Health Coaching | Comprehensive Case Management Certification

Welcome to Case Management Toolbox Podcast, sponsored in part by All CEU's Continuing Education. I'm your host, Dr. Donnelly Snipes. Case Management CEUs are available for these podcasts@allce.com slide that's allceus.com Casemanagement hey there everybody, and welcome to Case Management Toolbox Podcast. Today we're going to be talking about health coaching. I'm your host, Dr. Donnelly Snipes. In this episode, we're going to explain what health coaching is, differentiate it from counseling or medical practice, describe different skills a health coach needs, and discuss how to develop an individualized service plan. When we're talking about health coaching, the old adage give a man a fish, he eats for a day, teach a man to fish, he eats for a lifetime kind of comes to mind when we are in more of a paternalistic role as a clinician and we're maybe doing things for or to clients to help them improve, which is not ideally what we want to have happen, but a lot of times it does. Or we make these treatment plans and then we improve, implement them with the client. But the client still doesn't learn how to identify their triggers, learn how to find resources to address their issues. They don't increase their health literacy. With health coaching, we are helping empower clients to take charge of their own health and well being. Health coaches provide self management support. We reach out to clients and we say, okay, how can I help you live your highest quality of life? What do you need from me? Instead of saying these are the things that you need to do, we're asking them to be the expert. We educate clients and we're going to talk about what we educate them about, bridge the gap between clinician and patient. A lot of times a clinician can be a health coach, but that kind of starts falling in those areas of non reimbursable services. Techs may become health coaches. It's a great thing to use a behavioral health tech for because they can take the treatment plan and stuff and help clients apply it. They can help clients identify hiccups that they're having. They can provide more granular service and continuing service in a scaffolding format. We're going to talk about scaffolding later too. Health coaches also help patients navigate the healthcare system. Health coaches are kind of like the conductors or the bus drivers. They've been down that road 150 times in the past month, so they know every pothole and clients don't. They may be new to the area, if you will. A health coach can help clients figure out, where do I need to go first? Do I need a referral from my primary care? Where can I find good information? Yada, yada. Health coaches just offer support and encouragement. They are there to go. You can do this, you can do this on your own. You don't need to have additional services necessarily. Let's see what services or what things you can do on your own. Health coaching research shows that with the use of health coaches, people evidenced significant improvements in one or more of the following. Obviously, it depended on what their goal was, but it's been used for nutritional improvement, physical activity, increasing weight management, exercise frequency, perceived social support, patient engagement, and activation, which basically means treatment plan compliance and medication adherence. They've looked at multiple different sectors, including addictions, mental health, diabetes, people that are having kidney problems, cancer treatment. And they found that health coaching really helps keep people going. Sometimes a week between appointments is a little too long, and you may not be able to get approvals to have people come in for multiple sessions in a week. So a health coach can bridge that gap and keep people's motivation up, keep them moving forward without necessarily taking more of the clinician's time. Common features of effective programs are goal setting, motivational interviewing, and collaboration with the client and healthcare providers. You're kind of getting them on the same page, talking to the client, and if the client's having trouble in some way asking the client, have you talked with your provider about this? And if they say no, then talk about why not? And maybe rehearse having that discussion. If they say yes, but my provider doesn't seem to hear me, again, talk about how they're approaching it. You know, let's role play. Tell me, show me exactly what you're saying and let me see if I can help you advocate for yourself. One format of health coaching is called the care transitions intervention, and it's widely used. And it imparts skills, tools, and confidence to patients and family caregivers as they move from hospital to home. Whether this is due to a health condition, due to, you know, maybe somebody had a baby and they're transferring. I know when I had my son, my daughter too, but my son was more premature than my daughter. Transitioning from the NICU to home was really terrifying for us as a family. A health coach would have been able to help that transition go a little bit easier. So we're not getting home, going, well, it's do or die. I have no idea what I'm doing. But, you know, worst case scenario, we'll go back to the hospital. That's Health coaches prevent overutilization of the hospital and help parents or caregivers feel more comfortable with their ability to manage conditions. The Care Transitions intervention is focused on four pillars having an effective understandable management strategy. You don't want to send the client home with a treatment plan or a service plan that they're looking at going, I have no idea what half of this means. One of the things that frustrates me is when clinicians will send, especially prescribing clinicians will send clients home and they will say, take this medication bid or tid. And clients are going, I have no idea what that means. And it's much more effective if it is written down. Take it twice a day or three times a day, or at breakfast, lunch and dinner some way that the client understands. And depending on the client's cognitive capacity, that's going to vary pretty widely. Some clients you may need to pin down to specific times, you need to take it at 8am, noon and 4pm or whatever the case may be for that medication so they don't have to think about it because that may be too much for them. Especially people who have severe and persistent mental illness or who are recently out of detox and may still be kind of in a fog. They may need things that are really concrete. The first pillar, as I said, is having an effective understandable management strategy. The second pillar is overcoming barriers to follow up appointments and treatment compliance. Whether this means using telemental health or making sure the person has prearranged transportation. Looking at other barriers like work, maybe the person goes back to work and they typically work 8 to 5 and your office is open 8 to 5. That's a barrier to them coming back in for a follow up appointment. So we need to figure out how they might be able to manage that. Knowing how to recognize and respond to worsening signs and symptoms is a third pillar. That way people feel confident, okay, I've got this plan, this is what I'm going to follow. But I'm not out here flapping in the breeze all by myself. If I start to feel like things are getting worse based on these