Improving Patient Engagement and Results by Applying Coaching Best Practices

By Doug Schumann, Vice President, Client Success, Clinicient

The Affordable Care Act is working to link reimbursement to performance on patient experience metrics. At Clinicient, we have foreseen the pay-for-performance model approaching for quite a while now. In the near future, providers will at least partially be paid based on patient ratings as per the Value Based Purchasing Program.  As a provider it will become increasingly important for your patients to see true value in the services you are providing them, and to ensure they are fully engaged with their care management.

When it comes to increasing patient engagement, it is important for providers to focus on connecting with patients in order to achieve greater buy in and improved results.  According to the NEJM Catalyst Insights Report on patient engagement, a strikingly low percentage of patients are highly engaged.

One simple way providers can improve patient engagement is by incorporating systems such as the GROW coaching model, which have been developed based on coaching best practices and are leveraged in professional sports and the business world to improve overall performance. I personally have seen the GROW model utilized across a number of industries (healthcare, insurance, business) and in each industry the results have been tremendous.

The necessity of a framework in therapy

The GROW coaching model was originally developed in the 1980’s by Graham Alexander, Alan Fine and Sir John Whitmore. These professional coaches came together to develop a standardized decision making framework that could be utilized to develop achievable goals that are agreed upon and with immediate “buy in” by the patient as a direct result of the process.

The GROW coaching model provides a framework of questions that elicit a meaningful and engaging conversation, focused on creating an actionable plan for the patient to achieve those goals. The model consists of four sections or phases - Goal, Reality, Options and Way Forward.  One metaphor that is often used to explain the GROW process is to think of it as you would go about planning a trip. First you establish where you are going (your Goal). Next you confirm and validate where you currently are (your Reality). Once those are established you determine which potential routes can get you to your ultimate destination (your Options). Finally after you have considered all of the potential ways you can get there (plane, train, automobile, motorcycle, etc. and highways, backroads, hitchhiking… You get the idea) you finally determine which way you will go (your Way Forward). While selecting the plan or way forward, you are ensuring that you are fully prepared to get there and developing contingency or “if, then” plans in case your goal isn’t achieved.

“Plans are useless but planning is indispensable” - Dwight D. Eisenhower

It is critically important to take the time necessary to consciously plan to achieve our goals. When we fail to do this, our likelihood of achieving those goals diminishes significantly. Although most folks realize this inherently, how often do people leverage a standardized decision-making framework such as GROW to help make the right decisions? In most cases, folks fly by the seat of their pants and plan partially, albeit ineffectively.

Often we may go through some semblance of the stages/phases of GROW, but not in an effective, consistent or efficient manner. We might start by simply jumping to a solution without fully looking at what might get in the way and assessing all the possible options. Like the game of chess, when you don’t see the entire board, the game will likely end very poorly. Focusing on the four steps of the GROW process consistently with your patients will greatly improve the quality of the goals that are developed and significantly increase the likelihood of them achieving those goals.

Let’s try explaining and using GROW with a real-world example.  To establish a Goal, you might start by speaking with your patient and probing to define a “SMART” goal. In GROW, the acronym SMART often has a slightly different meaning than in other methodologies. Typically, SMART stands for Specific, Measurable, Achievable, Realistic and Time Based. In GROW, the acronym often stands for Specific, Meaningful, Agreed Upon, Realistic and Time Based. The two that differ are Meaningful and Agreed Upon. For the goal to be successful, it is imperative that the goal is both something that is meaningful to the patient and something they agree to do (Agreed Upon).

The GOAL

Typically a person will be more committed to achieving a goal that they find meaningful to them and have agreed to achieve. We often hear stories where a practitioner has set a goal for a patient because “they are the expert”. When this happens, the goal is very unlikely to be achieved. If the person never agreed to the goal and has not bought into it, they are likely to abandon the effort at the first opportunity. In our example, our patient wants to be able to run a 5K in three months, this would be the initial Goal that they have established.  Once the Goal has been established, it’s time to move into Reality.

The REALITY

In GROW, the Reality phase is focused on creating greater awareness of the current state. This includes things such as understanding what they are able to accomplish right now. The practitioner would ask additional questions that fully confirm the current state, which could include asking what could help the patient accomplish this goal? What could get in the way of accomplishing the goal? And, are there are any “elephants in the room”?  Probing for the realities is intended to help the patient understand what can be leveraged and/or avoided in pursuit of the goal. For instance, if someone has trained for a 5k before, knowledge of what worked for them in the past from a training perspective would be very helpful. Understanding if there are days when running won’t be as possible due to their work schedule, family responsibilities or for other reasons. Asking as well if there is someone they might be able to train with or something that has helped motivate them to achieve their goals in the past. These questions and techniques help them truly see that they already have many tools in their “toolkit” that will help them with making their goal a reality. Similar to Dorothy being told that she always had the ability to get home in The Wizard of Oz, folks often underestimate their current abilities and strengths.

