Articles  |   April 2010
Health-coaching strategies to improve patient-centered outcomes
Article Information
Cardiovascular Disorders / Preventive Medicine
Articles   |   April 2010
Health-coaching strategies to improve patient-centered outcomes
The Journal of the American Osteopathic Association, April 2010, Vol. 110, eS12-eS14. doi:
The Journal of the American Osteopathic Association, April 2010, Vol. 110, eS12-eS14. doi:
As outlined in the Joint Principles of the Patient-Centered Medical Home (PCMH) and other sources, the physician-patient interaction is crucial to the PCMH approach to ensure the rapport-building and engagement that leads to an optimal clinical relationship.1 This interaction is also critical for improving outcomes in cases where the patient receives chronic care management, such as in the treatment of dyslipidemia, when therapeutic lifestyle changes (TLC) and medication adherence play such a key role in determining treatment success. Using techniques from the behavior change science arena can serve to improve adherence to TLC and medication, and it is in this capacity that health-coaching strategies offer the greatest potential benefit. 
Currently, motivational interviewing (MI) is the only health-coaching technique to be fully described and consistently demonstrated as causally and independently associated with positive behavioral outcomes.2 Continued research that includes rigorous methodology has solidified the efficacy of MI, and there are good data and guidelines to support the use of this client-centered approach in the primary care setting.3 This approach is especially helpful in situations where the patient is less motivated, less ready for change, or “stuck.” It is important to note that the physician does not need to acquire the skillset of a counselor or psychologist to incorporate MI into brief clinical encounters. 
Following are some MI-based techniques that can be incorporated into the clinic setting using the example of a patient being treated for primary or secondary prevention of dyslipidemia. These strategies can be used alone or in conjunction with each other. 
Elicit-Provide-Elicit (E-P-E)
Before offering education or advice, the physician should first assess the patient's knowledge about the connection between lifestyle choices and reductions in coronary artery disease (CAD) risk. The objective of the Elicit-Provide-Elicit (E-P-E) technique is to find out what the patient already knows, fill in the gaps or correct misconceptions, and explore how this will fit into the patient's life. This is a timesaving strategy that both validates patient knowledge and allows time to address barriers. The E-P-E technique consists of three main components: 
  • Elicit: Find out what the patient already knows by asking him or her directly
  • Provide: Fill in the gaps and/or correct any misconceptions the patient may have
  • Elicit: Find out what this information means to the patient's life
The following is an example of a hypothetical discussion between a physician and patient using the E-P-E technique in the treatment of dyslipidemia: 
Elicit: “Mr. Jones, I'm curious about what you already know about reducing your risk of coronary heart disease. Do you mind telling me?” 
Provide (after patient response): “You are exactly right about diet and exercise playing a big part, even though it can be hard. I'd like to add how important medications can be...” 
Elicit (after patient response): “Of everything we just mentioned, what is the biggest challenge for you? What could help you in this area?” 
Assessing importance
The Assessing Importance technique can be employed to explore and enhance the patient's motivation for medication adherence. The objective of this technique is to assess the importance of the behavior to the patient on a scale of 0 to 10, find out why he or she cites this level of importance instead of a lower score, find out what would increase the level of importance, and summarize the discussion. 
An example of the Assessing Importance technique in the treatment of a patient with dyslipidemia is as follows: 
  • “Mr. Jones, it's helpful for me to get a better understanding of how this medication fits into your life. Can I ask you a few questions about it?”
  • On a scale of 0 to 10, with 0 meaning not important at all, and 10 meaning the most important thing in your life, where would you rate the importance of taking your lipid-lowering medication?
  • Why are you a 6 and not a 1 or 2? Why else?
  • What would it take to move you from a 6 to an 8? What else?
  • So you forget to take your meds sometimes but you really do understand the overall importance of how it helps to keep your blood pressure down. What do you think would help you remember to take it every day?
Evoking change talk
Evoking Change Talk is an important strategy to evoke reasons for the patient to change and elicit a plan of action in at least one area according to the patient's readiness to change. The objective is to evoke the patient's desire, ability, reasons and need to change in order to strengthen the patient's commitment to the behavior during a session. This “change talk” predicts increased commitment strength to the lifestyle change, which in return is correlated to positive clinical outcomes.4 The end result of this technique is ideally a plan of action elicited from the patient. 
