Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697637067374.pdf (Australia)
Inquiry into Chronic Disease Prevention and Management in Primary Health Care House of Representatives Standing Committee on Health !

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Submission Prepared by Kim Poyner, Practice Nurse, Health & Wellness Coach, Vicki Allan, Practice Nurse, Health and Wellness Coach and Dr Tim Denton, GP.

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Executive Summary !


Our contention is that we have a model to effectively and efficiently addresses chronic disease risk factors by using multidisciplinary teams in the primary health setting with the addition of health and wellness coaches.

The wellness coaches would work more intensively with those the team identifies are poorly engaged and responding sub-optimally to chronic disease management.

We also note that this cohort of patients have a high prevalence of undiagnosed mental health issues.
By defining the mental health issues appropriate intervention within the team would be offered.

We provide evi- dence that health and wellness coaching has been well researched internationally.

For an overview we look at the work of Stephen Begg et al.

(1) which helps us understand the task ahead of the health services in Australia needed to tackle the rapidly expanding incidence of chronic diseases.
Begg describes Disability Adjusted Life Years (DALY) as a measure of the gap between a person’s current health status and the ideal situation of living into old age.

1 DALY equals 1 lost year of health life.

This gap is known as the “health loss” and seems to be more accurate than “bur- den of disease”.

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Begg shows by his calculations that the leading specific diseases: • • For men are Ischaemic Heart Disease (IHD), Type 2 Diabetes (T2DM), Anxiety/Depres- sion, Lung Cancer & Stroke.
For women the leading specific diseases are Anxiety/Depression, IHD, Stroke, T2DM & Dementia.

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The attached chart, which is derived from Begg’s figures, is informative as it highlights the risk fac- tors we should be targeting for the most return on health outcomes.

For example in T2DM two risk factors dominate: high body mass & physical inactivity.
Whereas, looking at IHD we note that high body mass & physical inactivity are joined by hypertension, high cholesterol, smoking and low in- take of fruit and vegetables.

For cancer add alcohol.

In the mental health DALYs the mix is differ- ent with alcohol, illicit drug use, partner violence and childhood sexual assault dominating.

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!1 Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 101 High BP High BMI inactivity high Chol smoking alcohol low F&V illicit drug fam viol It is essential to factor in socio-economic status into his equation.

Begg notes that DALY rates were 31.7% higher in the lowest socio-economic quintile compared to the highest socio-economic quin- tile.
He concludes his article by stating: “All of the health risks examined here are amenable to modifications through intervention, and together explain a large proportion of the health loss in Australia...” The impact of increasing diabetes incidence will be magnified by the reduction in case fatality from cardio-vascular disease through the successful strategies to reduce smoking and lower cholesterol and blood pressure.
Increased survival will result in a greater number of people with di- abetes developing...renal failure, retinopathy, neuropathy and peripheral vascular disease.” Thus, we believe that our model can address the above issues.

If Australia is to meet the challenge of increasing chronic disease burden it has to shift the focus from secondary health services to pri- mary health services delivered by multidisciplinary teams.
To address this problem we note there are three funding streams available to make this sustainable within the primary health setting: • One of these streams is for private health funds to contribute to the wellness coaching mod- el.

We note in the Barwon region 50% of people have private health insurance and as stated below GMHBA is one health fund interested in this process.
Medicare through the various rebates for chronic disease management would substantially address the lower socio-economic quintiles and the uninsured, we believe that Health and Wellness Coaching needs separate item numbers to cover the more intense intervention for the higher risk patients who will if they remain disengaged significantly cost health services.

• • Uninsured clients may also be willing to pay for this service out of their own pocket.

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Throughout this submission we show strong evidence from both overseas and Australia that Well- ness Coaching does work to bring about long term sustainable behaviour change within the individ- ual, which results in better health and wellbeing.

The authors aim is that the House of Representatives Standing Committee on Health considers this submission favourably and acts upon it for the improvement of the health of all Australians.

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!2 Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 101!

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Examples of best practice in chronic disease prevention management in Australia and Internationally.

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Obesity: !

Essentially in addressing obesity and physical inactivity the greatest gains in health outcomes will be seen.

• Appel et al (2) cite a number of papers related to management of obesity.
He notes that obesity is an important and growing public health problem around the world.

In the United States, ap- proximately one third of adults are obese (3).

Obesity adversely affects each of the major cardiovascular risk factors — blood pressure, lipid profile, and diabetes.

