Using Change Theory to Increase Patient Adherence Carol Lee, MSW, LCSW & Julie C. Wood, RN, MSN, CNS, CHFN

We may have the best doctors, the newest techniques and equipment, the best staff and a beautiful hospital but all that does not matter if our patients are not medically adherent. Our hospital ratings and re-imbursement is measured on patient outcomes. Therefore finding new ways to enable patients to be successful in changing their behaviors to be medically adherent is the basic key to the success of a medical system. Realities in the Healthcare Business 2

Objectives 1. Identify the 6 basic principles to influence change 2. Identify the 2 basic questions that patients ask themselves before adherence is possible 3. Learn how to identify Vital Behaviors for a specific patient population and to measure these behaviors with Patient Self-Assessment Surveys

Change Theory Based on the work of Kerry Patterson, Joseph Grenny, David Maxfield, Ron McMillan and Al Switzler Books: Change Anything, Influencer: The New Science of Leading Change, and Crucial Conversations The authors researched what was effective in changing individual and group behaviors. Based on this research, they developed principles and strategies for successful change.

Medical Adherence is “Abnormal” Results of Preventative Health Self Assessment Survey Change Theory Principle: People choose behaviors on what they think will happen. Human tendency is to live “in the now”. We consider only the immediate result – “Will it make me feel good now?” Equally important, but often overlooked is the eventual result “How will this effect me in the(very distant) future? Medical Adherence is a practice requiring many decisions through-out the day and people need to stay mindful of their bodies and their health. 5

Sutter Memorial Transplant & Advanced Heart Service Provides: Treatment to a diverse adult patient population A continuum of care from Heart Failure to LVAD to Heart Transplants TAVR and Congenital Heart Clinics

Our Statistics In 2012, we implanted 29 LVADs and 12 heart transplants. Our total numbers are 108 LVADs and 148 heart transplants. Our heart failure program was the 1st in the nation to be certified CMS. 7

Change Theory: Strategies Identify Vital Behaviors by studying positive deviance Develop a recovery strategy when people make mistakes (anticipate mistakes and make a plan in advance) Test your results Update strategy accordingly, test results and repeat 8

2 Questions Preceding Change 1.Can I do it? o Stages of Change Applicable: Pre-Contemplation; Contemplation; Preparation; Action; Maintenance; Termination 2.Is it worth it? o Social Workers and Nurses often intervene to assist people in problem-solving these answers 9

6 Sources of Change, Cont. 4.Social Ability – Real change requires help, information and support from others 5.Structural Motivation – Environment impacts behavior Make the healthy choice the easy choice 6.Structural Ability – Small changes in the environment can have a big impact that are “forces that either push with you or against you” 10

Change Theory: 6 Sources of Change 1.Personal Motivation – An individual’s desires and wants 2.Personal Ability – An individual’s skill set 3.Social Motivation – “Bad habits are almost always a social disease – if those around us model and encourage them, then we’ll almost always fall prey. Turn accomplices into friends and you will be two- thirds more likely to succeed.” (Patterson, Change Anything) 11

Tools Self Assessments Medical Notebooks

Self-Assessment Tool Development for specific populations – (apply change theory and identify Vital Behaviors) Heart Failure Pre-Kidney Transplant Kidney Transplant LVAD Heart Transplant

Instructions: Please put an X to indicate your answer for your behaviors. If you are a returning patient, please indicate your answer since your last visit. 4 - All of the time 3 - Most of the time 2 - Occasionally 1- Rarely 0 - Never I take my medications as prescribed I follow fluid and diet restrictions I exercise as recommended I weigh myself daily I can recognize symptoms of a “flare-up” and who to call I avoid alcohol I avoid tobacco and illegal drugs Heart Failure Self-Assessment Components

Self-Assessment Components, Cont. ExcellentGoodFairPoor My energy level is: My appetite is: My sleep patterns are: Right now my shortness of breath is: 0….1….2….3….4….5….6….7….8….9….10 None Extreme My usual score for shortness of breath is: 0….1….2….3….4….5….6….7….8….9….10 None Extreme (Directions: Circle the number ) Dyspnea Score

Self-Assessment Components, Cont. Right now my quality of life is: 0….1….2….3….4….5….6….7….8….9….10 Poor Excellent (Directions: Circle the number)

Self-Assessment Components, Cont. Mood Questions Never Mild Moderate Severe Extreme Feeling sad, hopeless or loss of enjoyment or pleasure in life Feeling worried, anxious, or fearful and thinking about things over and over Feeling that life is not worth living Feeling frustrated, angry, easily annoyed or irritated

Self-Assessment Components, Cont. Current Concerns 4 - Not at all 3-Sometimes 2 - Moderate 1 - A lot 0 - Extreme Family Concerns Financial Problems Problems with getting the care that I need Medical Concerns Alcohol, drugs, tobacco, over- medicating, etc. Other Stressors

Instructions: Please put an X to indicate your answer for your behaviors. If you are a returning patient, please indicate your answer since last visit. 4 - All of the Time 3 - Most of the Time 2 - Occasionally 1 - Rarely 0 - Never I take my medications as prescribed I follow the fluid and diet restrictions I exercise as recommended I weigh myself daily I can recognize symptoms of a “flare-up” and who to call I avoid alcohol I avoid tobacco and illegal drugs Vital Behaviors for Renal Transplant