Asking about “elephants in the room” is intended to get the patient to look at themselves holistically to identify if there are any other things that could get in the way of accomplishing the goal. Especially things that are uncomfortable or typically go unsaid. When you ask “are there any elephants in the room” you are asking for people to address potential issues head on. If someone asks what an “elephant” looks like, it refers to any other factors that could impede the process. Think of it as “baggage” that the person is carrying with them. What is the baggage and what impact could it have on the successful achievement of the goal?

After going through the reality questions, the final step before moving onto the Options phase is to confirm that the goal is still realistic considering the current reality. If it is, it is time to move onto Options. If not, the patient would be asked to set a more realistic goal and begin again. If the patient is currently in traction, 3 months is very likely to be too aggressive a goal and it could require you to come up with a more realistic goal. In this case, our patient agrees that running a 5K three months from now is absolutely possible as they are currently able to jog 1 mile. It is time to move onto Options.

The OPTIONS

Next comes Options. Think of the Options phase as good old fashioned brainstorming. The first rule of brainstorming is that there are no bad ideas. In fact, often when you throw crazy or what may sound like outlandish ideas at the wall, it can spark truly inspiring results. Probing questions should be asked during this phase to see what sticks.  The intent of brainstorming is to come up with as many viable options as possible for them to pick from. Questions include some of the following: What are some of the things you can do to achieve the goal? What might a coach suggest you do? Where could you look to find other suggestions? What else? Would you like some suggestions from me? Other questions might include – What are some of the approaches to training you’d like to pursue? What amount of time can you dedicate to training/recovery/exercising? When you have seen other people train to run a 5K, what do you think they have done? What things do you think would work for you? When you have accomplished goals in the past, what types of things were successful for you?

One of the greatest values that GROW provides is in improved results. One way these are achieved is by getting people to feel like they are developing their own solutions rather than being told what to do. Because they are instrumental in the process and required to commit to the plan, they become much more energized and excited (to learn more about the importance of a completed plan, check out this blog by Jerry Durham). According to Dr. Jeffrey Schwartz and David Rock, when insights are generated from within through self-discovery, new brain circuits are created, adrenaline-like and dopamine-like substances are released and sudden bursts of high energy brain activity are created.  Think about the difference for yourself when you come up with a solution to a problem on your own. Aren’t you more energized? Don’t you feel more empowered to make it a reality? In fact, think about the last time you offered an idea to a group and the group thought it was a great idea. I’m sure you felt a sense of euphoria and self-confidence because of this. That is the intent of asking the patient to come up with the majority of options on their own. Because the process is cooperative, the patient will be open to any suggestions you as an expert in the field have, yet concurrently feel empowered by the collaborative approach you are taking in listening to their thoughts on what has worked for them in the past and what might work for them going forward.

After brainstorming, our patient has developed a number of options that include the following: Write down and commit to a training regimen, Schedule a time to run at least 4 days per week, Start with running 1 mile, consider a subscription to Runner’s World magazine, join a running club, add running times to their calendar, buy good running shoes.

The WAY FORWARD

In the GROW process, once you have a sufficient number of Options to pursue, it is time to develop the Way Forward. The overarching main difference between Options and the Way Forward is the following: Options are what you could do, the Way Forward is what you are going to do. A clear Way Forward outlines the specific action items or tasks that will be accomplished along with the timeline for when they will be accomplished. Questions include what will you commit to doing? When will you do it? If the goal is not accomplished what will you do, and when? How often should we meet to follow up in regards to progress?

Of course with any plan it is always important to create a backup or “if-then” plan. What if things don’t go as we expected? If so, it is important to make sure the patient is planning ahead and considering what they will do then. Using an “if-then” process also helps identify potential holes in the plan and develops a follow up plan ahead of time. HBR recently reported that “if-then” planners are approximately 300% more likely than others to achieve their goals.

Although this may sound like a lot of work, in reality the entire process can be completed in a matter of minutes and provides an outcome that is much more achievable than what would be developed otherwise. When leveraged effectively, the GROW model can help you truly improve your patient engagement as well as the overall results for your patients. Like anything else, this process takes practice. I am confident that the effort will pay significant dividends for you and your patients.