Telephone-Based Lifestyle Counseling

Diabetes Spectrum
Volume 13 Number 4, 2000, Page 190

Nutrition FYI

Telephone-Based Lifestyle Counseling

Jackie L. Boucher, MS, RD, CDE, Nicolaas P. Pronk, PhD, and
Eve M. Gehling, MEd, RD, CDE

Health care professionals have used the telephone for many years to provide a variety of services. Health maintenance organizations have used telephone advice programs staffed by nurses to improve access to care for their members and to provide acute care interventions.^1,2 Diabetes nurse educators often use the telephone to provide medical management, ongoing support, and education to clients.³ Telephone-based counseling has also been utilized as an intervention to promote smoking cessation and for university-based weight management programs in different settings with varying intensity levels.⁴¹¹

Research studies that use telephone-based counseling—with or without prior face-to-face counseling—for modifying lifestyle behaviors suggest that frequent telephone contacts between a counselor and a client can be a useful behavior maintenance strategy.^4,811 The advantages of telephone-based counseling are numerous. Telephone contacts can be tailored to client needs and can offer social support with some degree of anonymity, since there is no face-to-face contact.^4,810 As an intervention, telephone-based counseling can be effectively delivered using standardized protocols and can be done proactively, which encourages a certain level of accountability in clients.

From a client perspective, telephone-based counseling is convenient, time efficient, accessible from work or home, and offers follow-up opportunities, allowing clients to develop a relationship with a counselor and receive a personalized approach.

This article reviews a telephone-based counseling program currently delivered and integrated into a managed care organization (MCO) that incorporates a systems thinking approach. This unique program allows MCO members immediate access to health professionals who can screen for medical risks, assess the stage of readiness to change, provide lifestyle counseling, recommend health promotion and/or risk reduction programs, and link with their health care providers. Protocols used by health professionals for lifestyle behavior change counseling will be described in general and more specifically for use with people who have diabetes.

An Intervention Using a Systems Thinking Approach
A systems thinking approach to population health improvement in an MCO has previously been described by Pronk and O'Connor.¹² In this approach, a population health improvement cycle provides a framework from which interventions may be systematically provided to specific populations. In order to ensure that interventions are delivered effectively and efficiently, useful information and specific resources have to be made available to all key stakeholders in the process. Efforts may be coordinated via centralized services, facilitated by health promotion staff, integrated with physician-based care plans, and monitored using sophisticated databases.

At HealthPartners, a community-governed, nonprofit MCO in the midwestern United States, the systems thinking approach to population health improvement has been implemented. Telephone-based counseling services designed to support behavior change efforts have been centralized and systematically facilitate a process of access, communication, documentation, and intervention implementation.

The Partners for Better Health (PBH) Phone Line, started in August 1994, was created to help members take an active role in improving their health and preventing disease. The three goals of the PBH Phone Line are to:

provide members with personalized assistance in their efforts to change lifestyle behaviors,
offer services designed to support health care providers in improving patient health status, i.e., provider-directed health promotion and risk reduction services and support, and
develop supportive education resources tailored to the needs of the customer (member), i.e., health information materials, high-quality counseling programs for behavior change, and direct links to appropriate HealthPartners and/or community resources.

Since its inception, the call volume for the PBH Phone Line has grown to ~6,000 calls per month. More than half of those calls are for ongoing behavior change counseling. The main topics discussed are exercise, weight management, stress management, smoking cessation, and nutrition.

The Role of Each Health Professional
To meet the diverse needs of members, lifestyle behavior change counseling is provided by the equivalent of 12 full-time health educators (HEs), registered dietitians (RDs), many of whom are certified diabetes educators (CDEs), and pharmacists. RDs provide nutrition, stress management, prenatal health, and dental health counseling. HEs, who have degrees in the areas of community health, exercise physiology, or psychology, provide counseling on stress management, smoking cessation, back health, and exercise. Pharmacists provide counseling on polypharmacy and herb-drug interactions. Staff who are CDEs play an important role in educating and triaging members with diabetes. They also develop and administer nontraditional diabetes prevention education approaches.

Having staff with varying education backgrounds and clinical specialties available to assist members with lifestyle behavior change provides depth to the counseling program. It also increases customer satisfaction because members have instant access to health experts who can answer their questions on numerous topic areas.

