The StACC model is built on learning from earlier Supported Self-Management (“SSM”) interventions and programmes designed for people with Long Term Health Conditions, such as Stanford University’s Chronic Disease Self-Management Programme Model, the Department of Health’s Expert Patient Programme, and the Health Foundation’s Co-Creating Health Programme (Health Foundation, 2007-2012).

In general, Supported Self-Management Programmes can take a variety of forms and can be condition-specific or focused on addressing specific problems such as managing fatigue, pain, etc. This was the case, for example, with the Stanford model, the Expert Patient Programme, and in groups involved in the Co-creating Health Self-Management Programme. Many self-management programmes aim to build knowledge, skills and confidence by teaching patients about their health condition or symptom and supporting them to self-manage more effectively.

The StACC model evolved most directly out of the Health Foundation’s Co-creating Health Self-Management Programme (“SMP”) and a number of NHS pilot services that KYOH was involved with and that followed from 2013. The model is now being used across England by many of the new Health and Wellbeing Coaches introduced into Primary Care in 2020 as part of NHSE’s Personalised Care agenda.

The model focuses solely on what is important to the individual and supports them to achieve it, irrespective of any specific health condition or symptoms. This approach supports patients to take ownership and control and, in the process, supports them to develop their own knowledge, skills and confidence to manage their health and wellbeing. 

From the patient’s perspective, the StAC Conversation is an experiential intervention that taps into the patient’s own resources, enabling them to become aware of their own ability to positively affect, or even drive, their own health, wellbeing, and general life outcomes. It is most effectively delivered as an individual one-to-one intervention as it is highly personalised and wholly focused on what is important to the individual at that time: Coaching is focused on where the patient is ‘right now’ and how they would like to move forward.

The basis of the model

The StACC model is based on the five-steps established through the Health Foundation’s Co-creating Health Self-Management Programme (“SMP”) that ran from 2007 to 2012. This provides a structure that Health and Wellbeing Coaches can use to support self-management and increase activation, utilising the PCI-accredited core curriculum health coaching skills.

The structure is straightforward and easy to learn.  The skill, in terms of using the steps for patient activation, is in being able to move flexibly, forwards and backwards, within the structure in order to meet the patient where they are at any time, using the skills appropriately at each stage. 

How the model works to increase patient activation

‘Patient activation’ was defined by Hibbard and colleagues as ‘an individual’s knowledge, skill, and confidence for managing their health and health care’ (Hibbard et al, 2005), with the stages described as follows:

1. believing the patient role is important,
2. having the confidence and knowledge necessary to take action,
3. actually taking action to maintain and improve one's health, and
4. staying the course even under stress."

In the StACC model, these are abbreviated to:

• Importance (of own role),
• Confidence (to achieve goals)
• Problem-solving (when set-backs arise).

Moving through the steps of the Coaching Conversation enables movement through the activation levels. 

The tension in the model sits around the ‘Importance line’ in the diagram.

This means the Coaching Conversation can be regarded as a process of two halves:  One focused on the importance of the patient’s role and their sense of ownership, and one focused on action and their confidence to achieve their goals and problem-solve when setbacks arise.

Increasing activation is important as higher levels of activation are linked to better health and wellbeing outcomes for patients and reduced reliance on clinical services (Health Foundation, 2018).

How to use the model effectively

In the StACC model, patients are first ‘activated’ before moving to action. By being given ownership and control, patients are empowered to drive the agenda before being supported to set and achieve goals, building their knowledge, skills and confidence in the process. As a result, they are then able to internalise the process and apply it to other goals.

This differs from trying to build a patient’s knowledge, skills and confidence in the hope that they will become activated. 

The model works for people at all levels of activation. What changes is the pace.

People at low levels of activation, or who are stuck or struggling, are likely to spend more time at the ‘top-end’ of the Coaching Conversation, i.e. Eliciting the Story, before moving to action than someone at high levels of activation who is more likely to move more quickly onto Goal-Setting and Problem-Solving.