signs and symptoms that I've had before, then here's what I do. I know what to do. I feel confident that I can reach out. And the fourth pillar is using a personal health record to identify and record 30 day goals, health information and key questions to be shared with the physician at upcoming health care encounters. And I should have changed that word physician to clinician because this can be used in Mental health settings as well. But we want people to keep a 30 day record or keep a daily record basically of what they're doing towards their treatment plan or towards their recovery. And, and maybe other benchmark goals like the amount of time they're sleeping, the amount of water they're drinking, their mood, their physical activity level, whatever it is for that patient, have them chart it on a daily basis as it pertains to helping them achieve their goals. Remember that goals, what they want to achieve in 30 days, that's out here. Just like if you are Google something and you want to go from where you're at to some other destination, Google's probably going to have five or ten steps for you to take. You know, drive for three miles, turn left, drive for six miles, turn right. You know how directions go. Your 30 day plans are the same way. Your 30 day plan is your first destination, call it your rest stop if you will. But there are going to be directions along the way, there are going to be steps along the way that people have to accomplish. And we want to make sure that the information they're recording helps us see their progress toward that goal. So for example, if somebody is to start exercising four times a week for an hour at a low to moderate intensity level, let's just go with that. Because they're trying to improve their physical health for cardiac reasons or whatever the case may be, then what you would want to do is help them identify what days they're going to do it, what activity they're going to do. We already know they're supposed to do it for an hour, but initially they may need to break it into two 30 minute segments because a full hour is just too much for them. Okay, and then what else are we going to look at? So we know that they're exercising four times a week, four days a week, and they're breaking it up into two 30 minute segments. We're going to have them record did I do it? Did I not do it? How did I feel when I did it? What we want to see is them feeling increasingly better. That goal should be increasingly easy to accomplish each week as they move towards their ultimate goal of health and wellness. They also need to record any key questions. Maybe when they're doing it, they get a stitch in their side and they may want to talk with their physician about that because it's really uncomfortable and it's hard for them to continue. Or since they've started exercising, they're not sleeping as well because they've got aches and pains. What can they do about that as coaches? You know, most coaches are not in the position to prescribe doing anything. We can educate clients about where to find information, and we can empower them to advocate for themselves with their clinician. And if it's bad enough, even call their doctor in between. Because generally doctors have nurses that field their calls, and the nurse can probably answer some of those questions. But we want to encourage people to keep pushing forward, but also to know how to reach out and get help. If they reach a stuck point, that may impact their motivation. Because I don't know about you, but if I start working out and I'm feeling achy and in pain and I'm not sleeping very well because of it, I'm not likely to continue doing it. We want to make sure that patients are going to continue to work forward in their treatment plan. So if they reach one of those motivation blockers, we need to help them figure out how to traverse that obstacle. This is called a goal attainment scaling chart, and I really loved it. I have the link down here. It was created by Gordon Spence. Basically, you have a goal attainment and totally achieving the goal, knocking it out of the park. That's a five. And then you have incremental levels like a Likert scale, all the way down to worst expected outcome. So for this one, the goal was to become more social, as evidenced by increasing the number of social interactions each week in order to overcome feelings of shyness, the best expected outcome. So the ultimate goal that somebody was supposed to do was to start initiating conversations with four new people each day. If they didn't quite make that. Initiate conversations with three new people each day. Didn't quite do that. Initiate conversations with two new people each day, initiate conversations with one or I didn't talk to anybody. Each one of those levels has a number assigned to it. So if they didn't start a conversation with anyone, they get a zero for goal attainment for that day. If they started conversations with three new people, then they get a four out of five for goal attainment for that day, and they can start seeing their goal attainment score for the week, hopefully go up. You want to see it eventually get to the point where it's 35. They're getting fives every single day. I told you we would talk about what health coaches do in terms of educating clients. What do we educate them about? Well, we help clients. This is one of the biggest things. Learn where to find reliable, valid information about their concerns or conditions. Most health coaches are not in the position to prescribe nutritional changes, dietary changes, exercise, those sorts of things because of liability reasons. But we can help clients figure out, where do I go to find reliable information? Because if you go on the Internet, you can find a lot of crap, but you can also find a lot of nuggets that are in there. You can find some really good things. How do they know? How do they know if something is, you know, quackery or useful? Help clients learn how to evaluate that information. So, for example, they may go to a really reliable website and I won't name names and read about a condition that they have. And in that, that symptom that they're having, the article says it could be caused by a variety of things from over exercise. Let's just go with back pain. It could be caused from a variety of things from lifting wrong to over exercise to poor ergonomics to kidney cancer, to, you know, something else. And the client reads that and is like, oh, my gosh, they've listed four things there that could cause the problem. So there's a 25% chance I've got kidney cancer. No, no, no, no, no, no, no, no, no. We want to help them be able to evaluate the likelihood that whatever's going on, whatever they're reading applies to them. If there's a chance that there might be something terribly wrong, then of course we want them to go to the doctor and get that checked out. But we also don't want them to freak themselves out every time they read something on the Internet. I know some as far as to say, just don't go to these websites because they give you the worst case scenario and you're just going to freak yourself out whether you want to take that position or not. Again, it's helping clients figure out how does this apply to me. So if I'm looking at, personally, if I'm looking at something about low back pain, I'm going to read through that and go, well, I live on a farm and yeah, I was working out in the garden