View
216
Download
0
Tags:
Embed Size (px)
Citation preview
Cardiovascular Disease in WomenModule VIII: Behavioral Aspects for CVD Prevention in Women
This presentation is specifically designed to assist Primary Care
Providers in helping their patients TAKE HOME & TAKE
TO HEART THE HEART TRUTH
What to Change: Most of the Heart Truth lifestyle interventions involve a need for behavioral change. This change involves both the provider and the patient.
Strategy for Change: For Heart Truth lifestyle interventions to be effective they require a strategy that entails counseling for behavioral change and seeking the patient’s commitment to such change.
The following issues will be discussed:
Clinical Impact: It is extremely important that the provider determines on an ongoing basis the overall progress of the patient relative to the effectiveness of the provider-patient relationship in terms of achieving behavioral modification and reaching Heart Truth clinical measures and benchmarks
Also to be discussed:
What to Change
• Most of the Heart Truth lifestyle interventions deal with adverse behaviorsCigarette smoking Deficient physical activity Deficient dietary planDeficient weight maintenance or reduction
Adverse Behaviors
Sources: Mosca 2007
• Effective health care in general is an active phenomenon that requires the active participation of the patient and provider in order for positive outcomes to be achieved
• The degree of behavioral modification achieved is aggregate evidence of the effectiveness of this active participation
Level of Participation
What to Change
Sources: Prochaska 1992, Zimmerman 2000
• Some providers have doubts about their patients’ ability to change
• Some providers doubt that behavioral change will have any real impact on health outcomes of their patients
Provider Obstacles
What to Change
• Some providers have difficulty finding the time they think they need to become a change agent for their patient
• Some providers fear that they do not know what to do even if they wanted to help due to lack of training in this area
Provider Obstacles
What to Change
• Having a specific strategy to address change saves time and alleviates the provider’s fear of the unknown
• These provider-specific obstacles must be removed or the provider should refer the patient to another provider, in the best interests of the patient
Provider Obstacles
What to Change
Assess (or Ask)
AdviseAgreeAssistArrange
The “5-A”s
Counseling Framework for Change
Strategy for Change
Sources: Whitlock 2003
Assess (or Ask about) risk factors, beliefs, behavior, and knowledge about a lifestyle interventionAssess whether she is willing to initiate
steps towards modifying her behavior in the direction of the Heart Truth objectives
Assess knowledge, skills, confidence, conviction, supports, and barriers
Provide feedback to her about assessment
Counseling Framework for Change
The “5-A”s
Assess importance with good questions.“How important do you think it is to
change this [targeted] behavior?”“On a scale of ‘1 to 10’ with ‘1’ being ‘not
convinced at all’ to ’10’ being ‘totally convinced’, how important is it to you?”
“What makes you say ‘3’, why not ‘0’?”“What would it take to move it to a ‘6’?”
Counseling Framework for Change
The “5-A”s
Assess what or who is important“What or Who is important or of value to
you?”“What would they do without you or what
would they do if you became disabled from a complication of heart disease?”
Use the answer to these questions as leverage in your dialogue about the importance of changing targeted behavior
Counseling Framework for Change
The “5-A”s
Advise with a clear & personalized messageExpound on the dangers that are specific
to her in relationship to the targeted behavior
Advise her about the benefits of changeMake the source of your advice clear
(medical knowledge or from similar patients)
Counseling Framework for Change
The “5-A”s
Advise with a clear, simple, and personalized message.Provide advice at a patient-determined
level of comprehension Try not to overload her with
information in one session “Can you review for me what we just
discussed so I know that I made it understandable?”
