Defining the model, and how to use the model effectively to support self-management and increase patient activation
- Kate Henry, Know Your Own Health
- 25th May 2022
The Structured Agenda-free Coaching Conversation model is an established evidence-based coaching model that is designed specifically to support people in achieving what matters to them, and in the process, build their knowledge, confidence, skills and self-efficacy.
The model encompasses all the PCI-accredited Health Coaching Skills alongside a Coaching Conversation structure that enables the skills to be used effectively to support self-management. This enables Health and Wellbeing Coaches to use the Health Coaching skills as a short-term intervention; and enables those in other roles to have effective Coaching Conversations with patients. In all cases, the model has been shown to develop patients’ self-efficacy, leading to improved outcomes and more effective Shared Decision-Making Conversations with the patients’ Health and Social Care Professionals.
The model works as a behaviour change intervention that aligns well with existing theories of behaviour change being used in the NHS, notably the Transtheoretical Model and COM-B. It encompasses a set ofthe PCI-accredited core coaching skills for health coaching together with a structured consultation framework that can be used as an alternative to consultation frameworks such as the TGROW model.
The advantages of the model:
- Simple to use. Coaches can start working effectively with it very quickly; although it is a skill and requires some time and practise to become expert
- Shown to be effective in supporting self-management, increasing patient activation and patient self-efficacy
- Shown to improve health and wellbeing outcomes
- Short term – supporting independence and reducing dependency on clinical services
- Supportive in its approach, reducing the risk of creating or exacerbating any sense of failure that can set someone back.
The Structured Agenda-free Coaching Conversation model is built on learning from previous Supported Self-Management (“SSM”) interventions and programmes designed for people with Long Term Health Conditions, in particular the 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, 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 Structured Agenda-free Coaching Conversation model that evolved most directly out of the Health Foundation’s Co-creating Health Self-Management Programme (“SMP”) 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 Structured Agenda-Free Coaching 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 Structured Agenda-free Coaching Conversation model is based on the five-step ‘Coaching Conversation’ established through the Health Foundation’s Co-creating Health Self-Management Programme (“SMP”).
The Structured Agenda-free Coaching Conversation model provides a structure that Health and Wellbeing Coaches can use to support self-management utilising the PCI-accredited skills for Health Coaching and delivering Health Coaching as a short-term intervention for patients to support self-management and patient activation.
The structure is a five-step process that is straightforward and easy to learn. The skill 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.
To use the 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 a basic understanding of patient activation.
- To understand the supported self-management mindset, the principles of the model and how to apply the skills at each step.
These can all be taught within a 2-day course.
To become confident and expert in Health & Wellbeing Coaching to support self-management and patient activation, coaches also need ongoing supervision with a supervisor who has sufficient knowledge and experience of all the above.
A minimum of 12 hours supervision (ideally a mix of individual and group) alongside an active caseload is recommended in order to complete initial training.
There are other models and frameworks being used in the NHS that use the same PCI-accredited skills for Health Coaching even if the skills are presented in slightly different ways. Health & Wellbeing Coaches and others familiar with the different models are able to stick to one model or move between them according to their roles and the desired outcomes, utilising the skills appropriately and to best effect.
The skills and the coaching conversation structure can similarly be learnt within a 2-day training and used by practitioners in other roles, e.g. Care Coordinators, Social Prescribing Link Workers, GPs, Practice Nurses, Receptionists, other health, social and community care practitioners to support self-management and patient activation. Used in this way, rather than as an intervention specifically aimed at patient activation, the practitioners use the structure to identify the type of conversation they are having with a patient at any one time and therefore which skills they are drawing on at that point.
Whichever way the skills are being used, the Coach is expected to take a supportive, non-directive role and respect the patient as a resourceful expert in their own health needs, circumstances, and abilities.
