Hope and ActionTheory and Practice

Alan Glaseroff MD

Stanford Coordinated Care

aglasero@stanford.edu

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A Costly Health System Failure

• Avoidable Hospital Admissions 2x more likely for asthma and diabetes in US vs. average of 30 developed countries in Organization for Economic Cooperation and Development

“The United States does not do well in preventing costly hospital admissions for chronic conditions, such as asthma or complications from diabetes, which should normally be managed through proper primary care.”

(Organization for Economic Cooperation and Development. Expensive healthcare is not always the best healthcare, says OECD’s Health at a Glance [Internet]. Paris: OECD; 2009 Aug [cited 2010 Jan 3)]).

vs.

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Determinants of Health and Their Contribution to Premature Death

Schroeder, NEJM 357; 12

15%

5%

10%

40%

30% SocialEnvironmentalMedicalBehavioralGenetic

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Patient–Driven Care

• “Others have struggled to find a proper definition of patient-centeredness. Three useful maxims that I have encountered are these:” – “The needs of the patient come first.”– “Nothing about me without me.”– “Every patient is the only patient.”

Donald M. Berwick, What 'Patient-Centered' Should Mean: Confessions Of An Extremist Health Affairs, 28, no.4 (2009):w555-w565

• New definition: Patients largely produce their own outcomes!

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Behavior Change is Key…

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Why Do Our Patients Struggle?

(“strong” endorsements by physicians)

poor self-discipline 53.2%

poor will-power 50.0%

not scared enough 36.9%

not intelligent enough 16.3%

Polonsky, Boswell and Edelman, 1996

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Unachievable Self-Care Plans

• Unclear- “I’m supposed to start exercising.”

• Unrealistic- “My doctor told me to lose 10 lbs before the

next visit.”- “Taking care of my diabetes means I’m

supposed to eat perfectly and never cheat.”

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The Overarching Approach

The patient must… BELIEVE SELF-MANAGEMENT IS

WORTHWHILE: The patient must feel there is hope and benefit in doing a good job (GOALS)

KNOW WHAT TO DO: The patient must have a clear and achievable plan for self-management (ACTION PLANS)

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Time to Practice (1)

• Pair-up• Choose roles (one person be the provider, one person be

the patient). – You will get to switch roles

• 5 minutes for each section• Not “role-playing” – pick something real from your life• Follow instructions closely

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Persuasion Techniques

• Agree that patient should make the change• Explain why the change is important• Warn of consequences of not changing• Advise patient how to change• Reassure patient that change is possible• Disagree if patient argues against change• Tell the patient what to do• Give examples of others (other patients, peers,

celebrities) who have made similar healthy changes

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How did that feel?

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“Why wouldn’t a person with a chronic condition do everything in their power to live long and feel well?”

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WHAT DOESN’T WORK

• Labeling patient as “unmotivated,” “unwilling to change,” or “non-compliant”

• Taking sides in the patient’s ambivalence- Giving advice- Transmitting knowledge unasked- Threatening bad outcomes

- “you’ll go blind if you don’t do what I tell you.”

- Urging more willpower “- if you would just try harder…”

• Caring more than the patient…

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Unachievable Self-Care Plans

• Unclear- “I’m supposed to start exercising.”

• Unrealistic- “My doctor told me to lose 10 lbs before the

next visit.”- “Taking care of my diabetes means I’m

supposed to eat perfectly and never cheat.”

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The Overarching Approach

GOALS: BELIEVE SELF-MANAGEMENT IS WORTHWHILE: The patient must feel there is hope and benefit in doing a good job.

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FACTS AND FICTIONS

1. Diabetes is the leading cause of adult blindness, amputations and kidney failure. True or false?

________________________________________A. False. Poorly controlled diabetes is

the leading cause of adult blindness, amputations and kidney failure.

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Feelings Can Fuel Change

What are the patient’s feelings? Think of a patient you’ve seen recently Have you ever asked how he/she feels about

his/her diabetes? What “bugs” that person the most about his/her

diabetes??? What is working for that person in their current

lifestyle? (what is the function in the “dysfunction”)

ASK! (then listen)

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Behavior Change Strategies

1. Begin with your patient’s interests• Agenda must be personally meaningful for

the patient• Start with questions, not information:

• “What questions should we make sure to address today?”

• “What’s been driving you crazy about your chronic condition?”