Counseling Framework for Change
The “5-A”s
Agree on goals and plansGoals are something to achieve in 3-6
monthsCollaboratively select goals based on
patient’s interest and confidence in her ability to change the targeted behavior
Base goals on the patient’s prioritiesPlans are specific steps to help achieve
goals
Counseling Framework for Change
The “5-A”s
Assist with goals and plansDevelop a Personal Action Plan that
includes:What to do; How to do it; Where to do itWhat to use; When to do it; How oftenBarriers to doing it; Plans to overcome
barriersFollow-up plan
Counseling Framework for Change
The “5-A”s
AssistPersonal Action Plan
Patient should give herself a confidence rating in achieving the Personal Action Plan
The action plan should be re-worked if her level of confidence is lower than 7 on a scale of 1 to 10
Counseling Framework for Change
The “5-A”s
AssistPersonal Action Plan
Make certain that she has appropriate expectations
Early on, help her pick some easily achievable goals (“the low hanging fruit”) to help build confidence to tackle greater goals
Counseling Framework for Change
The “5-A”s
Assist in problem solving with Personal Action Plan.Identify problemList all possible solutions (brainstorm)Pick oneTry it for 2 weeksIf it doesn’t work, try another
Counseling Framework for Change
The “5-A”s
Assist in problem solvingIf that doesn’t work, find a resource
for ideasIf that doesn’t work, accept that the
problem may not be solvable nowMove on (but come back later)
Counseling Framework for Change
The “5-A”s
Assist in changing behaviorProvide self-help and counseling
pathways to aid patient in achieving agreed upon goals
Aid the patient in acquiring skills, confidence, and social/environmental supports
Counseling Framework for Change
The “5-A”s
Assist in changing behaviorWomen tend to respond best to
intensive interventions between the provider and the patient
Women tend to respond, more so than men, to support groups
Counseling Framework for Change
The “5-A”s
Sources: Whitlock 2003
Assist with resourcesMatch resources (community, literature,
groups) with patient preferencesUtilize outreach and community
opportunities whenever feasible
Counseling Framework for Change
The “5-A”s
Arrange follow-upSchedule follow-up visits or contacts for
purpose of providing ongoing assistance and support
Try a variety of follow-up methods when feasible (in person, phone, email, groups)
Counseling Framework for Change
The “5-A”s
Arrange follow-upMaking sure follow-up happens builds
patient trust in the agreed upon clinical pathway
Adjust the plan as needed during follow-up visits or contacts, including referral elsewhere for more intensive intervention
Counseling Framework for Change
The “5-A”s
Prochaska & DiClemente model
Stages of Behavioral Change
• Pre-contemplation• Contemplation• Preparation• Action • Maintenance•Transformation
Strategy for Change
Sources: Prochaska 1992
• The provider should be able to determine which stage of change the patient is in with respect to the targeted behavioral concern.
• Applying the 5-‘A’s at each stage of change process affords the provider a monitor in guiding and motivating the patient along her trip to ‘Transformation’
Stages of Behavioral Change
Prochaska Model
Sources: Prochaska 1992
Pre-contemplation stage• She is not ready to change
• She is not thinking about change
• She may be resigned to not changing
• She expresses feeling of ‘no control’
• She exhibits denial or believes consequences are not serious
Prochaska Model
Sources: Prochaska 1992
Contemplation stage• She is thinking about changing
• She is weighing the relative benefits and costs of the her current behavior and those of the proposed change
Prochaska Model
Sources: Prochaska 1992
Preparation stage• She has begun experimenting
with small changes
• She is getting ready to make a move towards behavioral modification
• She is establishing a goal or at least thinking about it
Prochaska Model
Sources: Prochaska 1992
Action stage• She has started her journey towards
Transformation by applying herself to her definitive Personal Action Plan designed to facilitate behavioral modification
Prochaska Model
Sources: Prochaska 1992
Maintenance stage• She is maintaining new behavior
continuously over an extended period of time (>180 days) to accomplish the overall goal
Prochaska Model
Sources: Prochaska 1992
Relapse • ‘The Ups & Downs’ is a normal part of
the process of change• She may regress to the beginning stages
of the Change Model• She may feel demoralized or
disappointed (which often occurs) by set back
• Sometimes original goals are set too high or low or aggressive
Prochaska Model
Sources: Prochaska 1992
Transformation• She feels self-assured and feels that
only time separates her from her ultimate goal (if not already reached)
• Transformed patients are often willing to and capable of being role models for other patients with similar clinical issues
Prochaska Model
Clinical Impact
Keeping Score of Clinical Impact• For each identified behavioral
change-dependent Heart Truth lifestyle intervention, document in the health record where the patient is with respect to the Prochaska stages
Keeping Score of Clinical Impact• In documenting the stage of change, a
numbered scale from 1 to 6 might help:1 / pre-contemplation 2 / contemplation3 / preparation 4 / action 5 / maintenance 6 / transformation
• This enumeration creates a Change Scale
Clinical Impact
• Where your patient is on the Change Scale scores how far you have advanced relative to the extent to which she is responding to your methodology and available resources
• Repeatedly ask yourself: Can I and What Can I do better or more of in helping and motivating my patient towards beneficial change, thus improving the score?
Keeping Score of Clinical Impact
Clinical Impact
• The clinical impact of the Heart Truth objectives is dependent on: Achievement of recommended Heart
Truth clinical measures and benchmarks Availability of and access to resources Degree of difficulty and severity of
the patient’s condition, inclusive of co-morbidities
Keeping Score of Clinical Impact
Clinical Impact
Keeping Score of Clinical Impact
Clinical Impact
• Finally, the clinical impact of the Heart Truth objectives is dependent on: The effectiveness of the provider-patient
relationship and all that it entails (e.g., dedication of time, use of resources, intensity of participation of all parties, provider & patient resourcefulness, and contributions of all parties)