This is because people at higher levels of activation are likely to already have a sense of ownership and level of confidence to achieve their goals. People at low levels of activation may therefore end up having a few more sessions than the standard 5 sessions plus a follow-up. See illustration, below:

The skill is in using the PCI Core Curriculum skills and moving flexibly within the model. The patient’s journey may not be in a ‘straight line’ and the coach will need to move up and down the Coaching Conversation Flow, using the Structured Agenda-free Coaching Conversation model in order to meet the patient where they are at any one time and to move the patient forward from there. The diagram below illustrates how that works across time:

The model adjusts ‘SMART’ goals to ‘SMMART’ goals or, as expressed in the correct but less memorable order, ‘SMMTAR’ goals.  These are SMART goals with Motivation added in alongside Specific, Measurable, Time-specific, Achievable and Realistic.

For Health & Wellbeing Coaches:

To use the StACC model effectively coaches need:

• Training in the PCI-accredited core skills for Health Coaching, including listening skills, exploring ambivalence, importance and confidence scaling, goal setting, and an understanding of patient activation.

• To understand the principles of the StACC model, and how to apply the skills at each step.

These can all be taught within a 2-day course.

Following this initial skills training, a minimum of 12 hours supervision (ideally a mix of individual and group) alongside an active caseload is needed in order to embed the skills. This supervision is included in KYOH”s standard ‘4-day’ PCI-accredited training for Health & Wellbeing Coaches alongside the Core Curriculum Skills training.

To become confident and expert in Health & Wellbeing Coaching to support self-management and patient activation using the StACC model, coaches will also benefit from their ongoing supervision, required by all Health & Wellbeing Coaches, to be with a supervisor who has sufficient knowledge and experience of the model.

Health & Wellbeing Coaches are required by the PCI ‘Roadmap’ to have knowledge of different models and frameworks. As a result, coaches can stick to one model or move between different models or frameworks, according to their PCN’s requirements and the desired outcomes.

For Care Coordinators, Social Prescribing Link Workers and other health and social care professionals:

The PCI Core Curriculum skills and the Coaching Conversation Flow structure can also be used by practitioners to have ‘better conversations’ to support self-management and patient activation. 

• Training in the PCI-accredited core skills for Health Coaching, including listening skills, exploring ambivalence, importance and confidence scaling, goal setting, and an understanding of patient activation.

• To understand the principles of the Coaching Conversation structure, and how to apply the skills at each step.

These can all be taught within a 2-day course.

Used for ‘better conversations’ rather than as an intervention, the structure is used to identify the type of conversation a practitioner is having with a patient at any one time (e.g. Eliciting the Story, Establishing Importance, Goal-setting, etc) and therefore which skills they are drawing on at that point.

Whichever way the model is being used – as an intervention or for ‘better conversations’ - the Coach, or the person having the coaching conversation, is expected to take a supportive and non-directive role, regarding the patient as a resourceful expert in the management of their health and wellbeing.

• Structured: 
  The intervention enables the coach to move flexibly forwards and backwards through a defined step order, meeting the patient where they are at any time, and remaining focused on one ‘thread’ at a time. It is effectively a two-stage model. The first stage is Agenda-setting, Eliciting the Story and Establishing Importance and the second stage is Goal-setting and Goal follow-up. It is the middle step, ‘Establishing Importance’ that divides the two stages and it is around this ‘Importance line’ that the tension in the model sits i.e. where ownership is established.

• Agenda-free:
  The intervention is not focused on a predefined outcome, or at least not one defined by anyone other than the patient. It acknowledges the biopsychosocial aspects of health and takes the patient through a process that enables them to take ownership, recognise and make choices and achieve goals in line with what matters to them, problem-solve where necessary, and to build on their successes.

• Coaching: 
  The model uses a range of coaching skills, including listening skills, exploring ambivalence, goal-setting, problem-solving, importance and confidence scaling, along with coaching principles including building trust and rapport, remaining non-judgmental, maintaining boundaries, and returning responsibility.

The Conversation is how the coaching is presented by the coach and experienced by the patient.