Instructions: Please put an X to indicate your answer for your behaviors. If you are a returning patient, please indicate your answer since last visit. 4 - All of the Time 3 - Most of the Time 2 - Occasionally 1- Rarely 0 - Never I take my medications as prescribed I follow the fluid and diet restrictions I exercise as recommended I weigh myself daily I can recognize symptoms of a “flare up” and who to call I avoid alcohol I avoid tobacco and illegal drugs Vital Behaviors for LVAD

Instructions: please put an X to indicate your answer for your behaviors. If you are a returning patient, please indicate your answer since last visit. 4 - All of the Time 3 - Most of the Time 2 - Occasionally 1 - Rarely 0 - Never I take my medications as prescribed I follow the fluid and diet restrictions I exercise as recommended I weigh myself daily I can recognize symptoms of a “flare up” and who to call I avoid alcohol I avoid tobacco and illegal drugs Vital Behaviors for Heart Transplant

Outcomes The Self-Assessment incorporates each patient’s analysis of their behaviors and symptoms into their clinic visit. This makes the clinic visit patient-centric, drives the decision-making of the clinician, and quickly identifies clinical social work referrals. Early identification of specific areas needing intervention Medical Adherence: o Self-Care: Identifies gaps in patient’s understanding o Physical Functioning: Identifies areas for medical intervention o Mood and Current Concerns: Identifies potential obstacles to adherence

Outcomes Self-Assessment Changes Dynamics of Patient/Provider relationship: o Eliminates need for each staff member to grill patients on their behaviors - Patients have already quantified their behaviors, answered the hard questions and are prepared for a conversation re: their behaviors. o Allows staff members to be in “Motivational Interviewer” and “Educator/Consultant” role rather than in Authoritarian role. Praise positive behaviors, problem-solve and teach to improve other scores.

“Medical Notebooks” Assists the patient with the Can I do it question by: o Providing structure to help patients be organized with their relevant medical directions, calendar of appointments, relevant health information, etc. o Creates one place for family members and caregivers to look to help the patient be adherent 24

“Medical Notebooks,” Cont. o Creates relevant, current information to show to ER and other health providers (Many of our patients are treated in at least 2 medical systems) o Patients now have necessary documents for travel o Provides one place for all staff members to place educational material and “homework” for patients 25

Self-Assessment Scores: Analysis, cont. o Patients do not generally “offer up” how they are beginning to lapse in their Vital Behaviors. If staff do not ask, patients often won’t tell. o Patients often assume that if staff do not keep asking, that specific behavior is no longer important. 26

Self-Assessment Scores: Analysis Initial analysis: o Patient’s Self-Assessment Scores increase on the following visit o As with any behavior, many patients regress in adherence – this is “normal” 27

LVAD Medical Notebook - Organization Front pocket of notebook = Labs & Rx “To Do” Business card holder Calendar Medications Coumadin Instructions Labs Dressings Daily Recordings Medical Problem List 28

LVAD Notebook Org., Cont. Emergency Guide Contact List (Emergency contacts, family) Healthcare Directives Nutritional Information Questions for M.D. (Add blank paper) 29

Heart Failure & Transplant Notebooks Org. Front pocket of Notebook = For labs & Rx “to do” Business card holder Calendar Medications Clinic Worksheets Labs Diagnostic Reports Medical Problem List Contact list 30

Heart Failure & Transplant Notebook, Cont. Healthcare Directive Nutritional Information Questions for M.D. (with blank paper) 31

Medical Notebook Given to Patient Presented as a gift – each notebook is personalized Patient instructed by SW or RN on how to use Patient asked to bring the notebook to all of their medical appointments 32

Medical Notebook Given to Patient, Cont. Staff assists patient in keeping notebook up-to-date Staff teaches the patients how to read their labs and follow along with staff & keeps information current Staff writes or has patient write appointments in the calendar 33

LVAD to Heart Transplant Patients When an LVAD patient receives a Transplant, staff re- organizes their notebook for them with the new tabs. When the notebook is thinned, staff asks if the patient wants to keep the outdated information or obtains permission to safely dispose of their confidential information. 34

Medical Notebook Analysis Effectiveness was observed by patient, their family and staff behaviors Physicians, RN Coordinators were involved in the organization of the notebooks All new LVAD & Transplant patients are presented with their Medical Notebook as part of their pre-discharge teaching by the RN Coordinators With our patients who were given implants before this tool was developed or with our Heart Failure patients, our policy is that any staff member can offer a notebook to one of our patients. 35

Medical Notebook Analysis Patients, patient’s caregivers and staff “love” this tool At least 90% of the patients bring the notebook to their appointments and use the notebook to show staff their current medication lists, daily recordings, etc. Staff updates patient’s notebooks with copies of recent labs, diagnostic reports, etc. 36

Instructions: Please put an X to indicate your answer for your behaviors. If you are a returning patient please indicate your answer since last visit. 4 - All of the Time 3 - Most of the Time 2 - Occasionally 1- Rarely 0 - Never Create Your Own Self-Assessment

References American Heart Association. Miller, William, and Stephen Rollnick. Motivational Interviewing: Helping People Change. 3rd ed. New York: Guilford Press, Print. Patterson, Kerry, Joseph Grenny, et al. Change Anything: the New Science of Personal Success. New York: Business Plus, Print. Patterson, Kerry, Joseph Grenny, et al. Crucial Conversations: Tools for Talking When Stakes Are High. Updated 2nd ed. New York: McGraw-Hill, Print. Patterson, Kerry, Joseph Grenny, et al. Influencer: the Power to Change Anything. New York: McGraw-Hill, Print. 38

Contact Information Carol M. Lee