for seven hours this weekend, hoeing and raking and doing all that kind of stuff. And I increased my weight on squats at the gym. So there's a good likelihood that the reason my back hurts is because of stuff I did over the weekend. This is not brain surgery. And, you know, let's look at, could it be kidney cancer? Well, my mother died of kidney cancer, so yes, it certainly could. However, do I have the risk factors for kidney cancer? How long has the pain been persisting? Do I have any other symptoms? That are going along with it. Have I had a physical in the last year that indicated that in my blood work or anything else that anything was wrong? These are the questions you want to help clients start learning to ask themselves so they can de escalate when they read something that is terrifying to them. Additionally, a lot of health insurance plans have an on call nurse that you can call if you've got questions. So if the client didn't know what questions to ask but they read that article and got themselves freaked out, then they may be able to call the nurse that's on call with their insurance company and say, hey, I've got these symptoms and I read this article and now I'm really freaking out. You know, what guidance can you give me? And the nurse will probably ask similar questions and then because of liability, follow up with. But it's always best to check with your doctor which is always, you know, kind of backs up. You get the person feeling good and then they give you that but there and you're like, oh, maybe they're just trying to keep me calm. But we do want to encourage clients to be informed consumers. We want to educate clients about the impact of nutrition, sleep, exercise, sunlight, relaxation, our thought patterns and our mood on our general health and our goals and whatever their condition is. We don't prescribe anything. We don't say this is what you need to eat every single day. We may say let's go to health.gov and look at the nutritional guidelines for recommended for adults. You know, provide them information that is educational that they can read, find out about. Then they can take their specific questions to their physician or their nutritionist or whomever and get those answered there. Teach clients about how to set smart goals. So we help them where to learn where to find this information. We help them learn how to find different interventions. They can get self help books and all kinds of stuff. They are great, they have all these tools, they are excited, they want to find recovery. And then they are like, okay, now how do I implement all this crap? And that's where the smart goals come in. Remember, smart stands for specific, measurable, achievable, relevant and time limited. And finally, we teach clients about motivational enhancement. Not every day is going to be an a game day. We want to help clients recognize when their motivation is waning and learn what to do to enhance it to keep them moving forward. And just like that trip that you may have googled, it's important to recognize that sometimes everybody needs a rest stop. Sometimes everybody needs to take a Break and just kind of solidify those gains for a minute, stretch their legs, so to speak, before they get back in the car and start moving to their next destination. It's important for coaches to use patient centered care to develop an engagement with clients and develop that rapport. Using a person centered model or patient centered model. We provide respect for the client as an individual, that unconditional positive regard. Maybe you're working with a client who wants to get healthy, yada yada yada, but they are determined that they quit smoking, but they're not going to quit using smokeless tobacco or they're not going to quit vaping. That is their choice. It is not up to us to tell them what they need to do. It's up to us to help them achieve the goals that they have. We need to respect clients preferences for their goals and their interventions. If we tell people they need to start getting more exercise, you know, maybe you're working with somebody who has diabetes and the doctor wants them to increase their physical activity. Maybe they don't like the gym. A lot of people don't like the gym. Okay, you know, their preference for physical activity interventions is not going to be go to the gym. What else could we do? Instead we want to use a collaborative approach to providing choice and self determination. Letting them know that here are your options. You know, when we're talking about physical activity, you can walk a dog, you can go on a walk yourself, you can get home videos and do yoga, you know, it's pretty limitless. Or you can just vigorously clean your house every single day. However, the choice of what you do or if you do anything is up to you. And that's where the self determination comes in. If they decide that they are not motivated to do that, there's only so much education and motivation that we can do. Ultimately, it is up to them to decide to determine what is in their best interest with a person centered model. As coaches, we help coordinate and integrate care around what that patient needs at that particular point in time. We provide validation, support, encouragement and empathy. And when appropriate, and you've got all the releases and all that kind of stuff, we involve social supports if we're not allowed to. If the client doesn't want us to involve other people, we can talk with them about how they might involve social supports. Maybe they're trying to live a healthier lifestyle, but everybody in their family eats lots. Maybe they just got diagnosed with diabetes and everybody in their, in their household eats lots of sugar and there's cookies and cakes and you know, just stuff all around that is just so tempting, but is so not healthy for them. How could they involve their family? Does that mean their family can never have donuts again? Certainly not. However, maybe keeping donuts in the house can be changed and the people who can eat donuts may go out to Dunkin Donuts or something once a week or however, often eat there instead of, you know, torturing the person who has been recently told that they can't have that anymore. To enhance motivation, there are six different dimensions of motivation. We want to ask clients when they're doing something. They're trying to start an exercise program, eat healthy, or whatever it is, how will this. Doing this help you be happier? And that could be, I'll have more energy, so I'll be able to do stuff I want, whatever it is. How will doing this help you be happier? And then the mental aspect of motivation is, how does doing this make sense in terms of helping you achieve your overall goals and do things that are important to you? Can you see how this is logical, that this needs to happen in order for you to reach your other goals? The physical aspect of motivation, how can this improve your health and energy? How is it going to make you have less pain? How is it going to help you sleep better? How is it going to impact your physical health and your body? The social impact of motivation, how will it enhance important relationships? Maybe if you are healthier, you're going to be around longer for your kids. You know, people who have uncontrolled diabetes tend to have lots of health complications, and so they make it to meet their grandkids or their great grandkids. It will help them