The importance line indicates the point at which the patient has taken ownership and control – when they’ve identified what’s most important to them right now and are able to recognise that they have choices and that they are the one who can make that choice. This is where they are ready to drive their own goal-setting and problem-solving with the support of the coach.

We’ve seen that, without ownership, goal-setting can be an uphill struggle for both the coach and the patient - and can even risk creating or exacerbating a sense of failure in the patient; conversely that there is no limit to what patients can achieve once a sense of ownership has been established.

The model also recognises that it’s the process rather than any particular outcomes that is important in the first instance.

Once the patient has internalised the process, they can apply it to anything.  It is due to this dynamic that quite extraordinary outcomes are often achieved as a result of the intervention.  As one of the coaches responded when asked whether she is often surprised by what patients achieve:

“I think they are often surprised by what they achieve.”

 

“The skills give me a set of tools; the structure gives me a toolbox.”

“This has changed things for me….it’s been like a lightbulb going on”

“I’ve realised that what works for one person is different from what works for another person;”

“I was coming in as an expert, offering tools and advice.  This is so much better –being more of a facilitator”

“I’ve learnt to trust the process”

“This is the most rewarding job I’ve ever done”

The following are a sample of the comments that patients have left in the optional free-text box of the feedback questionnaire.  The comments have been grouped to pick up on some common themes.

Achieving goals

“[My coach] came to me at a very dark time. I have a spinal cord injury (disabled and in daily pain), mum has dementia and my son has inherited my condition. I felt very low and couldn't see how to live positively. [my coach] encouraged (and enabled) me to set goals, reach goals and view life positively. I no longer feel overwhelmed. In fact, I feel well-armed to not only manage my life but succeed too! I was so impressed with [my coach] that when I finished I encouraged my son to apply. He now starts with her and I KNOW he will see life differently now!”

“The coaching has been useful. I found it supportive and helpful to have reinforcement to assist with motivation to keep going with my goals. The coach was helpful and I appreciated her approach very much. I feel it would be helpful if the service could continue.”

“Really felt comfortable and achieved some things that I have been procrastinating over and the solutions I have got from these sessions which definitely help me better my life and health in some ways.”

“I found the service really excellent and helpful. It exceeded expectations and I loved the fact I was given reasonable targets each time and then we were able to discuss them next time.”

“I have been amazed at the things I have achieved i.e. Reduced sugar in diet & smaller portions at dinner. I have also overcome a lifelong aversion to drinking water I now drink 11/2 litres of water per day. Well done [my coach]. Well done me.”

“I feel I needed the help from [my coach] to reach some of my goals. [my coach] was very helpful, kind and sensitive to my needs.”

“The sessions have helped me to understand the need to set goals - i.e. how much am I capable of doing (pacing) and also highlighted the importance of communicating problems with my partner.”

“I have been extremely impressed with the quality of this service. [my coach] has been wonderful at listening & also focusing and helping me to achieve very positive & helpful goals. She has given me confidence in myself and is extremely organised, professional and also supportive, friendly, helpful. I am very grateful to have been able to have this journey with [my coach].” 

“My blood sugars have come down and I feel much more in charge of my health issues.”

“I have found it interesting to attend sessions, particularly when I was feeling unwell. It was useful to look at my condition and reflect about the different kinds of support I needed. I am keen to recommend this service to friends and have already done so. I have used goal setting to manage my energy and pain. I feel the sessions were beneficial.”

“The service has been a very well and beneficial service for me. [My coach] has given me much to work on and has aided me to have some reasonable goals for myself. Well done !!”

“I am very grateful to [my coach] for helping me set goals and monitor health progress. The sessions were run professionally with excellent feedback from [my coach]. I strongly recommend this type of engagement.”

“I feel my coach has helped me realise that my goals are achievable. Already had the ideas, my coach made me realise that I can do it. I still feel uncomfortable with my emphysema but I am stable.”

“I feel that my coach has enabled me to think more objectively about achieving my goals and to maintain a healthier lifestyle!”

“I have found that my get up & go which had gone has come back. By [my coach] giving me some targets to reach!”

