Leading your patients to wellness can improve the health of your practice.
At a certain point in 2006, Michelle Robin, DC, began to experience a working midlife crisis. She had just turned 40 and was burned out. She offered adjustments, massage, and yoga at her practice, but felt like she wasn’t teaching patients the “chiropractic lifestyle.”
She brought on a nutritionist and a functional medicine doctor and attended a certified wellness training program. “I reinvented myself to figure out who I was supposed to be,” she says.
And in doing so, she reinvented her practice from one mainly offering chiropractic to one providing overall wellness. She calls what she does “dripping wellness”—offering small tips during visits that lead to big shifts in people’s lives.
Chiropractors, many of whom already believe in a holistic approach to health, are in an ideal position to take on the role of wellness coaches for their patients. By taking off your doctor hat, you can work with patients to help them eat better, exercise more, and cease smoking; all things that will improve chiropractic results and stimulate patient loyalty.
Learning to lead
Chiropractors are a natural choice for wellness coaching, says Jennifer Packard, program director for the Wellness Coach Training Program at the Mayo Clinic Nicotine Dependence Center.
The role of a wellness coach is to help patients connect with big-picture goals that motivate them to make changes. Whether they want to quit smoking or lose 20 pounds, the solution requires altering behaviors.
Packard says, “Chiropractors can work with patients, saying ‘What do you want for yourself in the next two to three years, and what would life be like if everything works out the way you want?’”
Most chiropractors possess enough knowledge of nutrition and exercise to help patients meet wellness goals. But it’s not only knowledge people need; people can join Weight Watchers or get a gym membership if they want to lose weight.
“They need to increase someone’s confidence that they can be successful, give motivation for making change, help them overcome negative thoughts, know where to start, and set attainable goals,” Packard says.
Getting started
Robin works with her patients by teaching a new tip at every visit—are they drinking enough water, have they had a salad or a green smoothie today? She spends a few minutes during each visit offering wellness information.
Wellness is quick to implement, but it can take time to get started. A patient’s first visit with Robin is three times longer than a normal one. She takes time during this appointment to learn about the patient’s goals, lifestyle, and barriers to wellness. She writes a report she provides during the second visit to offer ways of reaching target goals, whether it is having more energy, losing weight, or sleeping through the night without pain.
A wellness assessment is the best place to start if patients have the time and are willing, says Michael Arloski, PhD, PCC, and CEO of Real Balance Global Wellness Services. It provides a whole picture of a patient’s health and highlights the gaps that can be filled with coaching.
If a current patient brings up an issue that could be treated with wellness coaching, Corey Schuler, DC, president of Integrative Physical Medicine in Hudson, Wisconsin, doesn’t have an assessment process. He tells them, “Great, let’s talk about it next time,” and he puts a note in his files: health coaching, brief, smoking. During their next visit, he begins coaching before moving on to manipulation.
Interviewing with purpose
Healthcare practitioners of all kinds typically rely on the authority of their education to make patients healthier. But when has it really worked to tell a patient, “You should stop smoking,” “You need to stretch to keep your back healthy,” or “You need to lay off the McDonald’s”?
“Prescriptive medicine hasn’t been effective, ever,” Schuler says.
Wellness coaching relies more on putting the responsibility for change in the patient’s hands, and allowing the practitioner to be the coach, a motivator who assists in setting goals. One of the major ways this occurs is through motivational interviewing.
The purpose of this kind of interviewing is to ask open-ended questions that help guide the patient toward better behaviors.
“What person doesn’t know that they should quit smoking?” Packard says. “The problem with health behavior change is it is hard and requires an application of energy and overcoming a certain amount of inertia.”
Most people can’t stop smoking just because they know they should. Through motivational interviewing, you can help patients connect to larger goals connected to smoking like wanting to play in the yard with their kid, go on a hike with their partner, or take their grandkids to Disneyland. The goals should be client-identified and short-term to work toward a changed future.
It’s also important to understand a patient’s motivations. Healthcare providers might want a patient to stop smoking to avoid the risk of a heart attack or lung cancer. The patient, however, might want to stop because they feel bad about the cost to the family’s budget.
