1. A Strategy for Including Health Behavior Change Counseling in Routine Patient Visits A Strategy for Including Health Behavior Change Counseling in Routine Patient Visits John Nagle, MPA and Katherine Miller, MD U. Of Colorado Denver Family Medicine Residency December 5, 2008 December 5, 2008

2. Objectives At the conclusion of this session participants will be able to: Describe the elements of a brief behavior change counseling conversation. Assess patient’s self-efficacy rating for accomplishing their health behavior change goal. Identify conversational approaches to avoid when negotiating achievable health behavior change goals

3. Health Behavior Change Counseling Conversations with patients intended to support patients in identifying and successfully completing behavior changes that enhance patient health. It includes: –Conversations aimed at enhancing patient management of a health problem during the treatment and recovery stages –In the case of chronic conditions, conversations about the on-going optimal management of those conditions –Conversations about behaviors which enhance health and minimize health risks.

4. What makes Health Behavior Change Counseling different? Patient is a true partner in establishing goals The patient is doing most of the talking It is eliciting, not prescribing The patient is the expert on what they can and cannot do You are the coach

5. We have learned that patients go through a series of steps to make changes in their lifestyles. The scientists that created this model of change called it the “Transtheoretical Model of Behavior Change” but it is now commonly referred to as Stages of Change. Stages in the change process are linked to strategies for moving patients on to the next stage.

6. Stages of Change Precontemplation Contemplation Preparation Action Maintenance – –Don’t want to – –Might want to, might not – –Getting ready to change – –Changing – –Making the change routine

7. Stages of change assessment is useful to decide what would be the most useful activity to support a patient’s change effort

8. Stages of Change frees you from the tyranny of thinking that the only measure of progress in patient behavior change is the patient’s initiation of a new behavior

9. Physicians get frustrated because patients don’t do what they tell them to do. It’s important to realize that, in general, patients only do what they tell themselves to do.

10. A motivational interviewing approach is useful when you want to help a patient move out of pre- contemplation or contemplation toward action.

11. Motivational interviewing is persuasion.

12. By your questions and comments on your patients’ statements you guide patients toward a declaration to make a positive change

13. You need to elicit ideas about the “what and why” of changing and not changing from the patient.

14. Using Motivational Interviewing You need the patient to discover that they have their own concerns about their unhealthy behaviors and that they want to address them. You need to highlight the discrepancy between contradictory ideas or goals the patient holds. You have to avoid making the patient defensive.

15. Principles of Motivational Interviewing Express Empathy – Acceptance facilitates change. Ambivalence is normal. Skillful reflective listening is fundamental.

16. Principles of Motivational Interviewing Develop Discrepancy – Awareness of consequences is important. A discrepancy between present behavior and important goals will motivate change. The patient should present the arguments for change.

17. Principles of Motivational Interviewing Avoid Arguing - Arguments are counterproductive. Defending breeds defensiveness. Resistance is a signal to change strategies. Labeling is unnecessary.

18. Principles of Motivational Interviewing Roll with Resistance – Momentum can be used to good advantage. Perceptions can be shifted. New perspectives are invited not imposed. The client is a valuable resource in finding solutions to problems.

19. Principles of Motivational Interviewing Support Self-Efficacy – Belief in the possibility of change is an important motivator. The client is responsible for choosing and carrying out personal change. There is hope in the range of alternative approaches available.

20. Thoughts on applying motivational interviewing (MI) in practice First and foremost, the MI approach is a way to avoid traps that can undercut a behavior change conversation. It encourages you to listen, and to encourage the patient’s to talk. It focuses your listening on the contradictory statements that patients make about a change and to use those statements effectively. If your office visit sessions are leading nowhere, consider referring to someone with more time and experience.

21. A Brief, Targeted Behavior Change Intervention

22. Stages of Change Precontemplation Contemplation Preparation Action Maintenance – –Don’t want to – –Might want to, might not – –Getting ready to change – –Changing – –Making the change routine You are looking for changes where patient is in preparation or action or can easily get to that stage.

23. A Question to Get You Started “What are you going to do to improve your health in the next week?”

24. What are the elements of behavior change counseling? 1.Engaging with a patient to establish an achievable goal. 2.Assessing importance and patient self- efficacy in achieving the goal. 3.Adjust goals to make them achievable & improve self-efficacy rating. 4.Establish a method of accountability.

25. When the patient is suggesting a goal they wish to work on, you are already beyond pre- contemplation and usually past contemplation.

26. Goals should be Specific For a specific interval Achievable – Even with a large goal in mind pick an immediate goal that is “bite size”.

27. Once you have a goal Check to see how important the goal is to the patient Check to see how likely they think it is that they will achieve the goal (self-efficacy).

28. Importance A person’s assessment of the significance of this particular goal in their lives right now A person may feel able to make a change but it it’s not important to them they are likely to spend time elsewhere

29. Self-Efficacy A person’s assessment of their degree of commitment to or their likelihood of accomplishing a proposed change. Self-efficacy can be generalized to other situations. You can take patients success at achieving one goal and apply it to another change that is not necessarily related.

30. Checking for the level of self- efficacy provides you with an indication of the patient’s degree of commitment to a proposed change.

31. To test for self-efficacy…. “On a scale of zero to ten where zero means there is no way you can be successful making this change and ten means you are totally confident you can make this change and meet your goal, where do you think you are now?” Concerned about comprehension? Draw a line and then label the ends “0” and “10” and 5 at the midpoint. Have them make a mark indicating where they are.

32. If they score below 7 -- Renegotiate the goal so that the patient will score self-efficacy higher. “You are a bit below where we’d like folks to be on this scale to be successful. How could you change your goal so that you would rate your chances of success above a seven?”

33. Build in accountability How will patients report to you that they have been successful? How will you chart the exchange and the goal? The fact that you will be following up, provides encouragement to follow through. If you say you are going to follow up, be sure you do.

34. Putting the pieces together Ask the question Invite patients to choose a goal. Work to make the goal specific Check to see that the goal is important Check to see that self-efficacy is high Renegotiate the goal if its too lofty Build in accountability Repeat the cycle with the next goal

35. System Changes That Will Help A goal-setting form to complete A specific location in the medical record to record HBC goals A print-out you see before the visit that states the goal the patient is working on now

36. System Changes That Will Help Involving the office staff in making follow- up phone calls and/or e-mails. Audits of charts to note success in setting HBC goals For faculty and preceptors – make inquiries about patients’ HBC goals a regular part of your conversations with residents

37. The Challenges of Making this Work in Practice and in Residency Education

38. Challenges/Opportunities in Practice Different conversation than patient education Assessing stage of change can improve efficiency in the exam room Requires rapid, easy documentation of goal, self-efficacy, and follow-up Requires involvement of system

39. Challenges/Opportunities in Teaching Difficult to teach with medically complex patients with multiple problems. Works best when residents have had teaching around patient education and health behavior change skills. Reinforces patient centered skills. May be used to teach system changes and team work.

40. Questions and Comments?