Structured Agenda-free Coaching Conversation (“StACC”) Model
Defining the model, and how to use it effectively to support self-management and increase patient activation
- Author
- Kate Henry, Know Your Own Health
- Date
- 25th May 2022 (Updated 7th September 2022)
The Structured Agenda-free Coaching Conversation (‘StACC’) model is an evidence-based coaching model.
The model encompasses all the PCI-accredited Core Curriculum Health Coaching Skills and uses them within a Coaching Conversation structure in a way that supports self-management and enables patient activation.
Higher levels of patient activation are linked to better outcomes for patients and and reduced levels of clinical dependency (Health Foundation, 2018)
Advantages of the model:
- Delivered as a short term ‘intervention’
- Shown to increase patients’ activation levels (See evaluation results), leading to anticipated outcomes for higher activation, including:
- improved health and wellbeing outcomes, including anxiety, stress and depression, and clinical markers.
- reduced reliance on clinical services
- improved relationships with healthcare professionals, including more effective shared-decision-making conversations
- improved active engagement with life
- Is a behaviour change intervention that aligns well with theories of behaviour change such as the Transtheoretical Model and COM-B Model
- Is an alternative consultation framework to other coaching models, such as the TGROW model, and has the benefit of being designed specifically to support self-management and increase activation levels.
- Is effective for patients at all levels of activation, not only those who are already motivated to make changes.
- Simple to use. Coaches can start working effectively with it very quickly*
- Is supportive in its approach, reducing the risk of creating or exacerbating any sense of failure that can set someone back, which is important for everyone, but especially so for those starting at lower levels of activation.
*Note: It is a skill and, as with all skills, you have to know how to use it to get the desired outcomes, i.e. how to use the Coaching Conversation Flow structure (see basis of the model, below) as a supported self-management programme where the aim is to increase a patient’s activation levels.
The Conversation Conversation Flow structure can also be used by those in any role to enable them to have ‘Better Conversations’ with patients to support self-management and patient activation. The two uses have different dynamics and using it as a standalone 'intervention' will be more effective where the aim is increasing patient activation in the process of supporting self-management.
Background
The StACC model is built on learning from earlier Supported Self-Management (“SSM”) interventions and programmes designed for people with Long Term Health Conditions, such as Stanford University’s Chronic Disease Self-Management Programme Model, the Department of Health’s Expert Patient Programme, and the Health Foundation’s Co-Creating Health Programme (Health Foundation, 2007-2012).
In general, Supported Self-Management Programmes can take a variety of forms and can be condition-specific or focused on addressing specific problems such as managing fatigue, pain, etc. This was the case, for example, with the Stanford model, the Expert Patient Programme, and in groups involved in the Co-creating Health Self-Management Programme. Many self-management programmes aim to build knowledge, skills and confidence by teaching patients about their health condition or symptom and supporting them to self-manage more effectively.
The StACC model evolved most directly out of the Health Foundation’s Co-creating Health Self-Management Programme (“SMP”) and a number of NHS pilot services that KYOH was involved with and that followed from 2013. The model is now being used across England by many of the new Health and Wellbeing Coaches introduced into Primary Care in 2020 as part of NHSE’s Personalised Care agenda.
The model focuses solely on what is important to the individual and supports them to achieve it, irrespective of any specific health condition or symptoms. This approach supports patients to take ownership and control and, in the process, supports them to develop their own knowledge, skills and confidence to manage their health and wellbeing.
From the patient’s perspective, the StAC Conversation is an experiential intervention that taps into the patient’s own resources, enabling them to become aware of their own ability to positively affect, or even drive, their own health, wellbeing, and general life outcomes. It is most effectively delivered as an individual one-to-one intervention as it is highly personalised and wholly focused on what is important to the individual at that time: Coaching is focused on where the patient is ‘right now’ and how they would like to move forward.
The model
The basis of the model
The StACC model is based on the five-steps established through the Health Foundation’s Co-creating Health Self-Management Programme (“SMP”) that ran from 2007 to 2012. This provides a structure that Health and Wellbeing Coaches can use to support self-management and increase activation, utilising the PCI-accredited core curriculum health coaching skills.
The structure is straightforward and easy to learn. The skill, in terms of using the steps for patient activation, is in being able to move flexibly, forwards and backwards, within the structure in order to meet the patient where they are at any time, using the skills appropriately at each stage.
How the model works to increase patient activation
‘Patient activation’ was defined by Hibbard and colleagues as ‘an individual’s knowledge, skill, and confidence for managing their health and health care’ (Hibbard et al, 2005), with the stages described as follows:
- believing the patient role is important,
- having the confidence and knowledge necessary to take action,
- actually taking action to maintain and improve one's health, and
- staying the course even under stress."
In the StACC model, these are abbreviated to:
- Importance (of own role),
- Confidence (to achieve goals)
- Problem-solving (when set-backs arise).
Moving through the steps of the Coaching Conversation enables movement through the activation levels.
The tension in the model sits around the ‘Importance line’ in the diagram.
This means the Coaching Conversation can be regarded as a process of two halves: One focused on the importance of the patient’s role and their sense of ownership, and one focused on action and their confidence to achieve their goals and problem-solve when setbacks arise.
Increasing activation is important as higher levels of activation are linked to better health and wellbeing outcomes for patients and reduced reliance on clinical services (Health Foundation, 2018).
How to use the model effectively
In the StACC model, patients are first ‘activated’ before moving to action. By being given ownership and control, patients are empowered to drive the agenda before being supported to set and achieve goals, building their knowledge, skills and confidence in the process. As a result, they are then able to internalise the process and apply it to other goals.
This differs from trying to build a patient’s knowledge, skills and confidence in the hope that they will become activated.