As a consequence, obese persons have an increased risk of death, especial- ly from cardiovascular disease (4, 5).
• • The economic burden of the obesity epidemic is enormous; the estimated direct and indirect costs related to obesity exceed $110 billion annually in the United States.

(6).

• Few weight-loss trials have examined the effect of behavioural interventions in clinical practice (7) and the results of these trials have been inconsistent.
• Consequently, even though it is recommended that clinicians offer intensive counseling and be- havioural support to their obese patients(8) practicing physicians lack effective, empirically sup- ported models of treatment to guide their efforts in helping obese patients lose weight.

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The Role of Health and Wellness Coaching: Frates et al, (9) in their article “Coaching for Behaviour Change in Psychiatry” note that “health and wellness coaching is emerging as a powerful intervention to help patients initiate and maintain sustainable change…” Such coaching has affected healthier personal behaviours (such as exercise), improved measures of health (such as reduced cholesterol, or HbA1c) and reduced health utilisation (such as hospitalisation).
Successful coaching interventions included a consistent one-on-one rela- tionship in a patient centred collaboration, mutually agreed goal setting, and accountability through reporting to the coach on a regular basis.

Ruth Q Wolever et al, (10) provide a definition of health and wellness coaching as: “a patient cen- tred process that is based upon behaviour change theory and is delivered by health professionals with diverse backgrounds.
The actual coaching process entails goal setting determined by the pa- tient, encourages self-discovery in addition to content education, and incorporates mechanisms for developing accountability in behaviour.” The Look AHEAD research group (11) concluded after a 4 year trial that “intensive lifestyle modi- fication can produce and maintain significant weight losses and improvement in fitness in individu- als with Type 2 Diabetes.
After 4 years of follow up, those on the ILI (intensive lifestyle interven- tion) had better overall levels of glycaemic control, BP, HDL-C and triglycerides and thus spent considerable time with lower CVD risk.” Ruelaz et.

al (12) found that obese veterans, despite compelling data, only 9.8% of all patients re- ported receiving any advice from a physician to lose weight.
A recent study of 424 patient charts of Veteran’s Administration (VA) Internal Medicine residents found that only 7.3% of their overweight !3 Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 101 patients and 30.9% of their obese patients were identiﬁed as such and only 16.5% of those patients received any form of weight management.
(13) Thus recognising at risk patients and inviting them to partake in health and wellness coaching should result in far better health outcomes.
Rubak et al (14) in a meta-analysis showed a signiﬁcant effect (95% conﬁdence interval) for moti- vational interviewing for combined effect estimates for body mass index, total blood cholesterol, systolic blood pressure, blood alcohol concentration and standard ethanol content, while combined effect estimates for cigarettes per day and for HbA1c were not signiﬁcant.
Motivational Interview- ing had a signiﬁcant and clinically relevant effect in approximately three out of four studies, with an equal effect on physiological (72%) and psychological (75%) diseases.

Psychologists and physi- cians obtained an effect in approximately 80% of the studies, while other healthcare providers ob- tained an effect in 46% of the studies.

When using motivational interviewing in brief encounters of 15 minutes, 64% of the studies showed an effect.
More than one encounter with the patient ensures the effectiveness of motivational interviewing.

Motivational interviewing is one technique used by wellness coaches.

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Gale and Skouteris(15) state adherence to recommendations for the management of chronic dis- eases has been estimated to be around only 50% and there is growing recognition that provision of information/education/advice alone is not sufﬁcient to produce signiﬁcant changes in health be- haviour.
Adoption of new behaviours is more likely if patients are encouraged to form a behaviour- al intention at the time of being provided with health information, and if they engage in volitional planning processes in order to convert that intention to action.

Hence there is a recognition that health behaviour change interventions need to include strategies that directly target changes in cog- nition and behaviour in addition to providing patient education.
As a consequence, health coaching interventions are increasingly being used by private and public health organisations worldwide to increase adherence to recommendations and to facilitate health behaviour change for chronic dis- ease prevention and chronic condition self- management.

Health coaching techniques are also being integrated into everyday clinical practice by a growing number of health practitioners for the same reasons.
Education, while important, is not sufﬁcient in its own right for the development of long-term be- haviour change required in those with chronic illness.

A focus on behaviour change and strategies to achieve this also seems to be required.

