Is telephone health coaching a useful population health strategy for supporting older people with multimorbidity?
There is agreement that innovative services are required to better care for older people with multiple long-term conditions, which can be provided ‘at scale’ to enhance self-management and keep people out of hospital. Health coaching involves ‘a regular series of phone calls between patient and health professional...to provide support and encouragement to the patient, and promote healthy behaviours’.The overall evidence on health coaching is complex, There are a number of positive evaluations, but the studies have included a very mixed group of patients and interventions. Further research is indicated to assess the impact of this promising intervention and its place in integrated care for long-term conditions.
PROTECTS (Proactive Telephone Coaching and Tailored Support) is a pragmatic, individual level randomised trial to evaluate the effectiveness and cost-effectiveness telephone coaching in older people with 2 or more long-term conditions. The intervention was delivered by a health coach already delivering coaching to patients with diabetes. Training focussed on the additional skills needed to deal with a wider range of long-term conditions, and dealing with low mood. PROTECTS used the innovative cohort multiple RCT design (BMJ 2010;340:c1066), where a large population cohort is recruited and followed over time, and trials run within the cohort using a new ‘patient-centred’ model of consent.
1306 patients met the eligibility criteria and 504 were selected for ‘health coaching’, with 41% consenting to treatment. Over 80% of consenters received the defined ‘dose’. In the overall intervention to treat analysis, patients selected for the intervention and those not selected did not differ on outcomes (patient activation, quality of life, depression or self-care). In the analysis of economic outcomes using routine hospital data, patients receiving health coaching reported lower levels of emergency care, although their use of elective services increased. Overall costs were increased, but health coaching was also associated with improvements in health related quality of life. The overall cost per QALY ranged from £7-13,000, with a 60-70% chance of being cost-effective at conventional levels of willingness to pay.
The cohort multiple RCT estimates the effect of being selected for treatment, regardless of whether that offer is accepted. This compares to a conventional trial where patients who do not give consent are excluded. Demonstrating effectiveness in a cohort multiple RCT is even more challenging than a conventional pragmatic trial. We argue that the treatment effect estimated is an appropriate one for health coaching, as it is a model of care designed to be proactive to achieve population benefit.