Using the Structured Agenda-free Coaching Conversation model as an intervention to increase patient activation, the patient controls the agenda while the coach controls the process, maintaining a narrow focus and effectively working in a straight line from steps 1 to 5, with movement forward or back on that line as required until a goal, or a step towards that goal, is achieved. This highly structured, yet flexible, approach enables the discussion to remain on topic and helps to optimise outcomes.
Key features that define the Structured Agenda-free Coaching Conversation model
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 with the middle step (Step 3 Establishing Importance – and ownership) dividing the first half (Eliciting the Story and Establishing Importance) from the second half (Goal-setting and Goal follow-up).
The intervention is not focused on a predefined outcome; it is focused on patient ownership. It acknowledges the biopsychosocial aspects of health, focuses on what matters to the patient, and takes the patient through a process that enables them to achieve their goals. This develops self-efficacy and the patient’s confidence to recognise and make choices in line with what’s important to them at any time and build on their successes.
The model uses a range of coaching skills, including 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 model uses therapeutic communication skills include listening and silence, empathy and reflection, exploring ambivalence, etc.
How the Structured Agenda-free Coaching Conversation works and why it is an effective model for increasing 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:
"Activation appears to involve four stages:
- 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."
Taking each of the steps that were identified in Co-creating Health Self-Management Programme’s Coaching Conversation, looking at what is happening in each of these steps in the context of the Structured Agenda-Free Coaching Conversation Model and placing the steps alongside these patient activation levels, it is noticeable that key features of the activation levels are reflected in steps 3, 4 and 5 of the Coaching Conversation.
In the following diagram (Figure 3), the steps in the Coaching Conversation are shown on the left-hand side, alongside a description of patient activation levels shown on the right.
The key features of patient activation that can be seen reflected in the steps of the Coaching Conversation are: Importance, Confidence, and Problem-solving. These have been highlighted on both sides in the diagram above, demonstrating how the Structured Agenda-free Coaching Conversation model is able to support movement through the activation levels.
By treating the Coaching Conversation as a process of two halves, divided at the point of Establshing Importance (“the Importance Line” in the diagram above), the coach is able to focus the aim of the coaching specifically on ownership and increasing activation. Increased activation has been linked to better health and wellbeing outcomes for patients and reduced reliance on clinical services (Health Foundation, 2018).
Working with the Structured Agenda-free Coaching Conversation model
By being supported to identify what is most important to them at a particular time, patients are ‘activated’ to build their knowledge, skills and confidence by being enabled to take ownership of the agenda and then being supported to achieve their goal. This differs from trying to build a patient’s knowledge, skills and confidence in the hope that they will become activated. Also, by ‘activating’ patients first – finding their motivation and ensuring that they are taking ownership of the agenda – patients are empowered to drive the agenda, enabling them to internalise the process and apply it to other goals.
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, 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. See next illustration.
The model adjusts ‘SMART’ goals to ‘SMMART’ goals or, as expressed in the correct but less memorable order, ‘MSMTAR’ goals. These are SMART goals with Motivation added in alongside Specific, Measurable, Time-specific, Achievable and Realistic. Motivation is established in terms of what’s most important to the patient right now (Step 3) and why that’s important to them.
Why is the concept of ‘ownership’, inherent in this model, so important?
The importance line indicates the point at which the patient takes ownership – 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.
It has been demonstrated, in using the model, that patients are more likely to become active self-managers of their health and well-being if they are supported to:
- Articulate and own their story – how things are for them right now;
- Identify an immediate issue that is personally important to them, irrespective of what they have been referred for;
- Identify an action in line with what’s important to them;
- Build their confidence to achieve that action through the support of the coach;
- Problem-solve where necessary.
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 Structured Agenda-free Coaching model:
“The skills give me a set of tools; this structure gives me a toolbox.”
“This is very patient-centred. Now my approach is that the patient will lead where the coaching’s going. 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; this helps them to make a sustainable plan”
“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”
© Know Your Own Health and its licensors, 2022