Making Brief Action Planning Work for You

—Coaching Staff for Successful Self Management

Presenters:• Kristin Yeoman, MD, MPH, Clinical Consultant• LCDR Gwenivere Rose, MS,RD, USPHS, Program Director• Candice Donald, BS, Improving Patient Care Program National Team• Connie Davis, MN, RN, ARNP, Institute for Healthcare Improvement

Presentation Objectives:

1) Review use of Brief Action Planning.2) Learn methods for incorporating Menu of

Options and Brief action planning into routine care.

3) Describe a model of care team sequencing and plan for on-going staff coaching.

Improved health and wellness for American Indian and Alaska

Native individuals, families, and communities

Delivery SystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

C ommunity

Health Care Organization

IPC Care Model

Activated Family and Community

Informed Activated Patient

Prepared Proactive

Care Team

Prepared,Proactive

Community PartnersEFFECTIVE RELATIONSHIPS

EfficientSafe EffectiveEquitable

TimelyPatient-Centered

Patient

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Conditionspecific skills

and information

Conditionspecific skills

and information

Conditionspecific skills

and information

Conditionspecific skills

and information

Self-management education

Definitions

Self-care: The care of oneself without medical, professional or other assistance or oversight. (American Heritage Medical Dictionary, 2007)

Self-management: The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition. (Barlow)

Definitions

• Self-management support: the assistance caregivers give patients and their self-defined circle of support so patients can manage their conditions on a day-to-day basis and develop the confidence to sustain healthy behaviors for a lifetime.

-Bodenheimer, 2005

Definitions• Self-management education: programs that are

based on patient-perceived problems and address three self-management tasks (medical or behavioral management, role management, emotional management) and build skills in problem-solving, decision making, taking action, forming a patient/health care provider partnership and resource utilization. These skills can be applied in any chronic condition.

-based on Lorig & Holman, 2003

Patient Education

• Information and technical skills are taught

• Information is disease-specific

• Assumes that knowledge creates behavior change

• Goal is compliance• Health care professionals

are the teachers

Self-Management Support

• Skills to solve patient Identified problems are learned

• Skills are generalized and can apply to all areas

• Assumes that confidence yields better outcomes

• Goal is increased self-efficacy and self-reliance

• Teachers can be professionals or peers

Bodenheimer et al JAMA 2002;288:2469

Cultural Humility Health Literacy

Self-management Support Basics:Goal Setting, Action Planning,

Problem solving, Follow up

Stepped Care for Self-management Support

Advanced Techniques(MI, PST, Care Mgr, Group, etc.)

ExpertTechniques

Patient Role in Self-management

Making Brief Action Planning Work for You—Coaching Staff for Successful Self Management

Kristin Yeoman, MD, MPH, Clinical ConsultantLCDR Gwenivere Rose, MS,RD, USPHS, Program DirectorIndian Health Service, Chinle Service Unit , Diabetes Program

Chinle Service Unit Facilities

Chinle Comprehensive Healthcare Facility Pinon Health Center

Tsaile Health Center

Demographics298,000 Navajo Nation members across U.S., 57% live on the Reservation Encompasses 27,ooo square miles—the size of West Virginia CSU serves 30 rural communities, 16 Chapters, 34,817 user population 4251 active DM patients on the registry Phone coverage is limited Many elders do not speak or understand English Large % of population lives without running water/electricity

Diabetes Program Goal

Create Systems of Care That Support Healthy, Happy Generations Living In Balance and Harmony With Hope

and Belief For a Better Tomorrow

“Táá hwí’ájítéego – It’s Up To You!”

Clinical Teams and Community Partners Trained

Cedar TeamGhad ni eełíí

Yucca TeamTsá’ásze’

Sage TeamTsááh Juniper Team

Ghád

Other Teams and Groups To Be Trained:—Pinon and Tsaile Health Center Team, CHRs, Special Diabetes, PHNs, Wellness Center, Dietitians, etc.