However, not all individuals will be ready for immediate be- haviour change, and so a focus on determining the individual’s stage of change and counseling ap- proaches to move individuals to the action stages received support in the literature.
A coaching style focused on a “readiness to change” paradigm acknowledges the complexities of treatment for many chronic diseases, where individuals are not always “enthusiastic” about adher- ing to all treatment recommendations.

Therefore, a patient could beneﬁt from coaching that was ac- curately directed at the person’s stage of change, particularly for the ambivalence to change at pre- action stages of change, and the speciﬁc behavioural techniques to maintain health behaviour change (16).
Primary Health staff recognise the value of client self management in chronic disease and perceive it as wholly relevant to their role, but identify many barriers to implementing it into their practice.

Conﬁdence or self efﬁcacy of staff in implementing the training into practice is repeatedly cited as a barrier.

Effective self management in chronic disease relies largely on the skill and attitudes of clin- icians to facilitate it.
Despite undertaking training in health coaching and having a positive percep- tion of it as a useful tool to facilitate self management, most of the participants in this study strug- !4 Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 101 gled to implement it in practice.

Clinician conﬁdence, and perceived self-efﬁcacy, is reported to be a predictive indicator in successful practice change behaviour following training.
Health coaching only requires 16 hours of training and the evidence from this research document demonstrates that this is not sufﬁcient to produce the change required in clients long term, we refer- ence the US model of Health and Wellness coaching and additional 109 hours of training will allow for clinical conﬁdence and build staff efﬁcacy allowing for sustainable behavioural change long term (17).
10 Health and Wellness Coaching Results from Surfcoast Medical centre - 5 coached sessions 30 mins duration a month apart weight loss decrease in waist circumference Hba1c 20 15 10 5 0 Client A Client B Client C Client D Client E Client F Client G Client H Client I Client J As the results show all clients lost weight, on average 4.14kg, decreased their waist circumference on average 6.47cms and had improved Hba1c results on average 0.44%.

They also had increased self efﬁcacy and wellbeing.
These clients are now all within their clinical therapeutic target ranges for Diabetes management.

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!5 Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 101 Case Series of Patients who have received Wellness Coaching at Eastern Shore Doctors.

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Due to the small study group and limited time frame that Wellness Coaching has been conducted at this General Medical Practice, we offer a brief snap shot of some of the outcomes achieved in the short time frame and with a small study group.

Clients were seen weekly for 1 hour at a time of be- tween 2 - 8 months !

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6 clients within the cohort.

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GP visits in the preceding 12 months across the whole group 114 visits.
During coaching and at completion of coaching over an 8 month period GP visits 24.

< of 90 visits across the group.

All clients had improved self efficacy, and are now exercising regularly.

Despite the compelling evidence based research available from overseas, the authors appreciate Australian research is essential.

Hence a submission to Western Alliance is currently being consid- ered and we have successfully been shortlisted through stage one of the selection processes.
West- ern Alliance Academic Health Science Centre is a partnership of Deakin University, Federation University and 13 health service providers operating across the western region of Victoria.

The re- search with include regional and rural communities.

!6 Number of clientsMedical conditionTime frameOutcomeComments3T2DM2-3 months1 client HBA1c with desired range.
Other two reduced HBA1CAll clients wanted to take control of their Diabetes.6Overweight/Obese2-6 monthsCombined weight loss of 19kgsAll clients are continuing to work toward their goals.

All exercising regularly.

some had never exercised before.

5Hypertension2-4 monthsAll 5 reduced BP to within normal range2Smoking3 months1 ceased smoking.
1 cut down from 10 per day to 3 per dayThe client who has not completely ceased smoking is working on cessation.1 Drug addiction8 monthsDrug free for 3 months> self efficacy now attending study5Anxiety/DepressionAll report > in confidence and better able to deal with anxiety.Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 101 !
Opportunities for the Medicare Payment system to reward and to en- courage best practice and quality improvement Business Case For Wellness Coaches within the Primary Health Care Framework.

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The business case for Practice Nurses trained in Wellness Coaching working within a General Prac- tice and Primary Health Care framework is a strong one.
There is well supported data from Overseas on this model - see Section- Examples of Best Practice in Chronic Disease Prevention Management in Australia and Internationally.

Currently two of the co authors of this submission are working in the area of chronic disease man- agement and preventative health nurse lead clinics using Wellness Coaching.

