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Welcome to SocialPrescriberPlus™Care Navigation for Social Prescribers, Link
Workers & Community Support Coordinators
Module 2
Case Management Skills
& Techniques
Module 2
What’s Coming Up?
• Techniques and Skills:– Active Listening
– Motivational Interviewing
– Health Coaching
• Developing a Care Plan
• Evaluation:– For whom?
– Methods
– National Guidance
Active Listening
The 7 Stages of Grief
1. Shock and Denial
2. Guilt and Pain
3. Anger and Bargaining
4. Depression, Reflection and Loneliness
5. The Upward Turn
6. Reconstruction and Working Through
7. Acceptance and Hope.
Reacting – to BereavementThings That Can Be Helpful
Say how sorry you are
When someone is grieving, it’s important to acknowledge what has happened and express your sympathy. This
can be as brief as saying ‘I’m so sorry for your loss’, or ‘I heard about your dad, I’m so sorry’.
Offer them space to talk
Many bereaved people say it helps to be able to speak freely about how they’re feeling. Saying ‘How are you
doing/coping?’ gives them a chance to talk about it if they want to.
Tell them however they feel is OK
If they do talk to you about their grief, be open to whatever emotions they are experiencing. Let them know
that however they feel is OK – there is no ‘right’ way to grieve.
Although it isn’t possible to take the grief away, acknowledging it by saying, ‘I’m sorry I can’t make things
better’, ‘I’m sorry it’s so hard for you’, or ‘I’m sorry things are so tough right now’ can help them feel heard
and supported.
Ask if there is anything they need
You may want to help but not know how. Ask the bereaved person if there is anything they need, and let them
know you’re ready to support them. If they seem unsure, you could suggest specific things, such as cooking
them a meal or doing their shopping.
.
Reacting – to BereavementThings to Avoid Saying
Don’t make assumptions about how they feel
You may have experienced a loss in the past and feel you understand what someone is going through, but everyone
experiences grief differently. Give the bereaved person the space to tell you how they are feeling, and avoid saying
things like, ‘You must be feeling...’ or ‘I know exactly how you feel’.
Avoid trying to fix things
It can be tempting to try and make someone who is grieving feel better. That’s why, if someone has died after a long
illness, people might say things like, ‘It was for the best’, or ‘She’s at peace now’. When someone dies in old age, they
may say, ‘At least he had a long life’. Statements like these aren’t always helpful. The bereaved person might not feel
the same way or may not find it comforting, and they could resent being told what to think.
Don’t tell them they will ‘heal’, ‘move on’ or ‘get over it’
When someone is first bereaved, they may not be able to imagine a future without the person who has died. They
might worry about their memories fading, and find the idea of ‘moving on’ or ‘getting over it’ very upsetting. People
often say ‘time is a healer’, but bereavement isn’t about healing so much as finding ways to live with grief.
Avoid setting expectations around how long grief will last
Most people find ways to cope with their grief and feel better over time. But setting a specific timeframe (for
example, by saying something like, ‘It took my uncle two years to recover after my aunt died’) can make them feel
they are failing if things don’t improve. In reality, the grieving process is different for everyone and it can take years.
When it comes to religion, be guided by things the bereaved person says and only mention it if it feels appropriate.
Active Listening – Minimal Intervention
• Use nonverbal cues which show understanding:– Nodding occasionally
– Keep eye contact (where culturally appropriate) – bridge of nose
– Smile
– Body language/leaning forward/open and inviting posture
• Short Words of Encouragement: The person may need help to go on with their story – use words like “I see, Sure, I know, Uh-huh!, Really?, Tell me more or Go on”.
• Actively focus on listening to, and understanding the other person
• Don’t plan your response until they have finished talking
• It is okay to take brief notes but avoid writing while patient is talking to you
Motivational Interviewingand Health Coaching
The Differences
Motivational Interviewing and Health Coaching
Motivational Interviewing Health Coaching
Common strategies and techniques
A focus on ‘What Matters to Me’
Co-productionof plan for behaviour change
Resolves ambivalence
Based on the Cycle of Change
Focused on a primary behavioural issue
Tends to be of short duration (1-2 sessions)
Stops after patients verbal commitment to change
Assumes people have an underlying wish to maximise their potential
Supports patients across the behaviour change cycle
Helps people to gain the knowledge, skills, tools and confidence to become active participants in their care, so they can reach self identified health goals
Takes a holistic, longer term approach to the person
Empowers patients to engage in self-management activities
Motivational Interviewing
Motivational Interviewing
What is it?
