THE INCREASING COMPLEXITY of the healthcare environment requires healthcare professionals to reexamine their role in providing patient care. In outpatient settings, there is a shortage of primary care providers, yet practices are still required to improve patient outcomes or they may risk loss of reimbursement. With time constraints from seeing more patients, primary care providers may lack the time for adequate patient education. This can be detrimental for patients with multiple chronic illnesses and limited health literacy who are at greater risk for complications.
To improve healthcare delivery in primary care settings, increasing responsibilities for RNs has been advocated. RNs have the education and authority to play an important role in patient education and management of chronic illnesses through health assessments, medication reconciliation, case management for chronic illnesses, and health coaching.1,2
Using health coaching with patients who have poorly controlled hypertension is an example of an expanded and appropriate role for RNs. When patients have limited health literacy, they often lack the knowledge and skills for self-management. Health coaching has been used to improve medication concordance and adherence in “safety net” clinics, which provide care to patients regardless of their ability to pay.3 It has also been shown to build trust between patients and providers, which influences treatment and medication adherence.4 This article describes how RNs can use health coaching to improve hypertension self-management in patients with limited health literacy.
Being knowledgeable and experienced in health education and disease management, RNs are well prepared to provide health coaching.2 Unlike patient education, which is often a one-way exchange of information, health coaching is a partnership between a coach and the patient to promote achievement of health-related goals. Patients are active participants in health coaching. Health coaches partner with patients to provide education, support, and resources to help them gain the confidence and skills they need to self-manage their health and achieve their health goals.5
Because the coaching partnership is short-term and goal-focused, it is ideal for outpatient settings. RNs can incorporate health coaching in routine office visits, patient education, videoconferencing, and phone calls.
When coaching patients with hypertension, RNs can provide individualized education about hypertension, BP medications, and strategies for self-monitoring BP levels. Health coaching gives patients time to practice newly learned skills in a safe environment and empowers them to self-manage their hypertension.
RNs can incorporate technology into their health coaching. Patient education using online educational programs, videoconferencing, and telephones has been found as effective or more effective than face-to-face patient education.6 Patients can use patient portals to communicate with healthcare providers. Health-related smartphone apps can be used to track BP, physical activity, and nutrition. RNs can further supplement teaching with online videos and modules. All these options can eliminate transportation barriers and allow flexibility with appointments.
Some insurance companies may directly pay for RN health coaching and patient education as fee-for-service. However, with the emphasis on improving outcomes, payment is more likely to be included in alternative payment plans such as comprehensive care management services or quality-based plans.1,7 No Current Procedural Terminology coding is specific for health coaching, but preventive medicine and individual counseling session codes may be options.8 Because health insurance benefits continually change, the provider or patient should contact the insurance company for benefit coverage.
High cost of hypertension
In the US, almost one in three adults has hypertension, and the prevalence of cardiovascular disease is higher in low-income and minority populations.9,10 Even with the abundance of medications available to treat hypertension, half of adults with hypertension have poorly controlled BP, which increases their risk for myocardial infarction, stroke, and kidney failure.9,11
Not only does poorly controlled hypertension impact patient health, it is also a financial burden to patients and the healthcare system. In the US, the direct costs of treating hypertension, heart disease, heart failure, and stroke, plus the indirect costs from disability and loss of income, will increase to over $1 trillion by 2030.12 Furthermore, the prevalence of cardiovascular disease is projected to increase to over 40% of the US population by 2030.12 Health coaching may mitigate these costs.
Addressing health literacy issues
Health literacy is defined as “the degree to which an individual has the capacity to obtain, communicate, process, and understand health information and services in order to make appropriate health decisions.”13 It influences the management of chronic illnesses such as hypertension. Health literacy is more than reading and numeracy skills. It is using those skills to seek, comprehend, and use health information to make decisions to improve health.14 Limited health literacy is associated with poor medication adherence, poor health outcomes, and health disparities.15,16
The National Academy of Medicine estimates that almost half of American adults struggle with comprehending and using health information, and the prevalence is higher in low income, older adult, and minority populations.14 In response to the pervasiveness of limited health literacy and its impact on health outcomes, the US Department of Health and Human Services established a national plan to improve health literacy that centers on clear and simple communication and improving self-management of chronic illnesses.17
The Agency for Healthcare Research and Quality developed a Health Literacy Universal Precautions Toolkit to help primary care practices simplify communication, empower patients to self-manage their health, and improve navigation through their healthcare system (www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html).18
Health coaching plan
Enhancing patient-centered communication, improving medication adherence, and promoting self-management are the cornerstones of health coaching for patients with limited health literacy. To foster retention of knowledge, teaching is limited to two to three key points each session. Teach-back, which is asking patients to restate in their own words what they learned, is used to assess patients' understanding of educational content. Clear and simple communication includes using nonmedical terms, speaking clearly and slowly, and encouraging questions (see Examples of patient-centered communication). Visual aids are used, and all printed materials should use everyday language, avoiding health jargon, for adults with limited health literacy.5,18 RNs should also track outcomes, such as BP readings and medication adherence, to evaluate the effectiveness of health coaching on improving health outcomes.2
Lenahan and colleagues found that patients' ability to identify their antihypertensive medications by name was associated with health literacy.19 The ability to identify antihypertensive medications by name has been associ ated with increased adherence, better BP control, and fewer hospitalizations.19,20 Therefore, increasing patients' knowledge about their medications is a major focus of health coaching for patients with hypertension. Education includes instructing patients on the names, dosages, administration, adverse reactions, and mechanism of action for each antihypertensive medication.
