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Dialysis Discussion => Dialysis: News Articles => Topic started by: okarol on March 13, 2011, 11:12:19 PM
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March 4, 2011, 10:00 PM
The Health Coach You Know
By TINA ROSENBERG
Fixes looks at solutions to social problems and why they work.
Joyce Strickland, who works for the Center for Comprehensive Care, draws on her own experience with illness to help patients with their treatment.
On Tuesday, I wrote about how a health worker named Reynaldo Rodriguez worked with a patient, Joe McManus, to help him stick to his treatment plan to control his AIDS and Hepatitis C. Most of us don’t have the multiple serious illnesses and problems that McManus does, but a lot of us still share his basic challenge: how do we get ourselves to live more healthfully? We might need to eat better, quit smoking or drinking or exercise more. Instead of thinking of it as treatment adherence, we might call it keeping our New Year’s resolutions.
We don’t have a Rey Rodriguez to help us. But most of us have family, friends and neighbors, or other peers in our communities, who can help us stick to our health and medical regimens even if they have no medical training at all.
For H.I.V. Patients, a Team Effort
A doctor, health worker and patients talk about why a comprehensive approach to health care for those with H.I.V. works.
Joyce Strickland, for instance, volunteers for Rodriguez’s employer, the Center for Comprehensive Care (the program can only afford to pay her a small stipend), talking to people whose illness lands them in the hospital. She visits them in their rooms to urge them to begin coming to the clinic. She doesn’t have Rodriguez’s training in the curriculum of behavior change, but she does have something that can be equally valuable — a history of AIDS and drug abuse. She can talk to them about her own hesitation to disclose her disease to her family, her struggle to give up crack, her experience with the side effects of AIDS drugs. These are likely to be problems her patients share.
In St. Luke’s hospital, Strickland met a woman that she ended up seeing once a week and talking to at least three times a week on the phone. “When we first started talking she was undecided about quitting drugs,” Strickland said. Strickland kept asking her questions about why she continued to do drugs, asking her to evaluate the pros and cons of quitting. This method is what reader Liz from NYC (15) mentioned — motivational interviewing. Strickland wasn’t judging her, but the questions helped the woman to come to a decision on her own. She went into a detox program and later to 12-step meetings, often bringing Strickland with her. “When she was using she would only take her medicines some of the time,” Strickland said. “She thought the medicines wouldn’t work with drugs. I told her, ‘Even if you’re using something, take it.’ ” Now the woman is off drugs, getting treatment and taking her pills.
The most effective peer coaches are ones who are taking the same journey as the patient.
Several readers wrote in about their own experiences helping patients stick to their treatment plans. Bhusted of Portland, Oregon (30) visits geriatric patients who cannot get to the doctor’s office. Mike Cotton of Atlanta (28) wrote about the company he works for, Alere Health, which includes health coaching as one of its services. Bonnie Maegolis (23) of Stamford, Conn., wrote about her experience as a registered nurse working with underserved older patients in senior centers.
But a writer identifying herself as Female Surgeon from St. Louis (9) had some cautionary words. “Adherence is the 800-pound gorilla in the management of every chronic illness,” she wrote. “However, these programs work best among those who have the worst chronic illness and the greatest rates of hospitalization. They are not cost-effective if applied to all patients.” She is right. A middle class patient may not be very good at taking her hypertension medicine, but it is unlikely her health program will find it financially beneficial to send a home visitor regularly to help her.
What gets overlooked, though, is that nearly everyone has a potential health coach at home. Two weeks ago, I mentioned community health workers in Bangladesh who help villagers cure tuberculosis by watching them take their pills every day. The program, called DOTS, is now the global standard for treating TB. DOTS works because people who won’t take their medicines otherwise will take them if someone with whom they have a relationship is there to watch. That person cheers them on and holds them accountable.
It is very effective. When China began to use DOTS in 1991, the cure rate for TB rose in DOTS areas from under 50 percent to 94 percent. Prevalence of the disease fell by 40 percent over the next 10 years in areas where DOTS was used, and rates of the development of drug-resistant TB fell as well.
The nongovernmental group Partners in Health showed that DOTS can be successfully used to manage many diseases. DOTS is feasible everywhere because the companion is usually not a community health worker at all, but a family member or neighbor.
But DOTS is practically unknown in America. Why? Some prescription bottles say “take with food.” Why not “take with spouse?” Or child? A seven-year-old would love this job. “Too intrusive,” reader M.M. from Kentucky (21) said of these programs. They are intrusive. But if a doctor can explain to patients that having a coach is a proven way to help them get better, many patients would find it acceptable.
The most effective peer coaches are ones who are taking the same journey as the patient— they help each other. This is the theory, of course, behind Weight Watchers or Alcoholics Anonymous. Numerous studies have shown that people follow their diet plans or abstinence or exercise programs much better if they are not doing them alone. The relationship doesn’t have to be corporate-sponsored or even organized — a single neighbor who also wants to run at 6 a.m. is fine.
Medical programs in various parts of the United States are experimenting with using peer groups to help people stick to their treatment plans, and it is working. Michele Heisler, an associate professor of internal medicine at the University of Michigan, has collected various models that use peers to help people take care of their health into a booklet that can help others launch similar programs.
Some are programs that involve doctors. The Cleveland Veterans Affairs Medical Center, for example, holds group meetings — about 15 patients with diabetes gather, with doctors and nurses rotating in and out of the session. Patients do get one-on-one time with a doctor, but perhaps more useful is hearing how other patients dealt with similar struggles. Other programs depend completely on the patients themselves. The National Kidney Foundation, for example, recruits dialysis patients who successfully manage their disease and trains them to talk to other patients getting dialysis at the same time. Others, like Latino Health Access in California, recruit, train and pay local people to work in their own communities (and language). There are also patient-to-patient support groups – in person, by phone or on the Internet.
Heisler said that while programs using community health workers are fairly widespread in the United States, enlisting patients to help each other is not. But having the patients themselves support each other may have advantages over a community health worker model. Patients work for free, the main cost being their initial training. They also get a double benefit, because their interaction is two-way. Helping someone else can strengthen the resolve of the helper and make him feel competent and in control. Other researchers reinforced this finding — in programs such as A.A. or ones that provide newly-released prisoners with mentors, the mentors and sponsors end up benefitting more than the protégés. (Joyce Strickland talks about the positive personal effect of helping others in the multimedia feature accompanying this post.)
As several readers pointed out, the American health system throws up structural barriers to the use of peers and health coaches. Insurance plans will readily cover doctors and technology, but peers are still a stretch. One of the useful changes in the health reform law is that it encourages experimentation with such low-tech, high-touch strategies. Until these ideas are more widespread, however, getting health coaching is something many patients will have to do on their own. It’s fortunate, then, that good ones can be found all around us.
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