potentially be able to engage in more active things and do things with people that they care about for a longer period of time socially. You also want to ask them who's supportive of this change? Because getting that cheering squad going is really important to helping people with their motivation. Just somebody there that can always say, I know you got this, I know this sucks right now, but you can do this environmentally. How can you enhance motivation? Put things in the environment that enhance motivation. Put things in the environment that show you what's important to you. I remember when I was in college, before spring break, I would always hang my swimsuit in the kitchen. That way, when I went in there to mindlessly eat, I would see my swimsuit and go, you know what? No, I'm really not actually hungry right now, and I want to fit into that in a couple of months. Some people use pictures, some people use you Know sounds, whatever it is that helps that person remember to do what they're supposed to do. You know. Another environmental thing to enhance motivation would be when I go to the gym, I pack my gym bag ahead of time at night, I put it by the front door to remember that I'm going and I make a playlist for that day. So I'm excited about whatever the music playlist is that I'm going to get to listen to. It doesn't take much to get me excited. But have people just think about different things that they can put in their environment that remind them to do it and get them kind of excited. Another environmental thing kind of goes with social too, is maybe to have a buddy if they're trying to eat healthier, they can have a nutrition buddy if they're trying to work out more, an exercise buddy and spiritually ask them, in what ways does this change whatever you're trying to do, help you live in more harmony with your personal values and feel a greater sense of connection with other people. Now, not everybody's going to buy into the whole spiritual aspect of motivation, and that's fine if they don't. Most everybody can answer the questions about emotional, mental, physical, social and environmental aspects of motivation. The more of those aspects that you can bring to the forefront, the more reasons basically they have to maintain that treatment plan. Motivational techniques, I use the acronym ROADS Reflective Listening. We want to hear what they say, reflect it back to them, reflect how excited they are about this new challenge, reflect their and also reflect their concerns so you can talk about them and deal with them. But we want to reflectively listen in order to develop rapport and help validate the person's excitement as well as concerns and clarify for them or help them clarify for themselves what they're getting ready to do. We want to ask open questions, not yes or no questions, but tell me what the next step is that you need to do to achieve your goal. So ask them an open question that they have to answer with at least a full sentence, if not a paragraph. We want to use affirmations of self efficacy and optimism. Point out the things that they're doing well, look at their journal, point out even incremental improvements that they've got. And okay, maybe they had a bad day one of those days, but the next day they did better. All right, so you had a bad day. We may want to look at why you had a bad day that day. But look at you. You got up the next day and you got right back on the horse. So Good for you. We want to affirm what they're doing and encourage them to keep moving forward. We want to develop discrepancy between what they're doing and what they're saying they want. If they're saying they want to be happy and healthy and live to be 100, but they are continuing to maintain an unhealthy body fat percentage, smoke, not exercise, and eat high cholesterol foods, then we may want to point out the discrepancy between that. I hear you want to live to be 90, and I'm concerned that some of the lifestyle activities that you're doing are working against you for that. Or what do you think the effect is of not exercising? And then we want to summarize for them what they want, what their goals are, what their plans are to achieve those goals, why they can do that, that self efficacy and optimism and, you know, kind of tie it all up in a bow for them. So Rhodes in motivational techniques stands for reflective listening, Open questions, Affirmations of self efficacy, Develop discrepancy and summarizing. Part of what we're doing when we're increasing motivation and when we're educating is teaching. We're teaching people how to be their own best advocate and their own best provider. We want to provide explanations of why specific concepts are being taught. If you're teaching them about the five or six aspects of motivation, they may be sitting there going, yeah, yeah. How does this apply to me? You want to help them see at the beginning, give them a scenario about something that they weren't motivated to do, for example, and how motivational enhancement techniques can get them more motivated to do it. Or you might want to choose something that they're, you know, kind of on the fence, you know, not excited about doing, but they know they have to. Well, let's talk about some motivational techniques, some aspects of motivation that we can enhance to help you get more committed to that action. Adult learning theory also ensures that the learning is connected to people's health goals. You want to make sure that people know why this is relevant to their ultimate goals. And people are much more likely to remember stuff that is meaningful to them. You know, if you give me an address of somebody that maybe I have to go pick somebody up to take them to the airport, I may remember that address for as long as I need to to get to their house or to put it in my gps, but then I will forget it after that because that address is not meaningful to me. If you tell me something that's meaningful, to me, then I am probably going to commit that more to my long term memory. When you're working with clients to help them learn things, to educate them, to help them increase motivation, all that kind of stuff, clients don't like you to tell them stuff that they already know. They feel that that's patronizing, which it kind of is. So use self assessments to assess different levels of understanding and their different prior experiences and education so you know where they're starting at. If you're working with somebody who has a master's degree in dietetics, then you probably don't need to help them understand where to find reliable nutritional information. If you are working with somebody who is never graduated high school, is moderately literate and doesn't have, you know, maybe works in, you know, a blue collar job of some sort, they may need a whole bunch of additional information because they don't have that knowledge, not because they're stupid, just because they've never been privy to it. Nobody's ever taken the time to point it out to them. Another example, if you're working with somebody who has an eating disorder, most people, not all, but most people who have eating disorders have studied nutrition and exercise and calories and body fat inside and out. So if you start talking to them about how many calories they need every day, they're going to roll their eyes at you. You need to approach it from a different perspective with them because they have the