Motivational Interviewing is a structured conversation between you and the patient to strengthen the patient’s own motivation and commitment to change.
MI is grounded in the premise that we all have the built-in motivation to develop our potential to the fullest extent possible, even when faced with barriers and challenges.
Why would I use it?
Many patients will not have considered addressing their underlying social issues and will need your help to explore, understand and build their own motivation to change their behaviour.
Those that have considered addressing their underlying health issues may be unable to come to terms with the change needed to improve their health and wellbeing, and will need your help to do so.
Motivational Interviewing - The Stages of Change
Motivational Interviewing
Where does Motivational Interviewing fit in the continuum of Communication Styles?
Where users are guided effectively, they invariably feel:
Engaged (interested, cooperative, liking the counsellor, ready to keep talking)
Empowered(able to change, hopeful, optimistic)
Open(accepted, comfortable, safe, respected)
Understood(connected, heard, listened to)
Directing Guiding Following
Motivational Interviewing – Concepts
Empathy
The capacity to understand or feel what another person is experiencing from their perspective - the capacity to put yourself in your patient’s
position.
Empathy is both a natural human trait and a skill that can be learnt.
The ‘Righting Reflex’The desire to fix what seems wrong with people and to set them on a
better course – relying in particular on directing.
A default thought process for many GPs and counsellors – incompatible with Motivational Interviewing.
Motivational Interviewing - Concepts
Ambivalence
Ambivalence is a normal part of preparing for change.
Simultaneously wanting and not wanting something, or wanting both
of two incompatible things.
Change TalkThe person’s own statements that suggest they are open
to considering change
Sustain TalkThe person’s own arguments for not changing
and for maintaining the status quo
Change Talk and Sustain Talk
“I think my drinking is getting a bit out of hand……”(Change Talk)
“…..but I’ve tried cutting down and it never lasts”.(Sustain Talk)
“l really know l need to lose weight for my health……”(Change Talk)
But l just love burgers and kebabs and chips.”(Sustain Talk)
“I love the fresh air and know l will feel better if l get out of the house….”(Change Talk)
“But it’s always too wet or windy to go out.”(Sustain Talk)
The 4 Stages of Motivational Interviewing
Adapted from: Wagner and Ingersoll
Engage…in the interaction and build trust with client i.e. “I trust and I’m willing to work with this Link Worker”.
Focus…on a specific direction for the conversation i.e. “Let’s discuss your use of drugs”.
Evoke…the patient’s own motivation and commitment for change i.e. “This is what change looks like for me.”
Plan…how and when to change the behaviour i.e. “I am going to make this change in these ways.”
The Stages of Motivational Interviewing
The Techniques of Motivational Interviewing
• Open Questions: How? What? Where? Who? Why? Open questions require more than a single word answer and encourage the client to open up
• Affirmations: positive statements and gestures that recognize client strengths and acknowledge the effort or achievement they have made
• Reflecting: Repeating back or paraphrasing a word or phrase encourages the individual to carry on and expand.
• Summarising: A summary helps to show the individual that you have listened and understood their circumstances and their feelings.
O
A
R
S
Motivational Interviewing Techniques – Open Questions
Closed vs Open Questions:
“Did you have a good relationship with your parents?”vs
What can you tell me about your relationship with your parents?
Examples of Open Questions:• How can I help you with ___?• Help me understand ___?• Could you share with me…?• How would it make you feel if……..?• How would you like things to be different?• What are the good things about ___ and what are the less good things about it?• When would you be most likely to___?• What do you think you will lose if you give up ___?• What have you tried before to make a change?• What do you want to do next?• How were you so successful last time?• Tell me more about…• How was that…?• What are you doing that you find helpful?...• When do you notice that?...• Who supports you in your day to day life?...
