A pilot study of hospitalized patients with type 2 diabetes found that 80% of patients who received a case management health coaching intervention were not readmitted to the hospital within 30 days of discharge.
By contrast, the patients with diabetes who were enrolled but never participated in the intervention returned to the hospital within the first two weeks post-discharge.
The intervention involved people who had multiple health and socioeconomic issues, including difficulty accessing healthy foods.
“These were poor, fixed-income participants that were really struggling,” says Veronica H. Sullivan, DNP, MSN, RN, clinical assistant professor at the University of Alabama in Huntsville.
For some patients, lack of access to healthy foods were a major obstacle to maintaining their health.
“One lady had three grandchildren that she was trying to feed with her own food stamps,” Sullivan says. “She couldn’t afford fruits and vegetables.”
The patient was not the grandchildren’s legal guardian, so she had no food stamps for them.
“The woman said, ‘I could eat Ramon noodles all month long on what it would cost me to buy fruits and vegetables for myself,’” Sullivan says. “She said, ‘I’m trying to spread out my dollars to feed the children.’”
Sullivan helped the grandmother obtain vouchers for a local farmers market. She could use these to supplement food stamps and to buy fresh produce.
“Learning of these kinds of socioeconomic problems was an eye-opening experience,” Sullivan says. “You can’t tell someone to be healthy and forget about their grandkids. That was one obstacle.”
For the pilot study, patients were offered enrollment based on health and demographic criteria. Sullivan asked nurses for help in identifying potential candidates for the program.
Sullivan’s health coaching focused on these three areas:
• Self-management. Case managers can begin health coaching while the patient is in the hospital. Hospital case managers were doing a great job of educating patients about diabetes before they left the hospital, as Sullivan discovered from a pre-discharge diabetes self-management quiz she gave patients in the pilot study.
“When they were in the hospital, we met in person, and I’d get their demographic information and do a semi-structured interview,” Sullivan says.
Sullivan asked the following questions to find out how well the patient was managing his or her diabetes and to prioritize health changes:
- Are you monitoring your blood sugar?
- Do you have glucometers at home now?
- What kinds of food do you eat?
- Are you eating fruits and vegetables at each meal?
- Do you exercise?
- What kind of exercise could you do?
- Do you drink water regularly?
- How much do you sleep each night?
- What medications are you taking, and do you take them as prescribed?
• Set goals. From the start, Sullivan tells patients to think about setting goals for themselves. These can be about diet, exercise, medication management, and making appointments with physicians. She asked patients to set two major goals for the month.
“Most people would make a goal to increase their exercise,” Sullivan says. “I wanted them to do it with more structure, walk for 10 minutes. But they’d say, ‘I want to walk to the mailbox or cook a meal.’”
They were focused on tasks of daily living, which puzzled Sullivan at first. “I thought, ‘How else will you eat?’” she says.
But then she realized that some patients didn’t actually cook meals, so preparing even one meal a week was physically taxing.
“It does take a lot of energy to make a meal, so I went with their goal and what they wanted to do,” she says.
Walking to the mailbox might also seem like a light goal, but for these patients it did require some effort and stamina. Some patients had neighbors who would deliver their mail for them, and they lived in an area that might experience inclement weather. Heading to the mailbox several times a week was an accomplishment, she adds.
“I had one gentleman who started going to the gym a couple of times a week, and another gentleman started back to work, which was his goal,” Sullivan says.
Some patients were too vague in setting their goals. They might say they wanted to eat better, but they wouldn’t set a plan for what was better.
“So I’d ask them, ‘Are you going to eat more fruits and vegetables or use less fat and sugar?’” Sullivan says. “I helped guide them into a more specific plan.”
• Follow-up calls. Sullivan documented patients’ goals and would ask them about their accomplishments during weekly calls. “I would focus on their set goals,” she says.
For patients newly diagnosed with diabetes, she provided directions for how to monitor glucose levels and discussed any symptoms they had.
Her typical questions each week included:
- How successful have you been in reaching your goal of exercising?
- How successful have you been in glucose monitoring?
- Have you been eating more fruits and vegetables?
- Do you have any questions about how to manage your diabetes?
“Then I’d ask them what helps them move toward their goal. What motivates them? What are the things that help them feel in control and improve self-management?” Sullivan says. “And I’d also ask if they had a scheduled healthcare appointment.”
Sullivan found that it was very important to make sure patients scheduled and kept follow-up appointments with their doctors.
Some patients thought they would skip that first follow-up visit and just return to the ED if they experienced any problems.
Sullivan had to convince them that this was not the way to maintain their health and they should set that first follow-up appointment and ask their own doctors about any symptoms.
“I’d ask them if they had a spouse or friend who could help them reach their goals,” Sullivan says. “Of the 20 patients, 18 did have a follow-up appointment, and only two returned to the hospital before making their appointment.”
Sullivan also would send a letter that stated what she and the patients had discussed and what their selected goals were. The letter also listed the days when she would call patients to follow up on their health progress.
During the last phone call to patients, Sullivan gave them the same quiz she gave them at the beginning to see if health coaching made a difference in their motivation and knowledge.
“They were knowledgeable about diabetes at the beginning and were educated by hospital case managers on what they needed to do,” she explains. “The coaching program provided motivation and encouragement.”