Goals and Action Plans Theory into Practice

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Goals and Action PlansTheory into Practice

• Alan Glaseroff MD
• CMO, Humboldt Del Norte IPA
• Creating Confidence in Chronic Care

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Many Thanks to

• William H. Polonsky, PhD, CDE
• whp_at_behavioraldiabetes.org
• Behavioral Diabetes Institute
• Website www.behavioraldiabetes.org
• INFO info_at_behavioraldiabetes.org
• CALL 858-336-8693

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Why wouldnt a person with diabetes do
everything in their power to live long and feel
well?
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Whats So Tough about Diabetes?
Think how discouraging it is to fail at
something you really wanted to do. Then consider
what it must feel like to have diabetes and be
failing at something you never, ever, wanted to
do in the first place. -- J.W. Hoover, 1988
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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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Do As I Say, Not As I Do

• Attributional Bias
• Im too busy
• My patients come first
• Ill start exercising when I retire
• Character defects in patients, situational
  stressors in ourselves
• Life gets in the way

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Why Do Our Patients Struggle?

• Almost no one is unmotivated to live a long and
  healthy life.
• The rewards for good diabetes care are
• relatively subtle
• mostly long-term
• If you do everything perfectly, you can expect
  to feelnothing! What a concept to motivate a
  person to strive hard on a daily basis!

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Unachievable Self-Care Plans

• Unclear
• Im supposed to start exercising.
• Unrealistic
• My doctor told me to lose 10 lbs before the next
  visit.
• Taking care of my diabetes means Im 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

• Think of some healthy change youd like to make
• but you arent certain you
  really want to (or you would have already done
  it!)

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• Persuasion Techniques
• Agree that speaker should make the change
• Explain why the change is important
• Warn of consequences of not changing
• Advise speaker how to change
• Reassure speaker that change is possible
• Disagree if speaker argues against change
• Tell the speaker what to do
• Give examples of others (other patients, peers,
  celebrities) who have made similar healthy
  changes

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What Did You Think?
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• WHAT DOESNT WORK
• Labeling patient as unmotivated, unwilling to
  change, or non-compliant
• Taking sides in the patients ambivalence
• Giving advice
• Transmitting diabetes knowledge
• Threatening bad outcomes
• youll go blind if you dont do what I tell
  you.
• Urging more willpower
• if you would just try harder
• Caring more than the patient

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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 your own feelings about diabetes?
• Judgments (of those who are obese of smokers
  etc) are commonand dangerous
• Be honest!!!
• Put it on a shelf and focus on the patients
  reality

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Feelings Can Fuel Change

• What are the patients feelings?
• Think of a patient youve 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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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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Behavior Change Strategies

• Begin with your patients interests
• Agenda must be personally meaningful for the
  patient
• Start with questions, not information
• What questions should we make sure to address
  today?
• Whats been driving you crazy about diabetes?

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Behavior Change Strategies

• Begin with your patients interests
• 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

• Begin with your patients interests
• Believe that your patient is motivated to live a
  long, healthy life
• 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

• Think of some healthy change youd like to make,
  but you just havent done it yet.

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The Journalist Intervention

• Zero in on an area for behavior change
• Get the details
• Be a journalist, listen carefully, limit
  questions
• Explore relevant beliefs (4 importance
  questions)
• Your current score? Why not lower? Why not
  higher? How to bump it up?
• 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 isnt it a 3? (listen for the benefits)
• And why isnt it a 6 or 7? (listen for the
  obstacles)

Rollnick et al, 1999
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Listen Well and Summarize
It sounds like youre inclined in two different
directions. On the one hand, youre somewhat
worried about the possible long-term effects of
your diabetes if you dont manage it well
blindness, amputations, things like that. Those
are distressing to think about. On the other
hand, youre young and you feel fairly healthy
most of the time. You enjoy eating what you
like, and the long-term consequences seem far
away. Youre concerned, and at the same time
youre not concerned.
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What Did You Think?
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Behavior Change Strategies

• Begin with your patients interests
• Believe that your patient is motivated to live a
  long, healthy life
• Help your patient determine exactly what they
  might want to change
• Identify and respect ambivalence
• Present the bouquet
• Develop a reasonable, detailed action plan

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Time to Practice

• Think of some healthy change youd like to make,
  but you just havent done it yet.
• Importance and confidence should be elevated.

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The Action Plan Intervention
1. Dont tell patients what to do 2. Negotiate
what changes to focus on blending your expertise
and patients desires 3. Focus on 1 2 concrete
actions to start Not attitudes, numbers, or
actions to stop Not lose 5 pounds in 2 weeks
InsteadWalk 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 achievable
• even if physiologically silly
• 5. Selected actions must be personally meaningful
• 6. Do the first step right away
• What does this mean youll 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
• Youre more likely to go for a cervical smear if
  you decide when and where youll go. Please
  write in when, where and how youll make
  appointment.

Sheeran and Orbell, 2000
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The Power of Implementation
attending screening appointment
Sheeran and Orbell, 2000
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The Action Plan Intervention

• Identify area for behavior change
• Importance and confidence should be elevated
• Determine a specific action plan
• Meaningful, action-oriented, measurable,
  behavioral
• Make certain that goals are practical/achievable
• Break down, specify, and limit steps as needed
• Ask about obstacles, and problem solve
• Feed back your understanding of the plan
• Offer support/sincere encouragement, BUT
• OFFER AS LITTLE ADVICE AS POSSIBLE!

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What Did You Think?
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Behavior Change Strategies

• Begin with your patients interests
• Believe that your patient is motivated to live a
  long, healthy life
• Help your patient determine exactly what they
  might want to change
• Develop a reasonable, detailed action plan
• Stay alert for common obstacles

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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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Depression as a Co-Morbidity

• Depression has been shown to negatively affect
  diabetes outcomesi and costs (increases cost
  by 4.5x over non-depressed diabetics)ii. i
  Lustman, et al. Association of Depression and
  Diabetes Complications a Meta-analysis
  Psychosom Med. Jul-Aug 63(4)619-630, 2001.
• Comorbid Depression is Associated with Increased
  Health Care Use and Expenditures in Individuals
  with Diabetes ii Egede, et al. Diabetes Care
  25 464-470, 2002.

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PHQ-9 Depression Screen

• In the last two weeks have you been bothered by
• 1) Having little interest or pleasure in doing
  things?
• 2) Feeling down, depressed or hopeless?
• (0 points-not at all, 1 point-several days, 2
  points-more than half the days, 3 points-nearly
  every day)
• If score gt 0, do full PHQ-9
• 27 maximum points (0-4 nl 4-10 adjustment
  disorder/disease-specific distress 11-14
  dysthymia gt15 major depressive disorder)
• Not very specific Other diagnoses can affect
  scores (anxiety/bipolar/thought
  disorders/dementia)

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Depression Screening

• Who should screen?
• Clinicians, medical assistants, nurses, Readers
  Digest?
• Response protocols needed

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Address Health Literacy

• Assess patients recall or comprehension of
  recommendations
• 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 manage
  diabetes effectively
• The problem is that diabetes self-care is tough
• Our patients face many obstacles to good
  self-care
• Simple behavior change strategies are likely to
  help