The model works for people at all levels of activation. What changes is the pace.
People at low levels of activation, or who are stuck or struggling, are likely to spend more time at the ‘top-end’ of the Coaching Conversation, i.e. Eliciting the Story, before moving to action than someone at high levels of activation who is more likely to move more quickly onto Goal-Setting and Problem-Solving.
This is because people at higher levels of activation are likely to already have a sense of ownership and level of confidence to achieve their goals. People at low levels of activation may therefore end up having a few more sessions than the standard 5 sessions plus a follow-up. See illustration, below:
The skill is in using the PCI Core Curriculum skills and moving flexibly within the model. The patient’s journey may not be in a ‘straight line’ and the coach will need to move up and down the Coaching Conversation Flow, using the Structured Agenda-free Coaching Conversation model in order to meet the patient where they are at any one time and to move the patient forward from there. The diagram below illustrates how that works across time:
The model adjusts ‘SMART’ goals to ‘SMMART’ goals or, as expressed in the correct but less memorable order, ‘SMMTAR’ goals. These are SMART goals with Motivation added in alongside Specific, Measurable, Time-specific, Achievable and Realistic.
Training to use the StACC model
For Health & Wellbeing Coaches:
To use the StACC model effectively coaches need:
- Training in the PCI-accredited core skills for Health Coaching, including listening skills, exploring ambivalence, importance and confidence scaling, goal setting, and an understanding of patient activation.
- To understand the principles of the StACC model, and how to apply the skills at each step.
These can all be taught within a 2-day course.
Following this initial skills training, a minimum of 12 hours supervision (ideally a mix of individual and group) alongside an active caseload is needed in order to embed the skills. This supervision is included in KYOH”s standard ‘4-day’ PCI-accredited training for Health & Wellbeing Coaches alongside the Core Curriculum Skills training.
To become confident and expert in Health & Wellbeing Coaching to support self-management and patient activation using the StACC model, coaches will also benefit from their ongoing supervision, required by all Health & Wellbeing Coaches, to be with a supervisor who has sufficient knowledge and experience of the model.
Health & Wellbeing Coaches are required by the PCI ‘Roadmap’ to have knowledge of different models and frameworks. As a result, coaches can stick to one model or move between different models or frameworks, according to their PCN’s requirements and the desired outcomes.
For Care Coordinators, Social Prescribing Link Workers and other health and social care professionals:
The PCI Core Curriculum skills and the Coaching Conversation Flow structure can also be used by practitioners to have ‘better conversations’ to support self-management and patient activation.
- Training in the PCI-accredited core skills for Health Coaching, including listening skills, exploring ambivalence, importance and confidence scaling, goal setting, and an understanding of patient activation.
- To understand the principles of the Coaching Conversation structure, and how to apply the skills at each step.
These can all be taught within a 2-day course.
Used for ‘better conversations’ rather than as an intervention, the structure is used to identify the type of conversation a practitioner is having with a patient at any one time (e.g. Eliciting the Story, Establishing Importance, Goal-setting, etc) and therefore which skills they are drawing on at that point.
Whichever way the model is being used – as an intervention or for ‘better conversations’ - the Coach, or the person having the coaching conversation, is expected to take a supportive and non-directive role, regarding the patient as a resourceful expert in the management of their health and wellbeing.
Key features that define the StACC model
-
Structured:
The intervention enables the coach to move flexibly forwards and backwards through a defined step order, meeting the patient where they are at any time, and remaining focused on one ‘thread’ at a time. It is effectively a two-stage model. The first stage is Agenda-setting, Eliciting the Story and Establishing Importance and the second stage is Goal-setting and Goal follow-up. It is the middle step, ‘Establishing Importance’ that divides the two stages and it is around this ‘Importance line’ that the tension in the model sits i.e. where ownership is established.
-
Agenda-free:
The intervention is not focused on a predefined outcome, or at least not one defined by anyone other than the patient. It acknowledges the biopsychosocial aspects of health and takes the patient through a process that enables them to take ownership, recognise and make choices and achieve goals in line with what matters to them, problem-solve where necessary, and to build on their successes.
-
Coaching:
The model uses a range of coaching skills, including listening skills, exploring ambivalence, goal-setting, problem-solving, importance and confidence scaling, along with coaching principles including building trust and rapport, remaining non-judgmental, maintaining boundaries, and returning responsibility.
The Conversation is how the coaching is presented by the coach and experienced by the patient.
Why is the concept of ‘ownership’, inherent in this model, so important?
The importance line indicates the point at which the patient has taken ownership and control – when they’ve identified what’s most important to them right now and are able to recognise that they have choices and that they are the one who can make that choice. This is where they are ready to drive their own goal-setting and problem-solving with the support of the coach.
We’ve seen that, without ownership, goal-setting can be an uphill struggle for both the coach and the patient - and can even risk creating or exacerbating a sense of failure in the patient; conversely that there is no limit to what patients can achieve once a sense of ownership has been established.
The model also recognises that it’s the process rather than any particular outcomes that is important in the first instance.
Once the patient has internalised the process, they can apply it to anything. It is due to this dynamic that quite extraordinary outcomes are often achieved as a result of the intervention. As one of the coaches responded when asked whether she is often surprised by what patients achieve:
“I think they are often surprised by what they achieve.”
What Health & Wellbeing Coaches say about using the StACC model:
“The skills give me a set of tools; the structure gives me a toolbox.”
“This has changed things for me….it’s been like a lightbulb going on”
“I’ve realised that what works for one person is different from what works for another person;”
“I was coming in as an expert, offering tools and advice. This is so much better –being more of a facilitator”
“I’ve learnt to trust the process”
“This is the most rewarding job I’ve ever done”