Motivational Interviewing Techniques - Affirmations
• Affirmations are positive statements and gestures that recognize client strengths and acknowledge the effort or achievement they have made.
• Affirmations build confidence in the client’s ability to change. A positive statement offering emotional support or encouragement.
• Search for positive characteristics that support change and make them into an affirmation:
– Persistence– Commitment– Insight– Organized– Resourceful– Good at using the Internet– Goal-oriented– Committed to family– Loyal– Thoughtful
Motivational Interviewing Techniques - Affirmations
Examples of affirming responses (affirm change talk where possible):
• It is clear that you have thought a lot about why you would like to change.
• You told me you tried to change before, that shows great determination
• I appreciate that you are willing to meet with me today.
• It took a lot of courage to come in today
• You are clearly a very resourceful (thoughtful, caring person.
• You handled yourself really well in that situation.
• That’s a good suggestion.
• You were successful in changing in the past
• I’ve really enjoyed talking with you today.
• You really care a lot about your family*
• You are someone who really care about heir family*
• You are the sort of person who really cares about their family*
• You see yourself as the protector of your family*
Motivational Interviewing Techniques – Reflections
• Using the patient’s language helps them feel heard, builds rapport and ensures that the patient is an active partner in the dialogue. It is also very powerful to have your own thoughts and words reflected back.
“We know what we believe, when we hear what we say!”
• The listener’s voice turns down at the end of a reflective listening statement. This leads to clarification and greater exploration, whereas questions tend to interrupt the patients' flow.
• There are two ways to make a Reflection:
– Simple: The Link Worker repeats or paraphrases the client comment
– Complex: The Link Worker tries to identify what the patient really means and offers it back to them
“Reflections are more than a repetition, they are a revelation!”
Motivational Interviewing Techniques – Summaries
• Summaries can be used throughout a conversation but are particularly helpful at transition points, for example, after the person has spoken about a particular topic, has recounted a personal experience, or when the encounter is nearing an end.
• Summarising helps to ensure that there is clear communication between the speaker and listener. Also, it can provide a stepping stone towards change.
Structure of Summaries – 4 Steps
Step 1• Begin with a statement indicating you are making a summary. For example:
– “Let me see if I understand so far…”– “Here is what I’ve heard. Tell me if I’ve missed anything.”– “Would now be a good time to sum up where we are?”
Step 2• Give special attention to summarising Change Talk made by the client that points towards a
willingness to change. For example:– “You said that you recognised you have been drinking too much.”– “You explained to me about the negative impact on your family and how you wanted to address that.”– “You said you thought that getting out more would help your depression.”
Step 3• End with an invitation. For example:
– “Did I miss anything?”– “If that’s accurate, what other points are there to consider?”– “Anything you want to add or correct?”
Step 4• Depending on the response of the client to your summary statement, it may lead naturally to
planning for, or taking concrete steps towards the change goal.– “Given what we have just discussed, how do you think we might take that forward?”– “So shall we have a look now at how you might make that change happen?”
Motivational Interviewing - OARS Aide Memoire
Open Question Affirmations Reflections Summaries
Consider using Who?, What?, When?, Where?, Why?, How?
• How can I help you with ___?• Help me understand ___?• Could you share with me___?• How would it make you feel
if____?• How would you like things to be
different?• What are the good things about
___ and what are the less good things about it?
• When would you be most likely to___?
• What do you think you will lose if you give up ___?
• What have you tried before to make a change?
• What do you want to do next?• How were you so successful last
time?• Tell me more about…• How was that…?• What are you doing that you
find helpful?...• When do you notice that?...• Who supports you in your day
to day life?...
• You told me you tried to change before, that shows great determination.
• I appreciate that you are willing to meet with me today.
• It took a lot of courage to come in today.
• You are clearly a very resourceful person.
• You handled yourself really well in that situation.
• That’s a good suggestion.• If I were in your shoes, I
don’t know if I could have managed nearly so well.
• You really care a lot about your family.
• You were successful in changing in the past.
• I’ve really enjoyed talking with you today.