“I have found that the meetings with [my coach] have reinforced my motivation and helped to realise I am making progress towards better health & fuller life.”

“The positive reinforcement of regular sessions helped to motivate me to make the changes discussed and the fact it was one-to-one felt personal and individually tailored. Very good experience!”

“Very specific advice, changed my long held opinions on weight & attitude towards life-long activity & accepting challenges, regardless of age.”

“Thank you for providing this service, it has been really nice to have someone to talk to and help me with perspective and achieving my goals. I have already recommended the service to a friend.”

Building confidence

“The more that people know the better it is for them. The service has provided confidence so better able to ask questions of medical professionals who have all been very good.”

“I have found sessions surprisingly useful- I was unsure about what they could offer me, but have been pleased with the scope of discussion and the fresh perspectives on issues. I am pleased to have had access to the service and appointments at an important and challenging time for my health and when my husband has also been unwell. Sessions were supportive and I have gained confidence and communicate my needs better.”

“I now feel much more confident about speaking to my Doctor.”

“[My coach] has helped me so much; more confident and outgoing. Thank you.”

“I have found the sessions with my coach useful. I feel I am more able to manage my life in a positive way and be more assertive about my feelings & needs'.”

 “I feel the sessions have given me confidence to accept my condition with life.”

“I was able to feel more confident in making decisions. Also to challenge things I thought I couldn't do.”

“[My coach] has been such a wonderful support in my time of crisis. She has encouraged me and helped me to find inner resources of strength and courage.  Although my situation is still not resolved I feel more strength to cope and have faith that it will change.  Having someone kind and compassionate has helped me so much.  Thank you.”

“I've found the sessions very helpful in guiding me towards the future.”

“I have appreciated taking part in [the coaching service]. My coach has been excellent and I feel more confident to face the future.”

“Coach helped me with being more positive and confident discussing things with doctors and to set achievable goals.”

Mental health

“The service has been extremely helpful in improving my mental health. My coach has been excellent. Highly recommended.”

“I think that [my coach] has really helped me along the way to coping after my depression. She puts bad days into perspective and gives me strategies and encouragement. It had been very worthwhile.”

“Worthwhile service in my case. I feel my Health Coach is a good Samaritan -no longer in despair.”

“Extremely pleased with service. Felt had received a good, empathetic service which really helped provide coping mechanisms. Happier now.”

“A difference indeed from 1st mtg to last. Open doors to enjoying life and setting up activities that include fun! I feel my self-esteem which was rock bottom is right up the scale. Still room for improvement but I am getting there!”

“I think that when I was at 'rock bottom' it was a brilliant service to have access to. It stopped me doing 'something silly'.”

“I have found the coaching service to be very beneficial to my mental health.  It “filled the gaps” that mental health services are too stretched to fulfil at the moment.  Although I have medication for my bipolar, having the opportunity to discuss things around my health problems enabled me to make even more positive changes and to practise holistic self-care, as opposed to purely clinical self-care management and crisis prevention.  I have already told all my close friends about this service, and they were blown away by the fact it was offered free on the NHS.  I think it’s an innovative and modern service that is patient-focused and forward-thinking.” 

“Each meeting with my coach she encouraged me to look for ways to manage my pain and well-being; With the support of my coach and the goals we set for my particular challenges, the sessions with my physio and my determination not to stay depressed forever, there was improvement.  I'm really grateful to the service and for the patience of my coach enabling me to find the real ME again.”

Supporting people in engaging with other services

“If anyone is offered this service they should take up the offer. They will get a lot of help from it. Even my family have noticed that it has been helpful for me and have encouraged me to attend. The combination of this service and Health in Mind support have been so useful - I feel I have avoided hospital admissions because of it. The coaches and health in mind have been really helpful.”

“I feel great now thanks to the ladies (the Health Coach & the Respiratory team) that have helped me so much. Thank you all for all your help with me.”

“It’s certainly helped me to join things that I would never have joined before, joining a day club that I would not have done before has helped me feel more actively involved and I have made a few new friends. I would be interested in the group sessions if they were more local.”

