In technology-supported apprenticeship, patients are the novice apprentices of master coaches. Technology provides scaffolding and communication tools to allow coaches to support the patient in the management of disease within the context of daily life rather than in the clinician’s office. Patients are supported in gradually developing self-efficacy and independence until they are skilled enough to lead their care and even to help coach others to success. The hypothesis is that embracing the contribution of the patient to this extent will reap unparalleled rewards in the experience, outcomes, and cost of care.
We conducted a randomized controlled trial to assess whether a technology-supported apprenticeship in hyper-tension management would improve blood pressure control compared with a successful coaching model.
Methods
Setting
The health coaching model at the Ambulatory Practice of the Future (APF) at the Massachusetts General Hospital is designed to impact the whole health ofpatients. In the scope of hypertension management, a nurse health coach, under the supervision of a physician, is responsible for improving outcomes through longitudinal support via office visits, phone calls, and e-mails. Diet, exercise, stress management, and medication therapy are all emphasized through health coaching techniques, such as motivational interviewing and appreciative inquiry [23,24]. Patients are referred to dieticians, exercise coaches, mind-body specialists, and others as desired. Prior to the start of this study, the APF was outperforming the national average with ~70% of hypertensive patients in the practice below clinically recommended goal blood pressures.
Recruitment
The study was advertised to all clinical staff of the APF through word of mouth. Since the practice was relatively young, it also had a registry of patients with elevated blood pressure that had not been addressed. Adult patients (> 18 years old) from the registry or from routine visits with essential hypertension (average blood pressure ≥ 140/90 and ≤ 180/120) who were taking 0 or 1 medications and had internet connectivity were eligible for inclusion in the study. Patients with a history of hypotension, syncope, hypertensive urgency, hypertensive emergency, labile hypertension, and proven coronary artery disease were excluded, as were patients with significant visual, auditory, or cognitive impairment and patients who were not proficient in English. Clinical staff notified the nurse health coach for the study on identification of any eligible subjects. The same nurse health coach recruited and cared for all intervention and control subjects.
The nurse health coach contacted each eligible patient to assess interest. Interested patients were scheduled for an appointment to commence the study. A process of written informed consent was carried out with each study subject. Each subject was assigned the next sequential study number, which was pre-randomized to either the intervention or the control group.
The study period for each subject was 12 weeks +/– 2 weeks with staggered recruitment. Twelve weeks represents the minimal time required to progress through the standardized Medication Adjustment Plan that was used, assuming a minimum time of 2 weeks on each medication before a change is considered. A recruitment window from 1 March 2013 until 31 May 2013 was used. The goal was to recruit between 40 and 60 subjects, since statistical analysis revealed that a sample size of 36 was sufficient to detect a 5 mm Hg difference in the decrease in systolic blood pressure between groups given a 4 mm Hg standard deviation.