Behavior Change in PatientCentered Care

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Behavior Change inPatient-Centered Care

• Ana Perez, APRN, BC-ADM, CDE
• June 24, 2004

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What Motivates Change?

• Expectations Self Efficacy
• Style Relationship
• Readiness Approach-Avoidance
• Beliefs Health Belief Model

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Doctor/Patient Relationship

• Activity-Passivity
• Taught in medical school
• Emergency Room/Hospital
• Mutual Participation
• Chronic care illness
• Decisions made by patients rather than doctors
  will determine how diseases are managed.

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Productive Interactions
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Patient-Centered Care

• If we really want to help patients, we need to
  think about them and try to understand why they
  are or are not making the choices we recommend.
  We need to empower them with education, tools,
  and support.
• No more non-compliant patients
• Patients with diabetes instead of diabetic
  patients

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Informed, Active Patient

• Understands disease process
• Becomes engaged in self-management
• Involves family/caregivers in their care
• Views the diabetes team as a guide and resource
  for support

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Prepared Practice Team

• At the time of the visit
• Makes patient information available
• Has decision support and equipment ready
• Takes time needed to deliver evidence-based
  clinical management and self-management support
• Speaks patients language (high blood pressure
  instead of hypertension)

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Behavioral Changes

• Every person has the potential and capacity for
  making health behavior change
• The task of the clinician is to bring forth this
  capacity
• The focus is helping patients explore their own
  concerns, ideas, and strategies for change
• Creating safety in the relationship, the
  clinician can further facilitate behavior change

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The Stages of Change

• 1. Precontemplation/Not seriously considering
  change Denial
• 2. Contemplation/Thinking about change
  Ambivalence
• 3. Preparation/Motivated Getting ready to make
  the change
• 4. Action/Go Making the change
• 5. Maintenance/Living it Sustaining behavior
  change until integrated into lifestyle
• 6. Relapse/Start Over Ugh!
• (Prochaska and DiClemente, Transtheoretical Model)

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Motivational Interviewing

• A directive, patient-centered counseling style
  for helping patient explore and resolve
  ambivalence about behavior change (Miller, 1995)
• I. Quick assessment
• II. Patient identifies problem and solutions
• Motivation
• Confidence
• III. Target and follow-up

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Motivating Health Behavior Change

• Clinician style
• Empathetic, accepting, supportive of
  self-efficacy, collaborative
• Skills
• Listening, open-ended questions, summarizing
• Tools
• Option tool, road map ruler

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Not-Ready Patient

• Goal To raise awareness
• Major Task Advise, raise patient awareness of
  health behavior. Listen and try to hear patients
  perspective.
• Question How can I help?
• Do not jump ahead too fast. Do not judge, or
  argue about the validity of their thoughts or
  feelings.

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Unsure Patient

• Goal To build readiness
• Major Task Explore ambivalence. Explore pros and
  cons ask about next step.
• Questions
• What are some of the reasons for changing?
• What are some of the reasons why you would want
  things to stay the same?
• Success Patient leaves the office with
  educational material to review.

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Ready Patient

• Goal To negotiate a plan
• Major Task Strengthen commitment/ facilitate
  action planning
• Question How are you going to do it?
• Help patient set a specific, measurable,
  achievable plan of action

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Action Plan

• Desirable
• Realistic
• Specific What, How, When
• What barriers might you encounter? How can we
  support you?

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Relapse

• The person has re-engaged in the previous
  behavior to a significant degree
• After reverting back to the previous status quo
  behavior the person re-enters pre-action stages
  of precontemplation, contemplation, or
  preparation
• The person may feel like a failure and be
  discouraged about his/her ability to change

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Conclusion

• Effective diabetes care requires new roles for
  both healthcare professionals and patients.
• Creating a collaborative relationship can result
  in improved diabetes control and an increased
  level of satisfaction for both parties.

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Conclusion

• The healthcare provider needs to understand and
  accept that, in the end, the patient, not the
  physician, will decide what to do about a
  behavior, and it is the patient who must be
  responsible for enacting any change that occurs.