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Goals and Action Plans Theory into Practice

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Title: Goals and Action Plans Theory into Practice


1
Goals and Action PlansTheory into Practice
  • Alan Glaseroff MD
  • CMO, Humboldt Del Norte IPA
  • Creating Confidence in Chronic Care

2
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

3
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4
Why wouldnt a person with diabetes do
everything in their power to live long and feel
well?
5
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
6
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
7
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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11
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!

12
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.

13
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)

14
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!)

15
  • 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

16
What Did You Think?
17
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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

19
The Overarching Approach
  • GOALS BELIEVE SELF-MANAGEMENT IS WORTHWHILE
    The patient must feel there is hope and benefit
    in doing a good job.

20
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.
21
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

22
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)

23
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

24
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?

25
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

26
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

27
Time to Practice
  • Think of some healthy change youd like to make,
    but you just havent done it yet.

28
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

29
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
30
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.
31
What Did You Think?
32
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

33
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.

34
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
35
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?

36
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
37
The Power of Implementation
attending screening appointment
Sheeran and Orbell, 2000
38
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!

39
What Did You Think?
40
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

41
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

42
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.

43
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)

44
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45
Depression Screening
  • Who should screen?
  • Clinicians, medical assistants, nurses, Readers
    Digest?
  • Response protocols needed

46
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
47
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
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