditions; and, 3) individuals and their families are the greatest underutilized resource in healthcare. This knowledge is the foundation for three breakthrough ideas for transforming healthcare.

No. 1.

Most healthcare decisions take place in the bedrooms, bathrooms and kitchens of an individual’s home. In fact, seniors spend an average of only 5 hours annually (out of 8,760 in a year) in the doctor’s office. Wise providers recognize that they must reach into the setting of the patient, their personal culture, and align care with personal preferences and values for best practices to be sustained and influential. Competent providers know that reducing risk and improving health status by partnering can only be achieved by reaching into and inspiring behaviors in the 98% of healthcare that takes place outside of their office.

The question is, “How can an already busy provider get to and serve all of these new interests of individuals?” And, “How can appropriate attention be given to those with the highest risk and lower health status who will experience condition exacerbations and cost?” Quite frankly, if delivered in traditional ways, they cannot. Most often it takes a healthcare team, who along with the physician can effectively partner with patients to reach into and influence healthcare decisions occurring outside of the office, clinic or hospital.

Increasingly, healthcare has become serious about outcomes. The Triple Aim of better health, better healthcare and lower cost is more than a mere mantra for change. It is shifting our approach to healthcare and how it is paid for – from volume to value. Payors, health plans and patients are becoming more savvy regarding outcomes. Patients who have long exhibited priority interest in being “fixed” are grasping the value of reducing risk and maintaining health status. Attention to health risk and health status are longer term goals supported by improved access, prevention, timely care, management of chronic conditions and improved health behaviors.

No. 2.

The Agency for Healthcare Research and Quality (AHRQ) has reported that 95% of diabetes care is self-care. Self-care impacts many other conditions to a similar extent. Even the best of physicians and healthcare providers cannot get results by themselves. Historically, we have encouraged, sought and preferred patients who were compliant with and adherent to education, prescriptions and recommended behaviors. Those that were not were described as non-compliant or non-adherent. In truth, they were likely neither engaged nor activated toward better health.

There is a lot of talk and conversation about patient engagement. Technology is often touted as a path to engagement. Frequent contact is often a recommended path to engagement. Selected health plans and employers report that incentives prompt higher levels of engagement. These are not bad ideas. However, they miss a powerful point – engagement results most often from connecting an individual to their own expressed interests. It begins by changing the conversation from asking “What’s the matter?” to “What matters to you?”.

Health coaching is finding a patient’s “star in the world” and “hitching their health behavior wagon to it.” Self-care may include more complex activities such as injections, changing diets or managing symptoms. Often, it involves relatively simple actions such as taking medications, avoiding certain foods or weighing daily. Effective coaches help patients uncover their own motivations and inspire meaningful self-care behaviors that take them there. Coaches help connect the dots between the patient’s expressed long-term health interests and today’s behavior.

By coaching an individual to identify and claim their highest health interests – better quality of life, staying out of the hospital, remaining independent, thriving in life – the value of building self-care skills, improving health behaviors and living accountably comes alive. A patient’s stated interest or goal to be around for grandchildren or travel confidently for the next several years provides powerful self-motivation for changed behavior or the practice of evidence founded self-care skills. Building self-care skills, motivation to use them and accountability to sustain health is a new high calling for all of healthcare professionals.

No. 3.

Telling individuals what to do, educating or warning them about the consequences of their sub-optimal health behaviors has not worked. The New England Journal of Medicine has reported that 30 – 50% of patients leave their provider visits without understanding their treatment plan, hospitalized patients retain only 10% of their discharge teaching instructions and chronically ill patients receive only 56% of clinically recommended healthcare. If this is true, it reflects reasons many patients remain a great underutilized resource.

Prior to his recent departure from his position as Director at the Office of the National Coordinator for Health Information Technology (ONC), Dr. Farsad Mostashari shared an illuminating observation, “We are in an era of looking at all of the underutilized resources in healthcare. The greatest underutilized resource in healthcare is the patient and their families. The next big healthcare application will be behavioral informatics — how do we understand behavioral change, not just give people knowledge, but helping people tap into their rationality.”