Each Clinical Team Includes: Nursing Assistants, Health Techs (MAs), Medical Support Assistant, Nurses and Providers

Patient visit Feedback Survey

SMS Baseline Questionnaire Survey

Staff vs Patient Survey Comparison

Sample Self Management Agenda• Welcome & Introductions

• Overview of training• SMS Rationale

• Welcoming the Patient• Building Rapport • Menu of Options

• Making a Brief Action Plan • SMART objectives• Problem Solving

• Patient Follow-up and Feedback• Patient Potholes on the Road to Change• Provider Potholes on the Road to Change

• Ask, Tell, Ask, Teach Back• SMS Documentation

• Fitting SMS into the Office Practice• Coaching Model

• Training Review & Evaluations• Close the Loop & Adjournment

Menu of Options

5 Key Elements in Brief Action Planning (BAP)

1. Being patient-centered, including assessing patient’s needs

2. Helping a patient make a behaviorally specific action plan

3. Eliciting a commitment statement (have patient restate the plan)

4. Assessing confidence and problem-solving to improve confidence regarding plan

5. Providing regular follow-up

Steve Cole, MD Stoneybrook University, Adapted from AMA tip sheet for SMS

Personal Action Plan 3 Core Questions

1. Elicit patient preference for change: Is there anything you would like to do for your health over the next few days (weeks) until we visit again?

2. Check confidence: Changing behavior and sticking with a plan is very hard for most of us. How sure are you that you will be able to carry out this plan?

3. Arrange follow-up: Let's plan when and how we can check on how you're doing with your plan.

Ultra-brief personal Action Planning Steven Cole, MD Professor of Psychiatry, Stony Brook University Medical Center, Steven.cole@stonybrook.edu

Brief Action Planning (B.A.P.)“Is there anything you would like to do for your health

In the next week or two?”

“How confident (on a scale from 0 to 10) do you feel about carrying out your plan?”

“When would you like to check in with me to review how you are doing with your plan?”

Steven Cole, et. al.

SMART Behavioral Contracting Elicitation of Commitment Statement

If Confidence <7, “Problem Solve” Barriers

BehavioralMenu

BehavioralMenu

•Something I have been thinking about doing to improve my health: _______

•My plan for success includes;What I will do: _______When I will do it: _______Where I will do it: ____________________________________________________How often I will do it: _______

•My activity plan for the next two weeks is: _______

•How sure am I about this plan?

•If I am not sure or pretty sure:What could get in the way:What could I change to make it work: ____________

•My follow up plan (how and when):

•These are the things that will let me know I am successful with my plan:

MY HEALTH PLAN

SMART Commitment Statements (Goals)Specific: Include what you will do, when you will do it & how often you will do it.Measurable: Is there a measure of success?Attainable: Is this goal realistic?Relevant: Will this plan help to improve your life?Time-Oriented: What is the timeline for this goal? Can you find the SMART Statement (s)?:NutritionI will eat better.I will eat more fruit.Starting the week of 12/20, I will decrease my soda intake from 3 cans per day to 2 cans per day.Starting tomorrow, I will eat lunch at Burger King 3 times per week rather than 5 times per week.I will eat breakfast every morning before I leave home at 7 am for the next 2 weeks.ExerciseI will get more exercise.I will walk more often.I will walk 1 mi at the high school track three times a week.I will take a spinning class once a week at the wellness center.I will walk 10 laps around the outside of my house four times a week.I will walk to the end of my road and back on Monday, Wednesday and Saturday morning for the next 2 weeks.MedicationsI will take my medications every day. I will put my medicine bottles by the sink in the bathroom so that I remember to take my pills twice a day when I brush my teeth.I will take 2 metformin tablets in the morning with breakfast and 2 at night when I eat dinner for the next 2 weeks.