knowledge there and they have experience with dieting. They have experience with clinicians who don't understand that for them it's not about food so much as fear of being fat and control issues and other things. But we want to make sure that our clients basically walk out the door with the same level of information. They may come in with vastly different levels of knowledge, but we want them to leave with the same level of health literacy. Remember that prior learning is also the filter with which people conceptualize new information. If they have a negative prior filter, they've had negative experiences with counselors, for example, then they may not want to go to a counselor. They're hearing that and they're going to. Yeah, I see, I hear you're telling me that I need to do this, but I'm not interested. That's not going to help me. Maybe they've tried to lose weight before and they lost weight for three weeks and then they put it all back on again and then some. So then you start talking to them about dieting or implementing the plan that their doctors set forth for dieting. They're conceptualizing it as an insurmountable task. We want to hear these things as coaches. We can say, okay, I hear you're anxious about this goal that the doctor has set for you because you've had failures before. Let's look at what may have contributed to those failures and anticipate them so you can know what to do when they happen so you're more successful this time. Use multiple methods of instruction, including auditory. Talk with them, tell them about it, talk with them about it. Visual Use handouts that they can read. Graphs, charts and kinesthetic. Have them do it. Ensure access to sufficient resources. And if they're adult students, you know, some of your younger students are going to need a little bit more direction. But adult students prefer self directed approaches that allow for discovery on their own. They don't want you to hand them everything and go, here's what you need to read. They want you to help them figure out how to find stuff that will help them learn. Behavior Change Theory when presented with a need to act or behave, people choose what's most rewarding. One issue many people have is delay of gratification because they choose what's most rewarding in the moment instead of overall. So when somebody gets angry and they put their fist through the windshield of a car, probably not the best choice in the long term because then they have a big bill for replacing their windshield and maybe charges filed against them for, you know, whatever the charge would be for that. That's in the big scheme of things that goes against their goals, but in the moment, it was the most rewarding. What we want to do is help people learn how to delay gratification and look at the big picture and go, yeah, that would right now staying in bed sounds like the best thing. And that would be the most rewarding thing at the moment. But in the overall scheme of things that I want to accomplish, getting up and going to work so I get a paycheck is probably more rewarding. Remember that rewards or reinforcers encourage a behavior to repeated and consequences or punishments discourage a behavior. We want to eliminate the punishments and, you know, increase the rewards. Stimuli are things that prompt a person to engage in a behavior. If you want them to get up in the morning, you have them set a stimuli, an alarm that gets them up in the morning. There are other things that can also encourage them to get up. Like if they have a coffee maker that auto brews so it's ready when they get up, then when their alarm goes off, guess what? They smell that coffee and they're like, oh, no, that's a reason to get out of bed, and they can move on. We want to help increase the rewards for doing what they want to do, doing what's best for them in the long term, and decrease the rewards or even add punishments if we need to, for doing things that are counterproductive to their current behaviors. For example, there's somebody in my family who is diabetic. Rewards for eating right and eating healthfully is that they are able to reduce the amount of insulin. They don't have to take their blood sugar as much. Consequences for not following their dietary guidelines is that they end up having to take their blood sugar a lot more often, so they're having to stick themselves a lot more and potentially take more insulin. Behavior change examples Emotional eating. Well, food is associated with pleasure and happy times. When there's a celebration, we eat. When there's a holiday, we eat. When you get all A's on your report card, parents take you out to dinner, you eat. So food is generally associated with happy times. Food also releases pleasure chemicals in your brain, which correlates it with happy times. Food is a readily available stimulus. If you're at home, you've probably got a kitchen there, and in that kitchen is probably food, unless you're in college, in which case it may just be a box of baking soda in the fridge. But if food is readily available, and when people are stressed or bored, the sight or smell of food in real life or in the media can prompt eating behaviors. So if you're sitting at home watching TV and all of a sudden this commercial for a pizza comes on, you may be sitting there going, oh, I'm bored. I need. I need to eat pizza right now. I need a pizza. So then you call and have pizza delivered or something. And that can be associated with the stimuli in the environment and then the desire for immediate gratification, immediate reward, or pleasure. Another example would be a habit. If Sally smokes a cigarette when she's driving to work in the morning, she smokes another one after lunch, another one on the way home from work, another one after dinner, and another one before bed to relax. So Sally's smoking kind of throughout the day. Smoking, we know, strongly activates pleasure centers in the brain. So smoking has a reward, just like food does, or sex or a variety of other things. Triggers for wanting this pleasurable experience include being in the car. Then Sally starts to associate being in the car with smoking. So when she gets in the car, it's kind of an automatic behavior to light Up a cigarette after meals. A lot of times Sally probably doesn't even think about it. She's like, finished my meal time to have a cigarette. Or when she needs to relax, she may naturally, out of habit, reach for a cigarette. The goal would be to help Sally become more aware of these triggers. Put things in the environment, in the car that help her remember not to smoke. For example, maybe put a little sign on the dashboard that says, no smoking. Take the lighter out of the car. Have her not keep cigarettes in her purse. Things that can help break that habit. But we also have to make not smoking more rewarding and less punishing. We've all talked to people who've tried to quit smoking, and they say, oh, my gosh. Not all of them, but most of them that I've talked to said it is just an agonizing experience. We may encourage them to talk with their doctor about medications that can help curb those cravings so they don't feel as deprived, they don't feel as edgy, they don't feel as uncomfortable. When they feel that uncomfortable, it's hard to delay gratification. They're like, I've got to make this feeling stop. So if we can help it be less punishing, but also more rewarding, Other things