General comments in support of dedicated health coaching

“I entered into the sessions unsure about whether it would be of any help and as I am short of time I didn't know if it would be a good investment but it has been. It has been very helpful and [my coach] has been a wonderful person and I'm very grateful to have met her.”

“I think this coaching is far more constructive and helpful than CBT or counselling.”

“My coach has enabled me to make positive changes in my life and given me the opportunity to improve my general wellbeing. I am grateful that I have been given the input of such a worthwhile scheme.”

“I feel this has been one of the best things I have done for myself. My coach is so easy to talk to but is not a 'yes' person!!”

“Brilliant service”

“A very enlightening experience!”

“I appreciate the professional and efficient delivery of this service and believe that this is a great step forward in promoting proactive self-help to a wide range of people.”

“I felt this course of sessions was of great benefit to me and has made a huge difference for me and my family”.

“I am so pleased with the way things have gone at my meetings. I feel really good. So many thanks to [my coach] for everything.”

“Felt service extremely beneficial & should be nationally available.”

“Amazing one to one coaching. Transformation.”

“Helped me a great deal and to eat healthier and made me feel better in myself.

[My coach] has understood my personal needs in such an insightful way that she has been able to give me pointers that have made changes (which I believe will be lasting) in my life that no other therapist/coach/advisor has managed. In terms of the speed and depth of the positive changes my time with [my coach] has been the most effective of my therapeutic experiences.”

Treating the ‘whole person’

“It works for me as I am not defined by just my health condition but as a whole person, mentally and physically.”

“Anything that helps the mind is worth doing. We are a whole person, not just bad leg. I think we are very complicated beings and you need to look at the whole person. You (the coaching service) understand that.”

“I feel the sessions very well timed for me. I needed to make big changes to my working life and although I thought the focus would be solely on my physical health, resolving the issue above has had an impact on everything.”

“I have found the coaching really useful for getting my situation into perspective, setting intermediate, doable targets and exploring and finding constructive ways forward. I feel [my coach]'s warmth and understanding, so feel okay about expressing how I'm feeling - this is something that I don't get to do ordinarily. [My coach] is able to see the whole person and that makes all the difference to getting to the bottom of issues. Many GPs have to hurriedly address one or two symptoms and it can be such a drawn out 'bitty' process that may not lead anywhere helpful.”

“I personally think the service helped me to stay focused. My health coach has been very helpful and shows an interest in you as a person which encourages you to continue to reach your goal.”

“The health coaching appointments have been beneficial in support to medical support (given by doctors etc.) as they have helped deal with emotional aspects of medical issues and assisted my path to recovery as a result. This is despite a broken programme due to medical issues that needed special attention. It demonstrates that life is worth making changes to suit unexpected circumstances to make things better.”

“Really useful for putting things in perspective and techniques to best help myself physically and emotionally. Great to be able to talk to someone who has an understanding of what I'm going through and doesn't look at things from a 'doctor’ background - more holistic”

The simple value of talking to a trained ‘agenda-free’ Health Coach and being supported to think/talk through issues

“The support that I received was instrumental in making me see I had a choice/s still in my life and to feel that I had still power over my life - I thought I'd lost that.”

“Initially I didn't think this would improve my situation but it has. It's given me time to reflect on how I go forward.”

“Was not what I expected but it has been helpful in clarifying my attitude to not only my condition but my general life. The reflective dialogue with my coach was enlightening as to my own thoughts about my approach to life.”

“Amazing service. The lady I see is wonderful at her job and has helped me an awful lot. I feel so much better and happier in myself. Thank you so much!!!!”

“It has been extremely helpful to talk through my health issues with [my coach] and to have a different perspective on the issues raised. Thank you.”

“Really helpful to have the time and space to think/talk through the issues and recognise how they impact on other areas - lots of inter-connectedness. Fabulous service - thank you [my coach]!”

“The service has helped me through a difficult time in my life. I was glad to have someone, not connected to my family problems to discuss things with.”