There are two ways to make a Reflection:
Repeating: The Listener repeats the client comment/phrase as closely as possible, staying close to what the Speaker has said
Paraphrasing: The Listener makes a restatement in which the Speaker’s meaning is inferredThe listener’s voice turns down at the end of a reflective listening statement. This leads to clarification and greater exploration, whereas questions tend to interrupt the patients' flow.
Step 1Begin with a statement indicating you are making a summary. For example:“Let me see if I understand so far…”“Here is what I’ve heard. Tell me if I’ve missed anything.”“Would now be a good time to sum up where we are?”
Step 2Give special attention to summarising Change Talk made by the client that points towards a willingness to change.
Step 3End with an invitation. For example:“Did I miss anything?”“If that’s accurate, what other points are there to consider?”“Anything you want to add or correct?”
Step 4Depending on the response of the client to your summary statement, it may lead naturally to planning for, or taking concrete steps towards the change goal.“Given what we have just discussed, how do you think we might take that forward?”“So shall we have a look now at how you might make that change happen?
Motivational Interviewing Strategies
Social Prescribers can use a number of strategies for Motivational Interviewing to
build trust with patients, engage them in their own care, and help them find motivation to
adhere to their care plans
Motivational Interviewing – Strategy No. 1
Ask a question that will prompt change talk as an answer. For example:
“What are some things you could do to help you take you medication regularly?”
Motivational Interviewing – Strategy No. 2
Ask about the Positives & Negatives, Good and Bad, Advantages & Disadvantages of the target behaviour:
Positive/Pro/Advantage:
“What are the benefits of taking your medication regularly?”
Negative/Con/Disadvantage:
“Tell me about the bad things that happen when you don’t take your medication?”
Motivational Interviewing – Strategy No. 3
When the patient expresses change talk, use an open question to ask for more details:
“In what way could that happen?”
“ Could you tell me a little more about that?”
“When was the last time that happened?”
“How does that make you feel?”
Motivational Interviewing – Strategy No. 4
Look forward. Ask what may happen if the patient makes the changes according to their care plan:
“If you follow the care plan you have written, how do you think things will change for the better?”
“How do you see your health this time next year if you follow the steps we have agreed?”
Motivational Interviewing – Strategy No. 5
Ask about extreme outcomes:
“What is the best thing that might happen if you follow the care plan we have worked on?”
Motivational Interviewing – Strategy No. 6
Offer ways to help the patient measure the impact of making a change. For example:
“On a scale from one to 10 (where one is not at all important and a 10 is extremely important), how important is it to you
to improve your health/reduce your drug use/take your medication every day?”
Follow up Questions:
“Why do you think that score has improved since last time?”
“What do you think you can do to get closer to a 10?”
“What would it take to get from 6 to an 8?”
Motivational Interviewing – Strategy No. 7
Ask about the patient’s main health goals. For example:
“If you are able to improve your mobility, what would you like to be able to do this summer?”
Motivational Interviewing – Strategy No. 8
Think like the patient and reframe any barriers into a positive strategy:
“You mentioned that taking your medication every night before bed is a hassle. How would it be if you took it in the
morning instead?”
Motivational Interviewing – 8 Strategies
1. Ask a question that will prompt change talk as an answer.
2. Ask for the Pros & Cons, Positives & Negatives of both changing and staying the same.
3. Ask for more details when change talk theme emerges.
4. Ask what may happen if the patient makes the changes according to their care plan.
5. Ask about extreme outcomes.
6. Offer ways to clearly measure the impact of making a change.
7. Ask about the patient’s main health goals.
8. Reframe any barriers into a positive strategy.
Health Coaching
Health Coaching – The TGROW Model
Table Exercise
Using Motivational Interviewing Techniques to Encourage Change Talk
Motivational Interviewing
Moving towards Care Planning
Motivational Interviewing – The Next Steps
You will know when it is time to move towards co-producing a Care Plan because:
• It feels right from the conversation you are having with the patient
• You hear the patient use ‘Commitment Talk’ - a commitment to achieve a positive goal:
“I think l would like to give it a try.”
“I will make an effort to take my medication every day, as prescribed.”