Wellness Coaching encourages the client to achieve behaviour change to exact wellness within a supportive, inspiring, motivating environment.
This behaviour change is lifelong enabling the person to manage their chronic illness under a client directed care model rather than a biomedical model, which is clearly not working as evidenced by the rising health care costs.

The significant benefits of this type of approach are far reaching.

The client will better manage their illness from not only a physical perspective but also a psycho- logical and spiritual perspective.

Many people with chronic disease also suffer from some type of mental illness.
The authors have found within their work under these two models that often this mental illness has not been previously identified.

All of this has a significant economic cost to the community.

This cost is in the form of lost work days, people leaving the paid workforce and rely- ing on welfare benefits, multiple hospital visits, multiple visits to GP, multiple medications.

This is also evidenced by the DALY results previously discussed within this submission.
This cost can be reduced by behaviour modification with the client developing self efficacy and self confidence to manage their illness themselves.

Wellness coaches in Australia are currently trained under the Harvard Medical Centre Model by Wellness Coaching Australia.

Wellness Coaches receive 125 hours of intensive training as opposed to Health Coaches who receive 16 hours of training.
What we propose under this dynamic, innovative model is a Wellness Coaching Package available to people with chronic disease; those most often disengaged from the health system but are the big- gest users of the government health dollar.

The package would consist of 12 weeks of intensive coaching, 1 visit per week for 12 weeks.

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!7 Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 101 The coaching could be performed within a General Practice, or externally dependant on where the Coach is working.

We suggest training current Practice Nurses as Wellness Coaches, as they are best placed to liaise with the patients General Practitioner.
This training could be administered through the State Primary Health Networks or the Australian Practice Nurses Association in conjunction Wellness Coaching Australia.

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SWOT Analysis !

As can be evidenced by the above SWOT Analysis the Strengths and opportunities for this model far outweigh the threats and weaknesses.

The costing below reflect what we know to be a cost effective model in comparison to the current medical costs for people to change their lives.

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!8 STRENGTHSWEAKNESSESTHREATSOPPORTUNITIES1.

Highly skilled Wellness Coaches with a passion and commitment to achieving positive outcomes for clients, especially high and frequent users of the current health system1.

Current fragmented health care system which is still focused around a biomedical model rather than a client directed model of care.1.

The current Medicare system does not allow for this model.1.
The ability to expand this model to the private sector under private health insurance or the corporate dollar.2.

Support from the clients GP in a collaborative approach toward achieving best outcome for the clients health and well being.2.

A system which currently is reactive to the disease burden rather than proactive.2.

create the opportunity to expand the model to include people without chronic medical conditions therefore prevent chronic disease and save money over the long term.3.
Cost effective model to reduce the economic burden to the community and Government.3.

May be some dissent from other allied health professionals competing for the health dollar.3.

The capacity to offer further coaching programs for example group coaching aimed at a particular cohort.

i.e.
i.e.

smoking cessation, stress management, work/life balance.Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 101 When you consider the costs of hospital visits for say chronic pain management, or uncontrolled diabetes, the Wellness Coach can keep people out of hospital there is a significant cost save and this model makes economic sense.

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Government Investment.!

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Visits of $60 per session for 12 weeks !

- Total Cost of $720.00!


When we consider that a large percentage of people with the burden of chronic disease come from a background of lower socio-economic areas, this cost is out of their reach.

However there will be significant cost savings to the government if that person ceases smoking, loses weight and controls and manages their chronic disease it is a win, win for the individual and the community at large.

We propose that this would be a one off cost per patient under Medicare.
It is yet to be considered whether this payment would be to the patients General Practitioner and then paid to the Wellness Coach or the payment would be paid to the Wellness Coach under a separate Medicare Item Num- ber.

It is would appear to be more cost effective to pay the Item Number directly to the Coach to reduce the administration cost to the medical practice.

This cost covers all costs associated with business.
The Coach could work within a General Practice setting, the above cost to cover room hire, admin costs, coach wages.

Wellness Coaches are independent practitioners.

Alternatively the Coach could work offsite working independently.

Again, covering the costs of general business including the above and others such as marketing, in- surances, telephone, travel etc, it is envisaged that clients would be referred to the Coach via a Gen- eral Practitioner.
This proposed model is innovative and new and requires serious consideration by the Government.

The cost of maintaining a burgeoning health system in its current form is not sustainable.

This mod- el offers an alternative to the current chronic disease management model within general practice and primary health.