The Anatomy of a Call
Calls to the PHB Phone Line originate two ways. First, MCO members can self-refer. The program is frequently marketed in member communications. Second, many receive a proactive call from a phone counselor via a clinic referral written by their health care provider or in response to a health risk appraisal they complete at their worksite. All calls are triaged using outcome-focused, provider-approved protocols to assure high-quality, consistent care.

Phone counselors can access pertinent member data (e.g., diagnosis, medications, laboratory values, and physician transcriptions) via a computerized medical record. Using a screening algorithm, high-risk members are referred back to their health care providers for further medical management.

Members are assessed as to their readiness to change lifestyle habits to stage-match educational strategies and programs using the Transtheoretical Model of Behavior Change developed by Prochaska and DiClemente.¹³¹⁴ This model helps provide the framework for predicting willingness to change so that lifestyle behavior change counseling can be individualized to facilitate members in modifying and maintaining new behaviors.

Thus, RDs, HEs, pharmacists, and CDEs serve as "lifestyle counselors" who provide education and feedback to reinforce or change individuals' health behaviors. Goals are established and regularly reevaluated by members and their counselors during ongoing follow-up calls. Information from each call (generally 15 min in duration) is documented in an electronic medical record, and a hard copy is forwarded to callers' physicians, serving as a link with their health care providers. Since progress notes are sent to the providers at regular intervals, changes in members' health status receive prompt attention by physicians, which allows them to positively reinforce behavior changes that may prevent chronic diseases or promote risk reduction.

In addition to general counseling, the PBH Phone Line offers six courses that have been developed to be administered over the telephone. Courses include a 10-session weight management course, a 7-session smoking cessation course, an 8-session stress management course, a 7-session back health course, a 4-session heart health course, and a 4-session course to reduce the risk of developing type 2 diabetes. These courses consist of calls (also 15 min in duration) that are more structured in content and correspond with modular workbooks. Progress notes highlighting behavior changes made during the course are documented in the medical record. Additionally, with each course, outcome data are collected at the initiation and completion of the course and at other defined time points. Evaluation measures include clinical, functional, and satisfaction-related variables of interest.

Figure 1. Diabetes protocol for the PBH Phone Line triage process

Managing the Special Needs of People With Diabetes
When members call the PBH Phone Line, they expect immediate access to a health professional. Members with diabetes may call the PBH Phone Line to ask a question about diabetes management, inquire about a class, or receive ongoing support to make lifestyle behavior changes. Screens have been effectively used by the phone counselors to triage individuals with different medical conditions. As previously described, the call is triaged using a provider-approved diabetes protocol. (See call flow algorithm in Figure 1.) RDs and HEs triage the calls using standardized screening questions.

Five key questions (Figure 2) are included in the screening process for three reasons. First, the MCO strives to give all members with diabetes a comprehensive education background on diabetes. Second, the MCO encourages linking all members with diabetes to a health care provider who can help them manage this chronic disease. And third, these five questions ensure that consistent practices are used by the nondiabetes specialists, helping them identify members who need further assessment by a CDE.

Figure 2. PBH Phone Line's diabetes screening questions

If additional assessment is warranted after administering the initial screen, the member is transferred to an available CDE or scheduled for a follow-up phone appointment with a CDE. The CDE, using a more in-depth assessment form, determines diabetes self-management needs, provides education, refers members to diabetes-specific resources and programs, and links the member with his or her health care provider.

Summary
Telephone-based counseling is a brief, ongoing intervention that allows individuals immediate access to health professionals and continued contact to support lifestyle behavior change at a level that allows a large population to be reached. Integration of this approach in a MCO setting meets provider and patient needs by reinforcing clinic-based education, catching patients at teachable moments, and providing ongoing support to make lifestyle behavior changes. Thus, it allows the health professionals providing the telephone-based counseling to act as an extension of the clinic-based care delivery team, ensuring continuity of care.

References
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Jackie L. Boucher, MS, RD, CDE, is manager of the PBH Phone Line, Nicolaas P. Pronk, PhD, is senior director of the Center for Health Promotion (CHP), and Eve M. Gehling, MEd, RD, CDE, is manager of CHP systems at HealthPartners in Minneapolis, Minn.

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