Dr David Codyre is the Clinical Director, Tū Whakaruruhau (Auckland Wellbeing Collaborative)
The Tamaki Health “Health Coach” role evolved out of work to better understand and meet the needs of a group of patients struggling with complex long-term conditions needs, who were poorly engaged in planned healthcare, but frequently admitted to the hospital. The initial work involved testing a peer/cultural role to improve engagement, and based on the success of this, looking to the literature for evidence-based peer roles in primary care. The result was adapting and testing the Centre for Excellence in Primary Healthcare “Health Coach Curriculum”. Initial outcomes of integrating peer/cultural health coaches trained in this scope of practice into GP clinics were significant – for example, significantly improved HbA1c for patients with poorly controlled diabetes. The role was then formally evaluated as one of three new roles integrated into GP clinics, in pilots of the NZ “Integrated Primary Mental Health and Addictions” programme. The pilot evaluation demonstrated such positive outcomes from all three roles, that this programme was funded for national rollout in May 2019.
The New Zealand “Integrated Primary Mental Health and Addiction” (IPMHA) programme places three new roles into GP clinics, to create a truly multi-disciplinary primary care team to meet patients’ holistic wellbeing needs:
- Health Improvement Practitioners (HIPs) – experienced mental health clinicians whose core intervention modality is Focussed Acceptance and Commitment Therapy (fACT), aiming to see at least 50% of patients on the day they present, and working in a “one-off intervention with an open door to return” model.
- Health Coaches – non-credentialed practitioners, ideally bringing lived experience and/or cultural match to the clinic population, trained and working in a defined scope of practice, with a focus on improving health literacy and supporting lifestyle change for people with (or at risk of developing) long term health conditions.
- NGO Community/Peer Support Workers – taking introductions from the clinic team, but providing “walk alongside support” in the community, to address issues such as housing, income support, social isolation, need for advocacy and so on, which are impacting the patient’s wellbeing.
The three roles evolved as independent pieces of work, undertaken in primary care in Auckland NZ and focussed on better meeting patient needs. They commenced in 2013/14 and came together as pilots of IPMHA in 7 high-needs community GP clinics in 2017/18. Based on the very positive pilot evaluation findings, the programme was funded for national rollout in the May 2019 Government Wellbeing Budget.
The evolution of the Health Coach role commenced in 2013, with an initiative in partnership with a large Auckland hospital serving a high-needs community. The initiative aimed to improve outcomes and reduce admission rates, for a group of patients with complex health needs who were poorly engaged in planned healthcare, but were presenting frequently to the hospital ED and had high rates of admission. Our initial “change idea” was to have 2 senior Health Psychologists outreach and engage this cohort, assess their needs, support them into our peer lead group Self Management Education (SME) programme (https://selfmanagementresource.com/ ), and also provide individual Health Psychology intervention. Our data over the initial months of the initiative showed very low rates of engagement (40-50%), so based on my prior experience of the transformational impact of peer support in increasing engagement in mental health services, we decided to test the impact of a peer role in primary care. We had a cohort of peer volunteers who ran the SME programme so recruited 2 peers from this group. Overnight our engagement increased to over 90%, and this was the beginning of our journey with a peer role in a primary care setting.
Our early experience also changed the focus of the planned intervention. We learned that this cohort was experiencing significant barriers to engaging in planned healthcare. We found that when we were able to hear and understand these issues (“Patient Voice”), and coordinate support to address them (“Patient Choice”), that trust and engagement built, and health outcomes improved. The initial cohort of 69 patients was tracked for 5 years, and we saw a sustained reduction of 45% in hospital contacts, along with improved wellbeing outcomes.
Based on this success we looked to the literature for examples of evidence-based peer roles in primary care, and were impressed by the Centre For Excellence in Primary Care (CEPC) “Health Coach Curriculum” (https://cepc.ucsf.edu/health-coaching ). This was a defined role and scope of practice for a non-credentialed workforce, developed to work as an integrated member of primary care clinic teams serving high-needs communities, and with impressive research findings supporting the impact of the role.
We thus sent one of the two Health Psychologists to their “Train the Trainer” programme. She returned, and trained our first cohort of “Peer-Cultural Health Coaches”. Our first test of integrated this new role into a GP clinic team was in partnership with a clinic that despite the best efforts of a very dedicated GP and nurse team, had a large number of diabetes patients HbA1c over 75. We initiated a half-day “Diabetes Clinic” weekly, with a GP, Nurse, and the Health Coach. The Health Coach did the outreach and engagement, and patients came into the clinic, had a Health Coaching session, and then saw the nurse and GP. The Health Coach also engaged patients into a Diabetes SME group. Over 6 months we saw an average 12% reduction in HbA1c over a cohort of 200 patients.
In parallel to this work, the NGO Support Role had evolved and been tested by our team, a partner primary care organisation, and a number of NGOs. It had shown promising outcomes. However, in many clinics, there was a cohort of patients with moderate to severe and complex mental health and addiction needs, who either could not be engaged in the existing referral-based talking therapies programmes or whose needs were too complex to meet in a brief intervention model. The partner organisation were looking to test the Behavioural Health Consultant role (https://pubmed.ncbi.nlm.nih.gov/19184376/ ). Our two organisations and partner NGOs formed a collaborative to formally pilot and have evaluated, placing these three new roles into the 7 clinics mentioned above.
The outcomes of these pilots were extremely positive, the programme was funded for national rollout in 2019, and for the years since our major focus has been the learning resulting from implementation at scale here in Auckland. This has been a major transformation for primary care, and it can take 2-3 years for the programme to truly be integrated and operate as intended. As it stands, across the 4 regions of NZ we have up to 70% of the population with the programme available in their GP clinic, with annual access rates of up to 12% of the patient population where the programme is fully integrated and operating as intended.
As but one of many examples of the impact of the Health Coach role, the below data comes from a high-needs community clinic where a routine Health Coach-led Diabetes Pathway had been running for three years.