“[My coach] has been outstanding, prepared to listen and helped me to overcome difficult situations. Good to be able to discuss sensitive items.”

“I found help in prioritising myself very useful.”

“It's been very helpful, because I thought about things more.”

“Wasn't what I expected. Was worth coming and speaking to someone as I couldn't talk to anyone else about what I spoke about.”

“I have enjoyed our discussions. I appreciate the opportunity to talk about issues outside the family. Even when things can’t be solved it helps to discuss possibilities.”

“I feel that the Live Well service has helped me manage all my needs that I came to the service for.”

“I came to see [my coach] at a low point in my life when the thought of living much longer with Type 1 diabetes was not good. We have worked well together I have a sense of looking forward to my life and with the help of family & friends have found new goals.”

“I feel this service is very good to help to come to terms with my situation.”

“[My coach] has been an excellent source of information & support. I have appreciated all the support & individual time she has spent talking to me.  [My coach] has recognised & helped me change the way I think about things I saw as a problem before. Thank you.”

“This has been extremely useful for me at this stage in my life and with the issues I was dealing with.”

“It has been good to talk to someone who is neutral and understands my situation.”

“Talking with my coach has reinforced the idea that we have control over self-management and explaining to others how we approach this.”

“1-1 guidance has been very helpful.

This has been an incredibly beneficial and well-run service. So grateful for the expert help and support of my coach who has made an incredible difference to my health and state of mind.”

“The service has helped me to look at myself in a better way.”

“This service is very timely, when I needed help for myself to manage my stress in my life, it helped me focus on life & manage stress & emotion well. It teaches me to have more fun in life. I recommend this service to others.”

“The service has been very helpful by encouraging me to think seriously about my situation and do something about it.”

“I strongly recommend the benefits of the service. It’s been great for me as it turned my head around so I feel differently now and found determination to get up & on. I wouldn’t be this far ahead if it wasn’t for [my coach] & [my dietician]. Very thankful as not sure what would have happened if not had sessions with [my coach]. People need someone to talk too.”

“For me it has made me realise I was in a rut and has helped me realise that I could make a difference to how I controlled my health issues. Clearly from session 2 onwards it has reinforced that I can make a difference myself.”

“Very helpful as it made me focus on actions that would help me with some of my problems.”

“[My coach] was excellent. Supportive and an excellent listener but gently assertive in helping me address my behaviours and look at why [couldn't read next word]. Good view of big picture. She cleared the path and showed me the door was open.”

“When I first started the service, I was unsure about the service. It was much better than I expected. I feel much more positive and able to have things for me.”

“It is a really good service. If people feel sceptical it is worth doing the first one to realise how good it is for getting you thinking and understanding yourself.”

“Enjoyed the coaching even though apprehensive at first. Found it good to speak to an independent professional about things hadn’t discussed with wife.”

“Very, very helpful. I feel like I [now] have a way to move forwards and am not so confused!”

“It has helped me to see my situation and reactions more clearly, so that I can organise my life better in the future.”

“Found [my coach] to be very helpful and easy to talk to. These few visits have helped me no end to move forward in my life. Thank you.”

“I have found the support I received from [my coach] very helpful. Helped me to restructure my thought process to help me to not feel negative about my situation. Feeling positively encouraged in achieving my goals really helped too. I feel that I am now able to look forward with a more positive mindset.”

“Someone who has the time to sit and talk about problems and help to resolve them.”

“I've really enjoyed my sessions with [my coach] and feel she has helped me address and change my behaviour around some of my symptoms, especially tiredness, which has helped me recover. I think I now have a more positive attitude towards dealing with my physical problems and [my coach] has helped enormously with that.”

“[My coach] has helped me face a fear and find an answer.  I feel less anxious about the future.” 

 

• Health Foundation, 2012. Co-creating Health: Evaluation of first phase.
• Health Foundation, 2018. Reducing emergency admissions: unlocking the potential of people to better manage their long-term conditions.
• Hibbard, J. et al, 2004, Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers. Health Services Research.