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Vantage point: The SET coach's perspective
Vantage point: The SET coach's perspective
The integral role of coaches to SET app program success
By Beth Bales
“A good coach will make his players see what they can be rather than what they are.” Those are words ascribed to football coach Ara Parseghian, who guided the University of Notre Dame to two national championships in the 1960s and 70s. And that’s exactly what the coaches involved with the testing of the SVS Supervised Exercise Therapy (SET) app, designed to help treat peripheral arterial disease (PAD), do. It turns out an app’s bells and whistles, and trackers and counters, can do only so much— the coach who helps patients through is integral.
In fact, coaching is much more important than app developer Oliver Aalami, MD, a clinical associate professor of surgery and the director of Biodesign for Digital Health at Stanford University, ever envisioned. His theory was that “technology would solve everything.” Now, with the app in use, “I’m learning to be more patient-centric, because that’s what the app is,” he said.
The program, which emphasizes education, nutrition and exercise, is now in pilot testing at 13 sites across the country, with other trials set to start soon. Approximately 100 people participated in round one.
Key to the coaching aspect is knowing what patients want to achieve and why. Coaches help each of their learner patients set a SMART—specific/ measurable/achievable/realistic/timely— goal, and then check in weekly about the obstacles patients are encountering and how they can overcome those challenges.
These personal goals are critical, said coaches Waukecha Wilkerson, Amy Davis-Bruner, as well as Aalami. “Goals make this program powerful and personal,” added Aalami.
Whether the goal is to be able to walk more than 73 steps in one day, stay out of an assisted living facility, go dancing, or walk again after an amputation, a self-defined goal provides the impetus to change behavior.
And in so doing, to change lives. “We’ve learned that in our initial conversations, it’s really about understanding and acknowledging what the starting point is for that individual, what is reality for him or her and meaningful for the life they live every day,” said Davis-Bruner. “What would be different for their lives through meeting their own goals. It has to be meaningful for the patient—or there’s no motivation to walk. These are true personalized SMART goals.”
The app and coaching are the tools to empower the patient to be his or her own health advocate going forward, to be the architects of their own healthy lifestyles,” said Wilkerson. It works as well as it does, because “embedded in our coaching model are best practices and cognitive behavior science,” said Davis-Bruner.
The two coaches estimate 98% of those so far enrolled are excited to make this first step and start the program. “They feel like this is the path to recovery and to prevent further worsening of their condition,” said Wilkerson.
Patient goals have included to go to Great America amusement park, go ice fishing, help a spouse around the house again, wander the landscape and take photographs, and give the gift of hiking with grandchildren.
Wilkerson said her patient-learners have given mostly positive feedback, and have said the app itself is valuable in helping them monitor their daily activities and keeping them accountable. But, she said, “It’s not just the technology responsible for keeping them on track. It is also the human coach with onboarding, and building that rapport and expectation of accountability through the 12-week program.”
In their weekly conversations, coaches sometimes must help their patients work through challenges they face.
For example, snow or ice prevents a patient from going to the mall to walk? “What other solutions have you considered,” coaches respond. Answers may be using an exercise bike instead, or walking around the house. “They think of their own solutions.” Others walk one floor in their apartment building, get on the elevator, and go to another floor to walk some more.
“The program is effective because the patient has control over the where and the how,” said Wilkerson. The coach’s role, added Davis-Bruner, is to help participants “resolve challenges to get to the success they want.
Education, such as presenting research showing what has proven to be effective in decreasing PAD symptoms and nutrition information, are also part of the program. For one patient, education that explained the “how” of exercise therapy—the role of blood traveling to the arteries and what smoking does to that route—was critical to stopping smoking and continuing to walk.
And there are successes. One patient got a job and moved into independent living. “He opens the app and continues to walk. It keeps him optimistic that it will all work out,” said Davis-Bruner.
Coaches and patients assess progress at the six-week mark. The patient who wanted to walk more than 73 steps a day? She’s at 1,100. An amputee, “feeling pretty down about life after amputation below the knee,” has noticed pain levels decreasing after walking on a treadmill.
The value patients find in the program and the victories many of them have had do not, however, mean a 100% success rate. In the first 100-patient cohort, seven had to leave because of surgeries or exacerbation of other problems.
But they want to start again in the spring, said Davis-Bruner. “They want to keep the app because they’re getting results. They’re building a healthy habit around the app itself and the app is a cue for a habit routine.”
“This is not a program for everybody,” said Aalami. “We have some really, really sick patients. All kinds of things can surface,” including a patient who walked so much she aggravated her arthritis and had to cut back. “Many conditions affect mobility,” he said.
Other physicians involved in these patients’ care are not only impressed with their patients’ health changes but also have called the app team to find out more. The other providers tell their patients, “Whatever you’re doing, keep doing it!” said Davis-Bruner.
What happens when coaching ends? By then, say Wilkerson and Davis-Bruner, the motivation to make the changes lasting must come from within. “Lasting change must be intrinsically motivated. Highfiving only lasts so long,” said Wilkerson.
She acknowledged the appreciation the patients have for the coaches. But the patients themselves have to be the ones driving the change, she said. “Ultimately, they are the hero of their story—the story that is most meaningful to them. That’s how it has to be if it’s going to be longlasting change. We coach with a model that uses what is most meaningful to that person’s life, and have him or her be the champion of that life.”