In the treatment of dyslipidemia, there are numerous ways to evoke change talk. One of the most simple ways is to ask an open-ended question that will elicit desire, ability, reasons or need to change. The following are some examples of possible questions: 
  • Mr. Jones, when people have to make difficult lifestyle changes, it can help to consider the immediate benefits, or what's in it for you. Can we talk about this for just a minute?
  • So what do you think are the benefits?
  • Of all the things that we've advised you to do to protect your heart, which one seems like the one you would be most ready to do?
  • What would be the top three benefits to you if you did this? How would your life be different in six months if you were doing this on a regular basis?
  • What is one change that you could see yourself making right now—even if it's only a small step?
  • Was there a time in the past where you were able to exercise? How did you fit it in?
  • If you were able to make these dietary changes, and look forward six months, what do you think would be the pay-off?
Normalizing and validating
Since depression is common in patients with chronic disease, it's important to feel comfortable while assessing for this risk factor. 
The Normalizing/Validating technique is used while assessing for depression. This technique encourages rapport and an honest exchange between the physician and patient, normalizes depression for patients who suffer from the condition, and validates the patient's feelings before a formal screening is performed. An example of this technique in the treatment of a patient with dyslipidemia who presents with indicators for depression is as follows: 
  • “Mrs. Jones, it's normal for women who have been through what you have to experience a period of being down-in-the-dumps or experience some depression. Do you mind if we talk about this for a minute?” (patient response)
  • Can you tell me how you've been feeling? (patient response)
  • So even though you think that you will get through this, you still worry about what would happen to your children if you had another heart attack. And you just don't feel like socializing with your friends as much as you used to. (patient response)
  • With your permission, I'd like to give you a formal assessment for depression because there are a lot of options for you to consider. There are things you can do to feel better about your situation and life in general.
Menu of options
Offering a menu of options is a patient-centered way to provide advice or information. It is most useful after trying to evoke a plan of action from the patient first. It's also a great tool when a patient is “stuck” and not sure how to respond. In presenting a menu of options, the physician allows patients to take ownership of their own treatments as opposed to directing and telling them what to do. Offering assistance for medication adherence problems in the treatment of dyslipidemia through the menu of options technique may take the following form: 
  • “Mrs. Jones, you've said that you are having a difficult time keeping track of all your medications. Can we talk about this for a minute?” (patient response)
  • What have you tried in the past? (patient response)
  • So, nothing has worked for you. What other ideas do you have? (patient response)
  • You feel kind of stuck. I have some tips that have worked well for other patients if you'd be interested in hearing about them. (patient response)
  • Here are three ideas... (physician goes on to list the tips)
  • Of these three different ways, which of these do you think would work for you? (patient response)
  • Great, you're going to try that pill box. I look forward to hearing how it's working for you.
Final notes
The most important first step for a physician to improve his or her health-coaching skill set is for him or her to embrace a patient-centered approach. In an acute care setting, the traditional directive style is appropriate and effective; however, when addressing lifestyle management or treatment adherence issues, using a guiding style is far more effective. 
The worst case scenario is one in which the physician is arguing for the change while the patient argues against it or, more quietly, feels resistant. The best case scenario is one in which the physician listens, explores and understands the challenges of the lifestyle change from the patient's point of view, while evoking change talk when possible. The likelihood of improved clinical outcomes is also significantly increased when the physician encourages the patient to develop and own his/her own plan, versus prescribing the lifestyle management solution. 
While this client-centered approach runs counter to traditional medical training, by embracing the fundamentals of behavior change science—and with practice—physicians can influence their patients' success in lifestyle management and treatment adherence efforts. 
  Susan Butterworth, PhD, is the founder of Health Management Services, which was developed at Oregon Health & Science University in Portland. She is a member of the Motivational Interviewing Network of Trainers and serves on the Scientific Advisory Board for Health Future and Health Sciences Institute. Dr. Butterworth provides consulting and training activities through her practice, Q-Consult, and is associate professor at both the Schools of Medicine and Nursing at OHSU. She can be reached at
American Osteopathic Association, American Academy of Family Physicians, American Academy of Pediatrics, and American College of Physicians. Joint Principles of the Patient-Centered Medical Home. March 2007. Available at:
Butterworth S, Linden A, McClay W. Health Coaching as an Intervention in Health Management Programs. Dis Manage Health Outcomes. 2007;15:299-307.
Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press; 2008.
Martins RK, McNeil DW. Review of Motivational Interviewing in promoting health behaviors. Clin Psychol Rev.. (2009). ;29:283-293.