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!9 Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 101 !
Opportunities for the Primary Health Network to co-ordinate and support chronic disease prevention and management in primary health care !

Currently, standards for credentialing health and wellness coaches in Australia are under develop- ment but will most likely require 125 hours of training through Wellness Coaching Australia.
Professionalising the ﬁeld will require a clear and consistent deﬁnition and standardisation of train- ing essential for future robust research to accurately assess the effectiveness of bringing about changes in health behaviours; health outcomes and associated costs that are targeted to reduce the 1 global burden of chronic disease.
National Consortium for Credentialing Health and Wellness Coaches in the USA (NCCHWC) pro- posed the following deﬁnition of health and wellness coaches: “Health and wellness coaches are professionals from diverse backgrounds and education who work with individuals and groups in a client centered process to facilitate and empower the client to achieve self-determined goals related to health and wellness.
Successful coaching takes place when coaches apply clearly deﬁned knowledge and skills so that clients mobilise internal strengths and external resources for sustainable change.” 2 Given that the treatment of lifestyle-related diseases makes up 70% of health care costs, the next looming economic crisis is the ballooning of health care costs associated with an epidemic of pre- ventable lifestyle-driven diseases.
Even though the evidence for healthy lifestyles as a means to im- prove mental and physical health, and prevent and ameliorate lifestyle-related diseases is well es- tablished, engagement is woefully inadequate.

We propose that having a professional coach who is a well-trained expert in facilitating sustainable lifestyle change, supporting wellness and disease prevention, and serving as a motivating role mod- el will signiﬁcantly reduce the ﬁnancial burden on chronic disease in the health care sector.
Wellness Coaching Australia Founder and Director Fiona Cosgrove will provide training for level one and two totaling 16 hours in-house at Primary health Network sites with the additional level 3 training provided online to reﬂect the 125 hours credentialing provided in the US.

(10, 15) !

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!10 Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 101 !

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Role of State and Territory Governments in Chronic Disease Preven- tion and Management.
The research and evidence coming out of the US, as detailed above, we propose that extensive re- search to be conducted and funded in Australia on the impact of Health and Wellness coaches.

There is currently coaching at the primary health level in Torquay, Anglesea and Tasmania sites.

This includes two regional centres and one rural centre.

There soon will be another rural site con- ducting Health and Wellness Coaching in the rural town of Timboon.

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Innovation models which incentivise access, quality and efﬁciency in chronic disease prevention and management Current Medicare rulings allow for ﬁve chronic disease prevention nurse visits utilising item num- ber 10997 and a TCA arrangement with a nurse that is not conducting the same services that a GP is conducting.

This has allowed the Surfcoast Medical Centre to use the health and wellness coaching services within their chronic and preventative disease clinics using the current Medicare guidelines.
The limiting factor with this approach, despite it being sustainable currently, is that it only allows for a limited number of visits per year.

It is well referenced and documented for Health and Well- ness Coaching to be beneﬁcial long term the coaching needs to be delivered over a 12 week period for a one hour consultation.
To make a substantial impact on unengaged or poorly engaged patients with chronic diseases we believe there is signiﬁcant evidence that health and wellness coaching if reimbursed by a Medicare item number would allow for much better health outcomes for the high risk disengaged patients.

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!11 Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 101 BIBLIOGRAPHY: 1 S Begg et al, Burden of Disease and Injury in Australia in the New Millennium MJA Vol11 7 Jan 2008 p36-40 2 Appel et al., Comparative Effectiveness of Weight-Loss Interventions in Clinical Practice, N Engl J Med 2011 Nov 24, 365(21): 1959-1966 3 Flegal KM, Carroll MD, Ogden CL, Curtin LR.

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9 Frates et al., Coaching for Behavior Change in Psychiatry.
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Global Advances in Health and Medicine J. Vol 2 Number 4 July 2013 11 The Look AHEAD Research Group Arch Inter Med 2010 Sep 27; 170(17): 1566-1575 12 Ruelaz et al., Perceived Barriers to Weight Management in Primary Care – Perspectives of Pa- tients and Providers J Gen Inter Med 2007 Apr 22(4): 518-522 13 Ruser et al., Identiﬁcation and management of overweight and obesity by Internal Medicine Res- idents.
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15 Janette Gale and Helen Skouteris, Facilitating Health Behaviour Change for Chronic Condition Prevention and Self-Management, 2013 pg 15-28.
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