Tapping into patients and their family utilizing them as a resource requires knowledge about a patient’s interests and rationality. In the 1960s, a traditional healthcare encounter was physician centered and self-executed. The elements were: gather information; perform examination; offer diagnosis; and, give instructions. Today, effective encounters are collaborative, patient centered and team executed. The elements include: open discussion; build relationship; gather information; understand patient perspective; perform examination; share information; determine patient interest in change; agree on problem and plan; provide closure; and, plan follow-up.

Peter Diamandis, founder of the X Prize and co-founder of Human Longevity, Inc., has observed, “While technology has developed and evolved dramatically, individuals still have worries, fears, hopes, desires and ambitions. They want to be moved, validated, cared for, respected and seen as capable. It doesn’t matter the technology, platform or medium through which you reach them – people are still people. Humans haven’t had a software update in 200,000 years.”


Dr. Toby Cosgrove, CEO of Cleveland Clinic, appearing on Meet the Press, was asked, “What is the one big breakthrough opportunity we have to change the nature of healthcare in this country?” He did not talk legislation and funding. Instead, he observed that the biggest challenge, and opportunity, for the future of healthcare is getting people to take greater personal responsibility for their own health.

Believing in health behavior change and inspiring it, and partnering with the patient to tap this great underutilized resource represents a departure from, “how we have always done it.” Healthcare professionals must move from “do, teach, tell” to “ask, listen, inspire.” Rather than focusing service on the origin and treatment of disease, they focus upon the maintenance and development of health. In short, the effective healthcare provider is a designer and builder of health – an architect for health.

To effectively partner with patients in the new design and build of health, healthcare professionals must be skilled in transforming the conversation between themselves and patients they serve. They must be behavior change specialists, not seeing the end of their work as teaching or telling a patient the best steps to care, but growing the patient’s ability and confidence in long lasting behavior change. A patient labeled “non-compliant” is often someone who needs further exploration in discovering their own motivation for change. These healthcare professionals must also be attentive to population health processes, acting as care facilitators who align best practice care with patient centered resources.

An analogy can be drawn between what therapists do in working with patients and what coaches do. Therapists often look back at the causes and background of individuals as a source of what causes the present situation – they act as an archeologist. In contrast, a coach picks individuals up where they are and acts to design or create a new or better future – they act as an architect.

Health coaching is a fundamental approach to delivering patient-centered care. While this can be challenging for a healthcare team, there are powerful health coaching techniques and strategies that will complement the care team’s clinical expertise delivering a new level of patient engagement and activation. Health coaching strategies improve the entire team.

Coaching skills enable physicians, nurses, medical assistants, care coordinators, community health workers, ANPs, PAs, dietitians, social workers and others to move behaviors. Our mission in the Clinical Health Coach® training is building competent, confident, performance oriented coaches who can truly become architects for health! Who could ask for a higher calling?


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Meet William K. Appelgate, PhD, CPC

William K. Appelgate believes that inspiring improved personal health behaviors is the change-the-world strategy required for the future of healthcare in America. He is the Executive Director of the Iowa Chronic Care Consortium and Founder of the Clinical Health Coach® training. His professional work has included service as a director of a university research center, a college foundation director, a college president, CEO of two comprehensive, innovative healthcare systems as well as vice-president and clinical professor at a leading graduate health sciences university and medical school.

The Iowa Chronic Care Consortium, along with the Clinical Health Coach®, is a non-profit population health capacity building organization with clients and nearly 3,000 enrollees in 45 states. It has received national recognition for its particular skill in achieving validated clinical and cost outcomes through prompting health behavior change in patient populations.

Dr. Appelgate earned a B.S. from Iowa State University, an M.A. from Loyola University of Chicago and a Ph.D. from Southern Illinois University. He is a Vietnam Era Veteran and a Certified Professional Coach.