SMART Commitment Statements

WELLNESS TAB•Click ADD under Education•Click on “Name Lookup” under “Select by” at the top•Type in “Diabetes” or “Health” for Health Promotion-Disease Prevention•Highlight “Diabetes-Lifestyle Adaptations” or “HPDP-Lifestyle Adaptations”

EDUCATION BOX•Comments box: discuss what education you provided for pt•Level of comprehension box: click on patient’s comprehension level; if low comprehension level, do not set goal and see if patient is willing to see diabetes educators•Readiness to learn box: click on appropriate tab that highlights patient’s readiness•If patient sets a goal: click on “goal set”, write goal in box below (use patient’s own words, such as, “I will walk three times per week for 30 minutes.”•If patient not ready to set goal, click on “Not ready” under “Readiness to learn” box•In bottom box, put date of education, then click on “Other” under location and write CCHCF

FOLLOW-UP PATIENTS WHO HAVE SET GOAL•Click on previous education tab that states “goal set” and review goal•Add new education tab as above, but click on “goal met” or “goal not met”•If goal not met, discuss reasons and barriers, restructure action plan and determine if patient wants to set new goal. If they set new goal, add new education tab as above for this new goal.•If goal met, find out if patient want to set new goal and restart whole process from above.

Documentation of SMS Education

Morning Huddle1. HT prints out icare template2. Review all pts, decide what preventive care to focus on

NA rooms pt1.Greets patient2. Vital signs3. Determines chief complaint4. Determines and does appropriate GPRA screenings5. Performs POC testing (a1c etc)6. Writes exams/tests that pt needs from prescreening onto PCC7. Provides and briefly discusses menu of options; tells them we’re trying something new 8. Empanels patients9. Has pt sign release of information, send it to appropriate facility for records

Provider sees pt1. Greets patient2. Evaluates chief complaint3. Follows up chronic medical problems4. Orders labs/exams needed on pt5. Discusses pt’s choice on menu of options6.Provides pt education7.Provides teach back8.Fills out f/u appt sheet with provider, MR#, and when f/u should be set; leaves in chart or in room for HT to set appt

HT sees pt1. Greets patient2. Gives immunizations3. Provides education based on menu of options4. Makes action plan 5. Determines appropriate f/u 6. At follow-up session provides feedback on previous action plan7. Reviews plan agreed on by pt and provider to ensure pt understanding8. Make f/u appt if MSA can’t do it9. Send pt to lab if needed

GeneralTranslation by either NA or HT, whoever is available

Nurse1.Greets patient2.Provides follow-up on action plan3.Take phone calls re med refills, questions4.Leader of PI projects, reviews data and determines where to improve5.Team leader for SMS; helps with coaching, monitoring education codes etc6.Sees pts in f/u

Roles and Sequencing

SMS Training Feedback Survey

Coaching Guidelines What to look for in each patient encounter:• Did staff establish rapport?• Did staff offer and discuss menu of options?• Did staff recognize patient’s level of readiness?• Did patient set the goal him/herself and repeat it back?• Was the goal specific?• Did the patient seem confident with the plan?• Was the education/goal documented in EHR? • How was communication between NA/HT/provider?• How was flow? Did staff follow roles/sequencing developed during

training?

Coaching Schedule

McGarvey, Salay, Kobernick, Tamra Begay off

Monday 4/4 Tuesday 4/5 Wednesday 4/6 Thursday 4/7 Friday 4/8

8am-12 noon Debriefing with Henrietta/Brenda: 8:15 KristinCaroline and Lanora (Rountree provider): Kristin, Shirley

Coaching in observation room: 10-11 nursing assistants IvanDuane

Debriefing with Henrietta/Brenda 8:15Gwenivere

1-5 pm Caroline and Lanora with Henrietta (Rountree provider)Cassandra

Pt(date)

2/8/2011

Demographics, diagnosis

(age, gender)

Category of Response to Question One(fill in brief details or comments)

Healthy, Doesn’t need a plan

Makes a Plan Needs more information, not

interested, not familiar with taking on role in

self-management

Very challenging situation, very

complex life or social situations

1 45 male, diabetes

says you’re the nurse, I just do what

you tell me

2 80 female, heart disease

Has some memory loss. Might have to work with daughter

3 30 male, high blood pressure

Exercise at gym

4

5

6

B.A.P. Monitoring Patient ProjectResponse to the Question: “Is there anything you’ve been thinking about doing to

improve your health?”

Contact InformationContact Information

• Kristin Yeoman, 928-674-7452, kristin.yeoman@ihs.gov• Gwenivere Rose, 928-674-7080, gwenivere.rose@ihs.gov

Corn Pollen Path Garden HarvestCorn Pollen Path Garden Harvest