The situation can be particularly dire for those with chronic conditions, says Kelly Brassil, Ph.D., RN, director of medical affairs at Birmingham, Alabama-based Pack Health, which specializes in digital health coaching for just such scenarios. When the novel coronavirus upended the U.S. healthcare system, the number of people participating in the company’s digital health coaching programs more than tripled—and many of the new members are living with conditions like type 2 diabetes and hypertension. Twenty-seven new employees have been added to the member services team this year, she adds, with 33 more being onboarded by mid-September.   

In most cases, an employer or healthcare plan is paying for the coaching service as a strategy for improving and maintaining health to minimize unnecessary care costs, says Brassil. That includes preventing chronic diseases from developing in the first place by helping members lose weight and make healthy lifestyle choices. 

The digital health coaching service is available in all 50 states, Brassil says. Unlike healthcare providers, health coaches (aka Health Advisors) aren’t tethered by state or licensure jurisdiction. Clients of Pack Health also include patient advocacy organizations such as the American Cancer Society, through whom individuals undergoing cancer treatment can get access to the program.  

Pack Health also partners with academic and clinical organizations and life science companies to help engage and address the mental health needs of members in real-world evidence projects and treatment trials. The role includes collection of patient-reported outcomes (PRO) data and analysis of clinical outcomes tied to digital health coaching.  

Customized Interactions  

The digital health coaching experience uses common means of interacting to make engagement as intuitive as possible, says Brassil, as it is now second nature for many people to grab their smartphone to order groceries or chat with a friend or work colleague. “Increasingly, we see opportunities for healthcare to be delivered this way.”    

Pack Health’s mission, she continues, is to extend care beyond clinical spaces like hospitals and clinics because the majority of chronic care management happens at home—everything from diet and exercise and medication adherence to behavioral health and dealing with social determinants of health (SDOH) issues like socioeconomic status and education that can impact health risks and outcomes. “Human-to-human interaction” and customizing content and its delivery based on an individual’s preferences, health literacy and access to technology and internet connectivity is fundamental to an individual’s success.   

Since Pack Health is platform-agnostic, says Brassil, the service could seamlessly integrate with any electronic health record or telehealth platform if requested. But “the beauty of the model is that it’s not purely digital” and therefore extendable to individuals who may only have a landline for communication. App-based coaching models, in contrast, rely on people having an internet-abled device and Wi-Fi network. 

Coaching happens by phone, email, and text—dictated by individuals’ preferences—with an average of nearly 90 touchpoints per member, she adds. The average time on each call is just shy of 13 minutes, but the length of individual conversations can vary widely.  

Non-white individuals comprise 38% of Pack Health’s member population, while 17% reside in rural areas, reports Brassil. In a recent analysis, Pack Health was able to show that its digital health coaching eliminated the disparity between members with diabetes stratified to high- and lower-income groups (many of whom lived in rural communities), related to A1C levels and foot exam completion. 

Putting Data To Work 

Coaching sessions generate a broad diversity of data for assessing the impact of the intervention, she continues, including demographics and member touchpoints, diagnostic (e.g., hemoglobin A1C levels if diabetic) and PRO using validated instruments such as the PROMIS-Global 10. Data on SDOH also get collected, as it is a “huge predictor of how individuals are going to be able to respond to coaching. It’s great to try to coach someone on the importance of nutrition on their overall health outcomes, but if they have food insecurities or live in a food desert, then we can’t expect them to access the very kind of ‘medicine’ that we are prescribing.” Financial toxicity (aka cost-of-care distress) can also be a roadblock, she adds.  

Importantly, Pack Health seeks to turn the SDOH information it collects into actionable insights to help improve member health. It has been delivering food to those in need (including individuals sheltering in place due to the pandemic) thanks to a partnership with an insurer, and in collaboration with a ride share company is providing transportation for medical care, which recently helped a cancer patient whose treatment site was relocated due to COVID-19. For another member struggling to cover her healthcare expenses, a Pack Health Advisor helped secure a $16,000 grant to defray some of the cost.  

One optional program component is to integrate data from digital devices, such as activity trackers, scales, or blood pressure cuffs, into the coaching experience, Brassil says, but this usually happens only when payers or employers are willing to underwrite the cost. “We work with a broad diversity of members and not everybody has a potentially costly activity tracker on their arm, so our coaching isn’t predicated on that.” 

Data sharing happens, first and foremost, with the members themselves, says Brassil. “The data has to be valuable to the individuals who are engaging with us. We do not collect data for data’s sake, but rather to inform a customized coaching experience for our members.” Clients only see aggregated, blinded data, potentially undergoing third-party analysis, to protect the confidentiality of the information collected. 

Members are asked, but not required, to identify any healthcare providers involved in their care so any clinically actionable issues that arise get escalated to the appropriate party, Brassil says. “We’re not intending to replace clinical or medical advice offered by their provider.” 

With Pack Health’s academic and life science partnerships, the communication channel and escalation policy is contractually spelled out along with the outcomes that will be tracked and the thresholds for reporting back information to providers, she says. Individuals receiving coaching through their employer are typically prompted to reach out to their healthcare providers on their own with navigational assistance, as needed, from their Health Advisor—an issue that can come up for individuals with comorbid chronic conditions being managed by more than one physician. 

Tiny Steps 

The potential benefit of digital health coaching for providers is that it serves to offload some of the calls they receive from patients which, while relevant to their health, aren’t necessarily in the bandwidth of the health system to handle, says Brassil. For example, a Pack Health Advisor might help deescalate the anxiety around COVID-19 by sharing the latest evidence related to mask wearing and handwashing.  

“We have an entire team dedicated solely to the development of evidence-based content… in collaboration with external content experts,” which includes both clinicians and patients, Brassil says. The in-house team includes a physician who serves as clinical director and a pharmacist who serves as vice president for medical affairs, in addition to Brassil, a registered nurse. Member-facing information is gathered from “key reliable sources,” such as the National Institutes of Health and Centers for Disease Control and Prevention, and routinely updated.  

While Pack Health Advisors don’t give clinical advice, they do empower individuals to take charge of condition self-management and provide an “accountability partner” that can be contacted as often as needed to help them do that, Brassil says. Health Advisors and members touch base, at minimum, once per week. 

Health Advisors often provide general, publicly available information about medications, such side effects and foods that should or shouldn’t be eaten with a drug, she continues. “In that situation, we’re basically helping patients break down what is embedded in a 50-page package insert into something that is tangible and relatable to them. What we can’t do is make recommendations about adjusting dosage or [accommodate] member preferences for drug X over drug Y.” 

Although the Health Advisors come from a diversity of backgrounds, many of them have a health-related experience and all of them have completed or are working toward certification through the National Board of Health and Wellness Coaching. In fact, Path Health is a designated training site for the organization that is partnered with the National Board of Medical Examiners. 

Members call the shots when it comes to setting personal health goals and then work toward them using Pack Health’s “Tiny Steps” program. The idea, says Brassil, is have individuals set small goals that can be accomplished on a daily or weekly basis rather than strive for big goals that can seem unachievable.