“We are experts and think if patients would just listen to us, they would get better,” Packard says. “Then, when they don’t lose weight, we look at them as a noncompliant patient. But the deficit is in motivation, confidence, and the fact that the weight loss isn’t connected to the clients own personal goals.”
Course corrections
Change is hard. If it wasn’t, everyone would be perfect. Integrating wellness into your practice means you have to cultivate patience.
Robin says she is successful with engendering truly meaningful change in patients who need lifestyle interventions about 15 percent of the time. She has, however, seen results like a patient who lost 70 pounds and was able to stop taking copious amounts of daily medications, thanks to wellness coaching.
It’s important to understand that people are going to be at different stages of readiness for behavioral change: precontemplative, contemplative, or ready to take action. Your goal is to move them toward taking that action.
Some people may be ready to work on their diet, but not ready to exercise. Or they may want to focus on nutrition, but they don’t want to quit smoking. The point is to make their goals so attainable that success is practically inevitable.
“It’s easy to zoom in on something like stopping smoking,” Arloski says. “But it’s kind of like saying, ‘I know you aren’t a mountain climber, but let’s take on Mount Everest.’ You have to start with small changes and let them gain confidence.”
When creating goals for a patient, they should be behavioral instead of outcome-based, Schuler says. For example: People who are highly physiologically addicted to smoking typically have their first cigarette of the day within 10 minutes of waking. Instead of telling a patient to stop smoking, a better first goal would be to increase the time between their waking and their first cigarette to an hour, then make it progressively longer.
One of Schuler’s patients, L.M., who weighs 330 pounds, decided she wanted to lose weight. During a coaching session, Schuler found that one of L.M.’s major issues is that she has been stopping at a gas station for cream- filled donuts every morning for the past 10 years.
During their discussion, he discovered that L.M. doesn’t have a lot of support from her family. On the other hand, the staff at the gas station had become L.M.’s friends and a kind of surrogate family for her. Instead of asking her to stop going—and break important emotional ties—Schuler guided her toward the goal of telling the clerks at the gas station that she was going to start losing weight. This suggestion allows her to continue her routine but gets her to state her goals out loud and provides some account- ability and support through her social circle.
“Have people choose one thing they can do make them feel successful that they can start next week,” Schuler says. “Create an environment where they can’t lose.”
Return on the coaching investment
Behavioral changes aren’t easy to effect and they rarely happen overnight. But working with patients on achieving change can be a relatively quick process.
“People who want to stop smoking and change their diet don’t need a 90-minute session with a psychotherapist,” Schuler says.
Instead, treatment can be focused on brief, frequent interactions with the patient. Arloski says some of the work can be done by phone after an initial visit. Some sort of weekly contact is good for the first few weeks, then treatment can move to every other week or monthly as the patient makes progress. The model for patients and employees at the Mayo Clinic is weekly appointments over the course of four months.
The brevity of this treatment can be a good model for chiropractors to implement in a fairly seamless way. This is particularly helpful because it likely won’t be as lucrative as manipulation.
Robin says she doesn’t bill anything extra for the time she spends on wellness, but knows that it engenders patient loyalty and repeat visits.
Schuler says he bills insurers using CPT codes geared toward treatment of behavioral change for conditions considered “an illness” including tobacco use, substance abuse, and obesity. One code, 99406, is for three- to 10-minute visits (most likely to be used by chiropractors) and the other, 99407, is for visits longer than 10 minutes.
When Schuler sees change in patients, he shares in their excitement and asks if they would mind providing referrals to him among their friends and family.
“I tell them, ‘If you know someone who wants behavioral change, we are doing it, and I think we are effective at it,’” he says. “Sometimes they don’t even need anything from chiropractic, but people can always improve in the area of wellness.”
The term “wellness” can mean different things, depending on who is using it, but the experts cited above have found it to be a way of identifying health challenges that patients are facing, and a route to addressing them through behavioral modification. You adjust patients to help them heal naturally, but sometimes they might need just a bit more guidance on their way to better lifestyles.
Tammy Worth, a freelance writer based in Kansas City, Missouri, specializes in business and healthcare subjects. She can be contacted at tammy.worth@sbcglobal.net.