you can do, you know, I said, put triggers in the environment that remind her not to smoke, maybe a picture of her kid. You can also encourage her to reward herself for not smoking. So take the money she would have spent on cigarettes, and at the end of the week, she can do something that she really enjoys. All of those are examples of behavior change that can be implemented. And health coaches are in a great position to help clients really brainstorm and think through what are the obstacles or the punishments to this new behavior. You know, why don't I want to do it? And how can I make it so I do want to do it? All the education in the world isn't necessarily going to make somebody change. They have to be ready. And prochaska and diclemente created the readiness for change phases. We will say, because people don't go through these one after the other in a linear fashion. They'll go through go to one, then they'll go to the next one. Then they may step back. It's more like a cha cha than necessarily a forward linear progression. Pre contemplation is the first place. In pre contemplation, the person's not even contemplating the fact that they've got a problem. The person may say, I don't have a problem. With my blood sugar, I don't have diabetes. The test must be wrong, and they ignore it. Contemplation. The person may start to agree that, yeah, you know, something may be going on, but my symptoms really aren't that bad. I can just control it by eating healthier. I don't need to start testing my blood sugar and doing, you know, taking insulin or whatever it is that the doctor wants me to do because I really don't like those needles. Want to go there. Preparation is the next step, and the person may start realizing that, okay, this is a bigger problem than I thought. I'm having difficulty controlling my blood sugar. I really don't want it to get worse. Let me start looking at my treatment options. They're preparing to make a change. They're kind of increasing their motivation in this stage, in the action phase, they're ready to do something. They've decided that it's bigger than them. They. They need assistance, they need to change, and they're ready to do it. So the person may say, I need information and tools to help me manage my blood sugar and make better lifestyle choices. And in this action phase is when they're going to start seeing clinicians and experts that can help them develop a plan in maintenance. The person knows what they need to do, and they just need to maintain their motivation and willingness to do it. Like I said, motivation will wane. All of us who have set New Year's resolutions know about this, because motivation. In January, we're gung ho. By mid February, we're lukewarm. By March, we're not doing it anymore because our motivation has waned for some reason, unless we've stayed on top of it. And that's just natural, your motivation for a lot of things, you're going to get bored with it, so to speak, or find other things that are more interesting. So it's important to stay on top of motivation and relapse. While it's not necessarily a required phase in the readiness for change, it happens for the majority of people. It doesn't mean you go all the way back to the beginning necessarily. It can be what we call a slip, where people start kind of, you know, if they're. If they've got diabetes, for example, they may start cheating a little bit. They may have a great big old piece of cake or something that they're really not supposed to have here and there. And that here and there starts becoming a little bit more frequent. And that's what I would call a relapse. They're falling back into old ways of acting and behaving that contributed to their problem. And this is when we need to help them notice that before it gets completely out of control and get back into the action or maintenance stage. With health coaching, we start out by creating a wellness vision with clients. We want to have them describe their body and mind in their ideal state. So in your vision of wellness, if you were as well as you wanted to be, and most people don't even have a clue how to define wellness, but what would you look and feel like? You know, would you, you know, for me, I would be stronger. I would have a little bit more energy. What types of things would you be doing or not doing? What are the most important elements in your vision? It could be their weight, it could be their blood pressure, it could be their energy levels. You know, what are the most important elements and why are these elements important? How is whatever this thing is, maybe energy is an important element in your wellness vision. Having more energy, why is that important to you? How is that going to improve your life? Helping them identify the ways that it's going to improve their life and you can talk about how is it going to improve your life emotionally, mentally, physically, socially and environmentally? Which one do you want to work on first? You can't do everything at one time. People have to choose one, two, maybe three goals to work on. Any more than three, and I find that people really have a hard time effectively implementing anything. But any change in the person's health and well being is going to have positive changes in their whole system. So have them pick one or ideally one or two things that they want to start with. On a scale of 1 to 5, what is your level of confidence that you can achieve this goal? We want to help them get to a five in their confidence. If they say it's a two, then we want to ask why? And help get them the resources to empower themselves to get to a five. It could be prior failures, could be lack of knowledge, it could be lack of time or lack of resources. All of those the health coach can help with. What types of assistance might you need in achieving this? So again, if their confidence is low or even if their confidence is high, they may say, my confidence is high as long as I've got these widgets, these resources available to me. Then we start making a list and helping them figure out how to access those resources. What obstacles do you anticipate and how can you deal with them? This is a big question because if people don't anticipate any obstacles Then they're not really thinking it through. Everybody's gonna have obstacles in what they do. You know, if you're trying to exercise five days a week, what happens if you fall and sprain your ankle, you know, and then you're not supposed to bear weight on it for three weeks? You know, that's an obstacle. Or if your kid gets sick and you don't have childcare so you can't go to the gym, that may be an obstacle to exercising. What can you do and what strengths and resources do you have that will help you accomplish these goals? One of the ways that I have people fill this out is think about times in the past when they've tried to set that goal or tried to achieve that goal before and what's kept them from fully achieving that goal? Also, what has helped them when they were being successful with that goal, what helped them keep their motivation and helped them in their successes? For example, with me going to the gym, when I had a gym buddy, I was a lot more motivated to get there because I wasn't going to have her show up at the gym and then me not show up. That's just not who I am. So that got me to the gym every single day. Encourage people to visualize their goals. Have them use