“I will come to the group if you come with me.”
“I will try not to have alcohol during the week.”
“I think l could give that a try.”
If you meet resistance from the patient, you know you have moved too early - Step back and go back to MI.
Goal Setting
Goal AreaWhat do you want to
change?
Your Goals
Actions for Me Actions for Other
Looking after myself/Taking exercise/Getting out
Practicalities of life -Money/Housing/Benefits
Transport
My work/Hobbies/Volunteering
Happiness with LifestyleDesired social activity
Overall mental well-beingFeeling good about myself
Supported by Family/Friends/Groups
Thinking positively/Feeling optimistic
Managing symptoms & unhealthy behaviours/Taking
medication
Personalised Care and Support Planning
Personalised Care and Support Planning
Personalised Care and Support Planning empowers individuals, promotes independence and helps people to be more involved in decisions about their care. It centres on listening to individuals, finding out what matters to them and finding out what support they need.
Personalised Care and Support Planning is a series of facilitated conversations in which the person, or those who know them well (Carer), actively participates to explore the management of their health and well-being within the context of their whole life and family situation.
Self Care Plans - Principles
• Co-produced with Patient – a summary of ‘What matters to Me’• Make it colourful and personal, not ‘official’ - use the patient’s own
words• The client’s to keep at home and to use and refer to• Regular review at each meeting – basis for completing Prism and
discussing, “How has it been for you since we last met?”• The Plan is a work in progress, not a finished item and should include:
– How best to support me – what people need to know about me – Any health conditions that groups and agencies need to know about – My goals – What support I am being connected to, such as community groups and
services – What I can do to support myself to meet my goals – Review – how it’s going and what changes have taken place – Permissions – to share stories, be involved in evaluation and satisfaction
surveys.
I can relax my body and mind by….
I can look after myself by…
People & Groups important to me…
___________________________________’s Self Care PlanMy interests….
I can be a good friend by…
I would like to meet up and spend some time with….
I can meet other people by…
I could volunteer…
Relapse Prevention
ASK: ‘Thinking about the next few weeks, what might get in the way of you achieving your goals and carrying out your action plan?’
Identify Triggers:
– Holidays
– Injury
– Stress/emotional situations
– Pain
– Small lapses into old habits
– Low motivation
– Bad weather
Taking action
Maintaining
RelapsingThinking
Preparing
PCN SP Evaluation – Who For?
• There are at least four stakeholder groups for whom evaluation of Social Prescribing is important:– The Patient and the Social Prescriber - Impact
– The GP/Practice/Organisation providing the referral
– The service/organisation/Community Group the patient/client is referred to
– The Social Prescribing Scheme itself and the commissioners who fund it
Guidance on Evaluation of Your Social Prescribing Success
• NHS(E) are promoting PAM as they have bought 1.8 m licences and it provides a national overview
• Draft specifications for the 2020 contract suggest PAM will become mandatory
• Use PAM to determine patient activation (change cycle stage)
• To just measure wellbeing, use Warwick-Edinburgh
• To just measure loneliness use UCLA 3-point scale
• For a broader measure of health & well-being use the Star or Prism
The Patient and the Social Prescriber -Impact
Evaluating the Benefits to the Patient
• It is a challenge to persuade service users to complete or take part in formal evaluation.
• Most evaluation models are too long or complex
• Treat the need to evaluate the impact of the engagement as an opportunity to regularly review progress with the patient, not as an end in itself.
The Health and Well-being Prism
Happiness with LifestyleDesired social activitySupported by Family/
Friends/Groups
Thinking positivelyFeeling optimistic
Managing symptoms &unhealthy behaviours
Taking medication
My workHobbies/Volunteering
Looking after myselfTaking exercise/Getting out
Overall mental well-beingFeeling good about myself
Practicalities of life -Money/Housing/Benefits/Transport
Framework to chart Patient progress through Social Prescribing
The GP/Practice/Organisation providing the referral
Benefits to the Practice or Referrer
• Don’t underestimate the importance of providing positive informal and formal feedback to referrer organisations.
• Schedule regular feedback during the year and arrange several face to face reviews with lead GP/PMs.