Various strategies and tools are available to educate patients about drug therapy. For example, the nurse may use the analogy of a pumping system, which consists of a pump (heart), pipes (blood vessels), and fluid (blood), to help patients learn how their medications work on the cardiovascular system.
Medication reconciliation and adherence should be assessed at each visit by asking the patient, “In the past week, how many times did you take your medications late or miss a dose?” As an advocate, the nurse helps the patient identify barriers to taking medications as prescribed and strategies to reduce or eliminate the barriers. Using pill boxes and smartphone apps for medication reminders, simplifying the regimen, taking less expensive medications, and obtaining medications from convenient pharmacies can increase adherence. For patients with access to patient portals, teaching should include using the portal to request medication refills.3,5,18
Patients with a diagnosis of hypertension must learn to self-monitor their BP. To accomplish this, the nurse could encourage patients to purchase a BP monitor for home use or identify convenient community locations to check their BP during the week. Patients can use a BP log or mobile app to record BP readings.
Additionally, patients should learn to recognize if their BP is at goal (less than 130/80 mm Hg or individualized for the patient). The RN reinforces this skill by showing the patient his or her BP reading at each visit and asking if that BP is at goal.
Role play is used to teach patients to identify and modify behaviors that might contribute to hypertension. Examples include missing medication doses, increasing sodium intake, increasing alcohol use, and using certain over-the-counter medications, such as nonsteroidal anti-inflammatory drugs. During role play, patients are encouraged to reflect on the previous few days and identify any behaviors that might contribute to an elevated BP. If a patient identifies one, the nurse and patient discuss how to correct the behavior, continue to monitor BP, and return to the clinic if the BP remains elevated.
Because health coaching is patient-centered, the RN should ask if the patient has other areas of interest for education. Asking, “What else would you like to learn about?” validates the patient's interests. Potential topics include general nutrition, exercise, weight loss, and smoking cessation. Online health education websites, videos, and support groups can be incorporated in the teaching. See Health coaching in action for a scenario of typical health coaching sessions with a patient.
When patients express a desire to improve BP management, RNs can use health coaching as an educational strategy. In our experience, patients are very receptive to health coaching because they are active partners in working toward goals that are meaningful to them. Patients often comment that the individualized education makes the difference in helping them understand hypertension and their medications.
RNs provide care for patients at many points in the healthcare system and have unique opportunities to influence patient outcomes and reduce healthcare expenditures. Health coaching is one strategy nurses can use to improve health literacy associated with hypertension. Through individualized education and a supportive partnership, patients are empowered with the knowledge, skills, and confidence to self-manage their hypertension.
Examples of patient-centered communication
- What would you like to learn about?
- Tell me what you know about high BP.
- What makes it difficult for you to take your medications?
- In your own words, tell me how your BP medications work.
- Thinking about what we talked about today, what is one thing you can do differently this week?
- What questions do you have for me?
Health coaching in action
LD, 62, has a longstanding history of hypertension. He is currently taking three different medications to control his BP, but his BP is not at goal. Over 5 weeks, a nurse coaches LD in person and by telephone on managing his BP.
- At the first office visit, LD cannot name his BP medications and had not taken them as prescribed in the previous week. He also does not know the goal for his BP. The nurse reconciles LD's medication list and assesses his medication adherence. After explaining what hypertension is and potential complications of high BP, the nurse begins education on his medication and BP management by using a diagram of a pumping system to help him understand the mechanism of action of his BP medications. LD identifies a convenient pharmacy to check his BP the following week because he does not have a home BP monitor.
- The second health coaching session is done by telephone. Medication adherence is assessed, medication education is reinforced, and LD's BP measurement is reviewed. Throughout the phone call, the nurse offers encouragement.
- The third encounter is an office visit, and the nurse continues to reinforce the educational content. LD proudly names all three BP medications he is taking and accurately identifies that his BP is at goal. Role play is used to teach LD how to evaluate and manage elevated BP, and when to notify his healthcare provider. LD mentions he would like to lose weight, so weight-loss strategies are introduced.
- The fourth health coaching session is done by telephone. LD correctly names his BP medications and reports his BP is at goal. The nurse reviews and reinforces previous teaching.
- The final health coaching session is at the office. LD can correctly name all his BP medications and their mechanism of action. He states he understands why it is important to take his BP medications and regularly monitor his BP.
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