pictures, collages, scrapbooks, anything that they can put up there so they can visually see what they're working toward. You may have them use push notifications for their goals, and you can set SMSs to come to your mobile device that reminds you to do things and that reminds you why you're doing things. You may have a push notification that comes through going. Remember to keep pushing through on your exercise goals so you have more energy because you want to be able to play soccer with your kids or whatever it is. But those goals can come in the form of motivational statements and push notifications. Encourage clients, if they're so inclined, to write a narrative, not everybody's picture oriented. Maybe they want to write a narrative of what their life's going to be like, what this goal is. Encourage them to use charts so they can see progress. They can chart out how far they've come and the improvement in their symptoms. And finally, encourage them to use mental imagery. Encourage them to spend 60 seconds in the morning before they get out of bed or while they're drinking their coffee or whatever it is, closing their eyes and just seeing themselves succeed, achieving this goal. And it may be seeing themselves achieve in that goal for that day. Sometimes that's as far as I can get in the morning as I'm sitting there drinking my coffee and I'm visualizing myself getting to the gym and getting my workout in, and I'm like, okay, I can do this. I saw myself do it. I know I can do it. Now I got to get up off the couch. When we're teaching them how to set goals. One principle that I was taught when I first started working in community mental health was KSAs. Knowledge, skills and Abilities. Clients. And remember, we have to assess where clients are when they come in because they may have a lot of knowledge already, but we want to make sure that they have knowledge of the physical, emotional, cognitive and behavioral factors that mitigate or improve their situation, but also the physical, emotional, cognitive and behavioral factors that make their problem worse. We also want to have them have knowledge of the physical, emotional, cognitive and behavioral factors that can help them achieve their goals. So, for example, sleep. I do a lot of. I spend a lot of time educating people about the benefits of sleep for depression, for pain, for energy actually, and help them understand how some, you know, interventions in any of these areas may help them achieve their ultimate goals once they have that knowledge. Kind of like when we went to graduate school, you have all this book learning in your head, but what do you do with it? How do you actually implement it and translate it into practice? And that's what skills are. That's when we help clients take this knowledge. Okay, you know that eating five servings of vegetables every day is a recommended practice. Now how can you make that happen? You know, how can you turn that into something that actually happens in your day? You can write a menu, you can have a variety of vegetables pre prepared in the fridge. What can you do? And then abilities is taking those skills now that you know what you could do, you know, in theory, and it's actually doing it. And that's what we want clients to report on is how often did you eat your five servings of vegetables? Every day. And that shows us that they have the ability to do it every single day. Goal setting, as I said before, has to be smart, specific, measurable, achievable, relevant, and time limited. You want to make sure that there are numbers and so any person can look at this person's journal and say, yes, they achieved their goal or no, they did not. Not. Well, probably it's a yes or a no. It's a clear answer. I'll give you examples of that in just a minute. But when we're helping people learn things, sometimes they need scaffolding. We can't just Take them from knowledge and go. Okay, well, here are the skills. So now you know how to implement it. Go ahead. It's kind of like teaching somebody how to ride a bike. You don't tell them how to keep their balance, then put them on the bike and just push them. Sometimes you do, but I would hope not. No, you tell them what they're going to do. And then, you know, you have them get on the bike and you hold the bike while they pedal and kind of get their balance and get used to it. And then you may let go of the handlebars, but still have, have a hold on the back. And then at a certain point you let go and you let them try to do it on their own. And if they fall, you help them start over again. Scaffolding is kind of like that. Scaffolding helps people as much as they need help, but no more. Goals are specific and shared rescue or help is immediately available. And this is using the acronym grow me. Optimal level of help is provided. So we want to encourage self efficacy. We don't want to do things for people that they can do for themselves. I remember when my son was little, took me forever to get him to tie his shoes. Well, why? Because either I did it for him or he got somebody else in the house to do it for him, or he had Velcro closures on his shoes so he didn't have to learn it. He didn't feel like he needed to. So he didn't have the confidence that he could learn how to do it because he tried it a couple of times and it didn't go well. So we want to encourage self efficacy, encourage them to and help them succeed. Use concrete prompts for what you're doing. When you're teaching somebody how to tie their shoe, you teach them how to take the laces and then you make an X and then you tuck under the X. However, whatever metaphors you use when you're teaching, but you're using concrete prompts and there's steps each of the way, you know, cross under the X. So then you've got it tied. And then you make the bunny ear or the tree or whatever you call it, and then the bunny runs around the tree. We've all got our own ways of teaching how to tie shoes, but there are specific steps. And you have children or people do the steps up until the point that they can't independently do the steps anymore. Math is the same way. You know, you may get to the point where, you know, somebody can. I'm not Good with math. So I'm not even gonna go with that metaphor too well. But, you know, there was a point I could do addition, subtraction, multiplication, fractions, but then when they started throwing letters in there, it just kind of got icky for me. So I could get all the way up to the point where I had to start working with the letters, the algebraic functions, and then I needed a little bit of prompting here and there. So we want to encourage the optimal level of help using concrete prompts, prior knowledge, and their preferred learning method. If they don't learn well by having you talk to them, you may have to write it down for them. If they don't learn well by either of those, then you may have to do it kinesthetically, where they're actually doing the activity and you're along with them for the ride. And then you can. When they start to struggle, you can intervene. Use a whole task, holistic approach. You have this big task, whatever it is. And remember we talked about how there's multiple steps on the path to your ultimate goal? That's fine. We're going to break it down into smaller sub goals. We also need to recognize for each sub goal as well as the overall goal, there are cognitive aspects. You know, what is the