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Behavior Change Strategies

1. Begin with your patient’s interests

2. Believe that your patient is motivated to live a long, healthy life• You are both on the same side

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Behavior Change Strategies

1. Begin with your patient’s interests

2. Believe that your patient is motivated to live a long, healthy life

3. Help your patient determine exactly what they might want to change• Identify and respect ambivalence• Present “the bouquet”

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Time to Practice (2)

• Switch roles• 5 minutes• Again, no “role playing”• Follow instructions closely

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The “Journalist” Intervention

1. Zero in on an area for behavior change

2. Get the details• Be a journalist, listen carefully, limit questions

3. Explore relevant beliefs (4 “importance” questions)• “Your current score? Why not lower? Why not

higher? How to bump it up?”

4. Summarize and feed back the total story

DO NOT OFFER ANY HELP OR ADVICE

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Importance

“How do you feel about exercise now? If ‘0’ was not important, and ‘10” was very important, what number would you give yourself?”

0_________________________________10

not important very important

“You rated exercise importance at 4.”

Why isn’t it a 3? (listen for the benefits)

“And what would it take to make it a 7 (listen for ideas to overcome barriers)a 6 or 7?” (listen for the obstacles)

Rollnick et al, 1999

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Listen Well and Summarize

“It sounds like you’re inclined in two different directions. On the one hand, you’re somewhat worried about the possible long-term effects of your illness if you don’t manage it well–it’s pretty scary to think about such things. On the other hand, you’re young and you feel fairly healthy most of the time. You enjoy doing what you like to do, eat what you like to eat, and the long-term consequences seem far away. You’re concerned, and at the same time you’re not concerned.”

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The Overarching Approach

BELIEVE SELF-MANAGEMENT IS WORTHWHILE: The patient must feel there is hope and benefit in doing a good job.

KNOW WHAT TO DO. The patient must have a clear and achievable plan for self-management

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How did that feel?

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Behavior Change Strategies

1. Begin with your patient’s interests

2. Believe that your patient is motivated to live a long, healthy life

3. Help your patient determine exactly what they might want to change• Identify and respect ambivalence• Present the bouquet

4. Develop a reasonable, detailed action plan

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The “Action Plan” Intervention

1. Don’t tell patients what to do2. Negotiate what changes to focus on

blending your expertise and patients’ desires

3. Focus on 1 – 2 concrete actions to startNot attitudes, numbers, or actions to stopNot “lose 5 pounds in 2 weeks” Instead…”Walk briskly 20 minutes 3 x/ week,

Monday, Wednesday and Friday after lunch”

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The “Action Plan” Intervention

4. Start with changes that are achievableeven if “physiologically silly”

5. Selected actions must be personally meaningful

6. Do the first step right away“What does this mean you’ll do tomorrow

AM?”

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Implementation Intentions

• Promote cervical cancer screening appointment

• Random assignment to experimental or control procedure (n = 114)

• Control. Lecture about the need for screening

• Experimental. Lecture plus:- “You’re more likely to go for a cervical

smear if you decide when and where you’ll go. Please write in when, where and how you’ll make appointment.”

Sheeran and Orbell, 2000

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The Power of Implementation

Series1

40

50

60

70

80

90

100

Lecture Lecture plus implementation plan

% a

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Sheeran and Orbell, 2000

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How did it feel?

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Behavior Change Strategies

1. Begin with your patient’s interests

2. Believe that your patient is motivated to live a long, healthy life

3. Help your patient determine exactly what they might want to change

4. Develop a reasonable, detailed action plan

5. Stay alert for common obstacles

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Patient Self-Management Barriers

1. ……

2. ……

3. ……

4. ……

5. ……

6. ……

7. ……

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Patient Self-Management Barriers

Social devastation (poverty, homelessness, lack of access to health care services, etc)

Lack of information Cultural disconnect Low functional health literacy Relative lack of life skills Anxiety/disease-specific

distress/depression

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PAM – what the patient brings to the problem

The Patient Activation Measure® (PAM®) assessment gauges the knowledge, skills and confidence essential to managing one’s own health and healthcare.

Level 1 Level 2 Level 3 Level 4Starting to take a role.

Building knowledge and confidence

Taking action

Maintaining behaviors

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Address Health Literacy

• Assess patients’ recall or comprehension of recommendations

(aka “close the loop”)• D. "So . . . let's make sure. What

medications are we going to change?" • P. "I think we're going to stop this one (is

it metformin?) . . . and I'm going to take glipizide twice a day. . . I think that's the green one.“

• Develop strategies to overcome this barrier (case management, phone contacts, etc)

Schillinger et al, 2003

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Take-Home Messages

• Almost everyone would prefer to live a long, healthy life

• Our patients are not unmotivated to self-manage effectively

• The problem is that self-care is tough• Our patients face many obstacles to good

self-care• Simple behavior change strategies are likely

to help