• Share positive stories and testimonials with staff as well as management
• Using SNOMED codes, write a report for the Practice on their Social Prescribing engagement and outcomes.
The service/organisation/Community Group the patient/client is referred to
Evaluating the Benefits to the Referred Service
• Your referral may be welcome in that it adds attendees and may make the service viable – or it may be unwelcome in that it puts additional strain on scarce resources/increases waiting times for users
• Always provide positive feedback to the service on the experiences of your users
• Arrange regular meetings with services to understand pressures
• Look for opportunities for synergies and funding opportunities you can help with.
Evaluating and Reporting the Benefits to the Commissioning Organisation
Evaluating the Benefits to the Commissioning Organisation
• Make a pragmatic assessment of what will deliver continued funding/support for the scheme
• Devise a data collection process that meets the needs of both commissioners and the scheme
• Agree qualitative/quantitative metrics and targets with commissioner that will be used for evaluation
• Use SNOMED codes to deliver hard data on performance
• Use Patient Activation Measure (PAM) to deliver subjective data on success
• When reporting, use words such as Increase, Growth, Improve, Expand, Enhance, Build, Enlarge to demonstrate performance.
• Include Stories and Testimonials to support hard data.
The Patient Activation Measure(PAM)
NHS(E) Evaluation Measure of Choice
The Patient Activation Measure
• The PAM® is a validated, licensed tool that measures people’s knowledge, skills and confidence (referred to as ‘patient activation’) in managing their own wellbeing.
• By understanding a patient’s activation level, care can be planned appropriately with the individual, leading to improved wellbeing and fewer episodes of unplanned and emergency care.
• The PAM® is a validated questionnaire comprising 13 questions and is licensed from Insignia Health LLC. The responses match the respondents to one of four levels of ‘activation’, each of which reveals insight into a range of health-related characteristics, including behaviours and outcomes.
The Office for National Statistics(ONS 4)
NHS(E) Evaluation 2nd Choice Measure
Office for National Statistics (ONS 4)
Personal Wellbeing Score
Each PWS item is scored as follows: Disagree=0, Neutral=1, Agree=2 and Strongly Agree=3. A high score is better than a low score.
The PWS calculates a summary score as the sum of the four item scores, giving a 13-point scale from 0 (4×Disagree) to 12 (4×Strongly agree). ONS4 does not provide a summary score.
Scoring:
Record Keeping – Electronic SNOMED Codes
The SNOMED codes for the Network Contract DES are listed in the Technical Requirements for 2019/20 GMS Contract (published January 2020). Two SNOMED codes for Social Prescribing are listed as:
– Referral to Social Prescribing service: 871731000000106
– Social Prescribing declined: 871711000000103
• On this basis, PCN staff should use:
– The first code (ending in 106) when referral is made to a social prescribing link worker.
– The second code (ending in 103) if the person declines the offer of referral to a social prescribing link worker.
– PCNs should ensure that social prescribing link workers have access to GP IT systems, so that they can record referrals, particularly in the case of self-referrals or referrals from outside of the PCN.
Professional Resources
• NHS Social Prescribing Pages and Assets https://www.england.nhs.uk/personalisedcare/social-prescribing/
• *Future NHS Collaboration Platform – Personalised Care Group – Request membership via [email protected]
• Social Prescribing Network - https://www.westminster.ac.uk/patient-outcomes-in-health-research-group/projects/social-prescribing-network and @SocialPrescrib2
• Twitter Social Prescribing Wednesday - @SocialPresHour
• Monday Social Prescribing email meet-up [email protected]
• National Association of Link Workers www.connectlink.org Christiana [email protected]
• NHS Social Prescriber E-Learning Modules https://www.elfh.org.uk/programmes/social-prescribing/
• PCN Reference Guide and Technical Annexe https://www.england.nhs.uk/publication/social-prescribing-link-workers/
• PCN Link Worker Welcome Pack - https://www.england.nhs.uk/wp-content/uploads/2019/09/social-prescribing-link-worker-welcome-pack-web-2.pdf
• Will Moyle ([email protected]) SystmOne trainer able to help with Social Prescribing assessment template.
