THE COACH Program — a standardised, structured coaching program delivered by highly trained health professionals to people already diagnosed with a chronic disease or who are at high risk of developing chronic disease — has recently been rated the most evidence-based cardiovascular disease (CVD) prevention program in the world on clinical and cost effectiveness, by the British Heart Foundation and Public Health England’s International cardiovascular disease prevention case studies report.
Developed in 1995 by Associate Professor Margarite Vale as her PhD thesis, The COACH Program was selected from a field of 118 programs across the globe. It is now in its 25th year and underwent 10 years of clinical research before expansion to private and public health care systems throughout Australia and other parts of the world. The past 15 years of operation has been applied research of the program operating in the real world.
The program has been used extensively in Australia for more than 10 years, particularly in the private health sector, with many private health insurers providing it for their members with chronic disease.
The use of The COACH Program in the public health system is funded by state government health departments but its provision is inconsistent between the states. Queensland Health’s Health Contact Centre recently celebrated its 10-year anniversary of using The COACH Program and is the only state providing a statewide approach for all eligible patients. Tasmania offers the program statewide from Diabetes Tasmania for people with type 2 diabetes, pre-diabetes or high risk of type 2 diabetes. The program is also operating in Western Sydney Local Health District and Primary Care Connect Shepparton.
The COACH Program is available for use by organisations wanting to deliver it using their own staff. NPS MedicineWise, through its subsidiary VentureWise, also delivers the program as a full service program to organisations preferring to outsource delivery.
Given the results of the International CVD prevention case study report, there could be a significant positive impact on CVD outcomes in the Australian environment if the program were more widely available. The current debate around the Medicare Benefits Schedule Review taskforce’s position on CVD systematic risk assessment needs to focus more on what can be done – that is, an evidence-based solution – for improving patient CVD risk factors and the International CVD prevention case study report summarises well the world-leading outcomes the program delivers.
How The COACH Program works
The COACH Program is delivered by telephone and mail-outs over a period of 6 months. The program is focused on closing the “evidence–practice gap” – the gap between guideline-recommended care and the care patients actually receive. The coaches identify the treatment gaps for each individual patient, when medication has not been optimised and risk factor targets for their modifiable risk factors (eg, lipids, blood pressure, blood glucose and glycated haemoglobin levels, alcohol intake, smoking, physical activity, waist measurement) have not been achieved.
The coaches then inform the patients of what guideline-recommended treatment they are missing out on (ie, their treatment gaps) and provide them with specific advice on how to close their treatment gaps. Patients are advised to discuss with their usual doctor regarding medication changes required to achieve the guideline-recommended target risk factor levels for their biomedical risk factors. They are also coached to achieve the guideline-recommended targets for all of the lifestyle risk factors.
Patients with more than one chronic disease are coached on the risk factors for all of their conditions, such as coronary heart disease, peripheral vascular disease, heart failure, stroke, transient ischaemic attack, type 2 diabetes, pre-diabetes, chronic obstructive pulmonary disease, asthma, chronic kidney disease, hypertension, or for the primary prevention of vascular disease.
Each telephone coaching session is followed by a structured written report that summarises the session. These reports are sent to the patient and copied to their usual doctor and serve as reinforcement and a written record of each session. Health professionals trained in the COACH system use a web-based customised software program to support the delivery of the program to patients.
The COACH Program provides the patient with knowledge of the treatments they should be receiving according to the guidelines; emphasises adherence to the recommended treatments; trains the patient on how to improve their diet, exercise levels and other lifestyle factors; and teaches patients frequency of monitoring of their surrogate disease markers to ensure that the risk factor targets are maintained long term. Patients are coached to achieve all of this through visiting their GP and other usual health professionals. Importantly, the program does not compete with usual medical care.
Key points from the report
“When assessing the published literature for the case studies COACH had more evidence-based publications outlining the benefits to patients and the health economy than any of the other programs.”
“The COACH approach has been used extensively in Australia and has the most evidence of all the case studies with two decades of reporting on clinical and cost effectiveness.”
Evidence highlighted by the report included (but were not limited to):
- two randomised controlled trials, which showed that The COACH Program was highly effective in reducing risk factors in patients with cardiovascular disease;
- a 4-year follow-up of participants in a randomised controlled trial, showing a reduction in any-cause hospital admissions of 16% and a reduction in any-cause hospital bed days of 20%; and
- a 6.35-year follow-up and private patient claims analysis of cardiovascular patients who underwent The COACH Program, showing an absolute reduction in all-cause mortality of 5.08%, and an average net cost saving to the funder of AUD$12 115 per person in those who received the program compared with those who did not.
“Of the five programs that focused on people with high risk conditions, COACH is employing the greatest number of strategies (9/11) that might increase the likelihood of a successful program.”
“Empowers and supports individuals to better manage their chronic disease and the associated lifestyle and biomedical risk factors.”
The British Heart Foundation report is a rigorous evaluation of cardiovascular disease prevention programs on a global scale. Chronic disease management programs should always be evaluated based on evidence of their efficacy and cost effectiveness. Over the past 25 years, many programs have been promulgated that have not released or published any outcomes, either in terms of clinical results or net cost assessment for the funder.
Greg Hughes from VentureWise comments: “We selected The COACH Program because of the evidence base and strong alignment with our mission to improve health outcomes for patients with chronic disease. We have had excellent patient and health professional feedback and our client funders like that the program has a fixed duration and cost with enduring results, as demonstrated by long term follow-up studies.”
Greg Hughes is an economist and Managing Director of VentureWise, a company focused on connecting health service funders with best practice programs, interventions and research to improve health and economic outcomes. VentureWise is an independent, wholly owned subsidiary of NPS MedicineWise.
Associate Professor Michael Jelinek is a clinical cardiologist, formerly Director of Cardiology at St Vincent’s Hospital Melbourne (1995 to 2007); formerly President of the Cardiac Society of Australia and New Zealand (1998 to 2000); honorary medical advisor to The COACH Program.
Associate Professor Margarite Vale’s background is in secondary school teaching and human nutrition and dietetics. Completing a PhD in chronic disease management in the University of Melbourne’s Department of Medicine in 2002, she is Director of The COACH Program, Clinical Associate Professor in the University of Melbourne’s Department of Medicine, and Fellow of the Cardiac Society of Australia and New Zealand.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.