goal the person wants to achieve? What is the sub goal the person wants to achieve today? What are their concerns about it? And can we elicit confidence in their ability to do it? And then ask them, what is it that you need to do today? So the behavioral aspects of the task, we want to model desired behaviors, whether it be riding a bike or tying our shoes or eating healthfully. We want to show them how to do it. You know, we're over here doing it. Okay, you can do it. Do it too. And then we want to empower them to take chances. I'm teaching my son how to make banana bread right now because he loves banana bread, and. And I've used a scaffolding format with him. I taught him what he needed to do, showed him where to find the recipe, and I did it while he watched one time, and then he did it while I watched one time. And now we're to the point where I can tell him, you start trying to make it, and if you get stuck, give a shout and I'll come in and help. And he's getting to the point where he's more confident in making his own banana bread, which is great because he can eat an entire pan of banana bread in a day. With behavioral health and chronic conditions, the treatment Plan is often developed by a clinician or could be developed by a person for wellness enhancement maybe. And we see this a lot with Alcoholics Anonymous. For example, people decide they want to quit drinking, they don't want to go see a clinician, and they decide what they need to do to address their alcoholism. The person needs to overcome barriers to participation such as follow up appointments, homework assignments, going to meetings, whatever the case may be. The coach can also help them identify warning signs of relapse and recognize and respond to those signs and symptoms. A health coach, or in the case of of 12 step programs, a sponsor will often have people keep a 30 day goal and record progress chart so they can see how the person's doing not just with their drinking, but also with their homework, which is generally working the steps and maybe their mood, their sleep, it depends on the sponsor. They will have the person journal health information including what they're eating, their nutrition diary, their sleep and their mood, etc. Which can be used to present to a clinician, whether it's a doctor or a mental health clinician as needed. And sometimes this is only information that's collected and may be presented to a clinician at an annual health checkup. They're not seeing the clinician for this condition, but they're collecting information to provide to their care provider and get any questions answered at that exam. For self improvement, help the client identify goals for 30, 60 and 90 days. You know, ultimately, what's your big goal? Okay, that's great. Now, three months from now, where do you think you want to be? 60 days from now, where do you think you want to be? What do you want to accomplish in the first 30 days? What's most important? Help them start breaking it down so it doesn't feel so insurmountable. Losing weight. For example, you know, people generally aren't going to lose more than a pound or two a week. So if they have £100 to lose, that's a huge goal. All right, so what's realistic, specific, measurable, achievable, relevant and time limited? What's realistic for a week? £2. If they've got £100 to lose £2, it's probably realistic. So their goal, their smart goal is to lose two pounds in a week, to lose eight pounds in a month, to lose 16 pounds in two months. You see where we're going with this? So they have these incremental goals and when they finish one, they lost two pounds in a week, they can go, alright, I made progress. Develop an effective, understandable Management strategy based on smart goals. So the next step is, okay, you want to lose two pounds a week, what are you going to have to do to make that happen? And then you work together and the person will tell you what they're going to do and you can help them chart it out in a service plan. Help them overcome barriers to achievement by looking at prior failures and figuring out why it hasn't worked before or anything. They anticipate being a problem this time. Identify triggers for and signs and symptoms of backsliding, relapse, and develop a prevention or intervention plan. That way the person can see, you know, if they start, you know, having cravings for chocolate or, you know, binging on pizza or whatever it is, you know, that may be a sign of relapse and they may need to look at why that's happening. And coaches may not be in a position to help them really address those issues. They may, they may not. That may be something a clinician needs to handle, depending on the person, but being aware of obstacles to goal attainment and things that obstacles to maintaining motivation are really important. And health coaches can help point out to people when it seems like their motivation might be waning a little bit. And again, have the client keep a record of what they're doing every day to chart their progress towards their 30 day goals. In a sample wellness plan, encourage the person to identify their vision. And in this sample, 1, the person wants to have good energy, maintain mental functioning and stay physically healthy. Now that's all real, general, that is not specific, measurable, time, limited, yada yada. As a wellness coach, I will educate them about the importance of sleep, nutrition, exercise, stress management and in this person's case, smoking cessation on those things, how does poor sleep affect their energy? Or likewise, how does good sleep impact their energy, how does good nutrition improve their mental functioning and help them stay physically healthy, etc. So I will help them see how different interventions can help them and then they're going to choose from those interventions which ones they're willing to do, have them set their six, three and one month goals and then finally have them set their week goals. So this week I am going to do what, how often and how much. I am going to drink eight glasses of water every day. I am going to exercise for 30 minutes a day at a moderate intensity that gives the person a very clear yes or no, yes I did it or no I didn't, and then have them keep a log, for example, what I did for each of my goals, my energy level on a scale of 1 to 5, 1 being no energy, 5 being I was just, you know, a little energizer bunny. My ability to concentrate and remember, because remember, mental functioning was one of their goals. Again, a one to five. One couldn't concentrate to save my life. Five Laser focus, my weight and my blood pressure. And that goes with staying physically healthy. And for this person, you might also have a line in there about how many cigarettes they smoked, but that gives them data to track to see how they're progressing towards their goals. Health coaching is a valuable resource to improve client retention and success. Health coaches can help with treatment plan implementation and relapse prevention. Health coaches have the opportunity to increase people's health literacy, teach people how to enhance motivation, teach people how to set smart goals and help them attain those goals. Thank you for listening to Case Management Toolbox podcast. Go to allce.com casemanagement to access the CEU course for this episode. You can also subscribe to Case Management Toolbox Podcast to be notified when new episodes are released.