A case series of an off-the-shelf online health resource with integrated nurse coaching to support self-management in COPD

Abstract

Background

COPD has significant psychosocial impact. Self-management support improves quality of life, but programs are not universally available. IT-based self-management interventions can provide home-based support, but have mixed results. We conducted a case series of an off-the-shelf Internet-based health-promotion program, The Preventive Plan (TPP), coupled with nurse-coach support, which aimed to increase patient activation and provide self-management benefits.

Materials and methods

A total of 19 COPD patients were recruited, and 14 completed 3-month follow-up in two groups: groups 1 and 2 with more and less advanced COPD, respectively. Change in patient activation was determined with paired t-tests and Wilcoxon signed-rank tests. Benefits and user experience were explored in semistructured interviews, analyzed thematically.

Results

Only group 1 improved significantly in activation, from a lower baseline than group 2; group 1 also improved significantly in mastery and anxiety. Both groups felt significantly more informed about COPD and reported physical functioning improvements. Group 1 reported improvements in mood and confidence. Overall, group 2 reported fewer benefits than group 1. Both groups valued nurse-coach support; for group 1, it was more important than TPP in building confidence to self-manage. The design of TPP and lack of motivation to use IT were barriers to use, but disease severity and poor IT skills were not.

Discussion

Our findings demonstrate the feasibility of combining nurse-coach support aligned to an Internet-based health resource, TPP, in COPD and provide learning about the challenges of such an approach and the importance of the nurse-coach role.

Keywords:

• COPD
• self-management
• Internet
• coaching
• patient activation

Acknowledgments

The Preventive Plan was supplied by UK Preventive Medicine Ltd (Acre House, 11/15 William Road, London NW1 3ER, UK), and we are grateful to Stefan Wisbauer from UK Preventive Medicine for technical support in its use. We thank Kate Homan who conducted the qualitative interviews, Petrea Fagan who supported the nurse coach in developing the self-management support skills necessary for the study, and the patients who participated in this study. The study was funded by NHS East of England Regional Innovation Funding, and delivery of this work was supported by the Cambridge Biomedical Research Centre.

Author contributions

JF and FE conceived, sought funding for, and designed the study. FE and ER conducted the qualitative data analysis. FE, Ella M, and JF conducted the statistical analysis. JY and Emma M were key contributors to the interpretation of the data. All authors have been involved in drafting and revision of the manuscript for important intellectual content, and have approved the final version to be published. All authors agree to be accountable for aspects of the work. JF is the guarantor of the paper.

Disclosure

The authors report no conflicts of interest in this work.

Supplementary materials

Further detailed description of the intervention and interview-topic guide are available from the corresponding author.

The Preventive Plan

The Preventive Plan (TPP) was a web-based program encompassing primary prevention (health promotion), secondary prevention (biometric and lab screening and early detection/diagnosis), and tertiary prevention (chronic condition management). TPP was personalized through the uploading of personal details, including medical history, medication, family history, weight, waist measurement, current lifestyle, dietary intake, and activity levels, via a 77 item questionnaire. The application incorporated four elements, described in the following paragraphs.

Following the uploading of personal details, a personalized health-risk assessment was generated, which indicated the individual’s highest risks of developing a range of conditions if no action were taken on current behavior. Risks were graded high, severe, and moderate and calculated using a variety of risk models, such as Framingham heart risk.¹ Based on this a personalized prevention plan was generated to address the health risks with a range of pre-programmed recommended action programs. Focusing on health-related behaviors, such as healthy eating, alcohol consumption, exercise, and smoking cessation, these guided the user through behavior change and offered step-by-step recommendations to achieve health benefits, while encouraging users to upload individual goal achievements. The duration of these action programs was around 8 weeks. This process was personalized to the extent that the action plan addressed an identified risk for the individual, but the plans themselves were not patient-led or -formed.

TPP also incorporated information resources, including daily health-news bulletins, which could be preselected relevant to identified health risks and action plans, and a health library/tutorial facility. In addition, local uploads were installed including links to the British Lung Foundation, carer support, local resources, and a COPD self-management personal health plan that included condition-related information, symptom-monitoring, and self-management action-plan templates. Participants also received a handheld copy of this personal health plan. Access was available to health information aimed at enhancing health literacy, an important aspect of self-management. TPP enabled email communication with the nurse coach, who could also monitor when users accessed the program.

Nurse-coach support

Use of the package was integrated with support from a trained respiratory nurse via home visits, telephone, and email contact. The nurse coach assisted participants to use the website and hardware (if provided), and supported patient self-management through individualized patient-led goal-setting. The role comprised user support for TPP, encouragement to use TPP, and “signposting” to other online resources for self-management through supportive email messages.

Patient-centered coaching to enhance confidence to self-manage was also a component. This included agenda-setting, patient-led goal-setting, support for and action planning to complement TPP-generated action plans, problem-solving, goal review, verbal encouragement, and focus on past successes. Patient-led goals could range from specific health-related behaviors, such as healthy eating, to broader lifestyle issues, such as meeting friends. Specifically, the communication style of this role incorporated coproduction, and was distinct from that of the nurse coach’s usual role as a respiratory nurse specialist, in that there was a strong emphasis on support relative to expert medical advice. For example, if a patient were to say that they thought they were having an exacerbation and ask if they should start their rescue pack, the role of the nurse coach was to educate through asking:

Why do you think you are having an exacerbation? What are your symptoms? What advice have you been given about these symptoms previously? Do you have any written instructions, such as a self-management plan?

This required specific skills distinct from medical knowledge. Education to complement information was available through TPP, with condition-specific education as appropriate to each participant’s needs.

When a participant joined the project, the nurse made an initial home visit. During this visit, she introduced the participant to TPP, provided contact details and written information about the program, collected baseline assessment data, supported the patient in completing the health-risk assessment, generated the personal prevention plan, and discussed self-management priorities, patient-led goal-setting, and action plan, and agreed on follow-up contact.

During each subsequent contact, the nurse would support the participant in problem-solving and working toward their goals, agreeing on methods and timing of goal follow-up on each occasion according to patient preference. Participants were asked whether they would like the next contact to be a visit, phone call, or text. If more than 14 days had elapsed since the previous contact, then the nurse coach would text the patient inquiring what progress they were making. If no reply had been received within 3–4 days, then she would telephone. The level of support provided by the nurse coach was flexible and responsive to the patient’s level of engagement with the intervention, eg, more frequent phone calls or emails to encourage contact with patients who were not readily engaging.

Table S1 Interview-topic guide

Reference

• KannelWBDawberTRKaganARevotskieNStokesJ3rdFactors of risk in the development of coronary heart disease: six-year follow-up experienceAnn Intern Med1961551335013751193
   PubMed Web of Science ®Google Scholar