Transcript Using Change Theory Presentation 6 7 13

Using Change Theory to Increase
Patient Adherence
Carol Lee, MSW, LCSW
&
Julie C. Wood, RN, MSN, CNS, CHFN
Realities in the Healthcare Business
• We may have the best doctors, the newest techniques and
equipment, the best staff and a beautiful hospital but all
that does not matter if our patients are not medically
adherent.
• Our hospital ratings and re-imbursement is measured on
patient outcomes.
• Therefore finding new ways to enable patients to be
successful in changing their behaviors to be medically
adherent is the basic key to the success of a medical
system.
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Objectives
1. Identify the 6 basic principles to influence change
2. Identify the 2 basic questions that patients ask
themselves before adherence is possible
3. Learn how to identify Vital Behaviors for a specific
patient population and to measure these behaviors with
Patient Self-Assessment Surveys
Change Theory
• Based on the work of Kerry Patterson, Joseph Grenny,
David Maxfield, Ron McMillan and Al Switzler
• Books: Change Anything, Influencer: The New Science
of Leading Change, and Crucial Conversations
• The authors researched what was effective in changing
individual and group behaviors. Based on this research,
they developed principles and strategies for successful
change.
Medical Adherence is “Abnormal”
Results of Preventative Health Self Assessment Survey
Change Theory Principle: People choose behaviors on what
they think will happen.
Human tendency is to live “in the now”.
We consider only the immediate result – “Will it make me feel
good now?”
Equally important, but often overlooked is the eventual result
“How will this effect me in the(very distant) future?
Medical Adherence is a practice requiring many decisions
through-out the day and people need to stay mindful of their
bodies and their health.
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Sutter Memorial Transplant
& Advanced Heart Service
Provides:
• Treatment to a diverse adult patient population
• A continuum of care from Heart Failure to LVAD to Heart
Transplants
• TAVR and Congenital Heart Clinics
Our Statistics
• In 2012, we implanted 29 LVADs and
12 heart transplants.
• Our total numbers are 108 LVADs
and 148 heart transplants.
• Our heart failure program was the 1st
in the nation to be certified CMS.
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Change Theory: Strategies
• Identify Vital Behaviors by studying positive deviance
• Develop a recovery strategy when people make
mistakes (anticipate mistakes and make a plan in
advance)
• Test your results
• Update strategy accordingly, test results and repeat
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2 Questions Preceding Change
1. Can I do it?
o Stages of Change Applicable: Pre-Contemplation;
Contemplation; Preparation; Action; Maintenance;
Termination
2. Is it worth it?
o Social Workers and Nurses often intervene to assist
people in problem-solving these answers
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6 Sources of Change, Cont.
4. Social Ability – Real change requires help, information
and support from others
5. Structural Motivation – Environment impacts behavior
Make the healthy choice the easy choice
6. Structural Ability – Small changes in the environment
can have a big impact that are “forces that either push
with you or against you”
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Change Theory: 6 Sources of Change
1. Personal Motivation – An individual’s desires and
wants
2. Personal Ability – An individual’s skill set
3. Social Motivation – “Bad habits are almost always a
social disease – if those around us model and
encourage them, then we’ll almost always fall prey.
Turn accomplices into friends and you will be twothirds more likely to succeed.” (Patterson, Change Anything)
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Tools
• Self Assessments
• Medical Notebooks
Self-Assessment Tool
Development for specific populations – (apply change
theory and identify Vital Behaviors)
•
•
•
•
•
Heart Failure
Pre-Kidney Transplant
Kidney Transplant
LVAD
Heart Transplant
I take my medications as prescribed
I follow fluid and diet restrictions
I exercise as recommended
I weigh myself daily
I can recognize symptoms of a “flare-up” and
who to call
I avoid alcohol
I avoid tobacco and illegal drugs
0 - Never
1- Rarely
2Occasionally
3 - Most of
the time
Instructions: Please put an X to indicate your
answer for your behaviors. If you are a returning
patient, please indicate your answer since your
last visit.
4 - All of the
time
Heart Failure Self-Assessment Components
Self-Assessment Components, Cont.
Excellent
Good
Fair
My energy level is:
My appetite is:
My sleep patterns are:
Dyspnea Score
Right now my shortness of breath is:
0….1….2….3….4….5….6….7….8….9….10
None
Extreme
My usual score for shortness of breath is:
0….1….2….3….4….5….6….7….8….9….10
None
Extreme
(Directions: Circle the number )
Poor
Self-Assessment Components, Cont.
Right now my quality of life is:
0….1….2….3….4….5….6….7….8….9….10
Poor
Excellent
(Directions: Circle the number)
Feeling sad, hopeless or loss of
enjoyment or pleasure in life
Feeling worried, anxious, or fearful
and thinking about things over and
over
Feeling that life is not worth living
Feeling frustrated, angry, easily
annoyed or irritated
Extreme
Severe
Moderate
Mild
Mood Questions
Never
Self-Assessment Components, Cont.
Family Concerns
Financial Problems
Problems with getting the care
that I need
Medical Concerns
Alcohol, drugs, tobacco, overmedicating, etc.
Other Stressors
0 - Extreme
1 - A lot
2 - Moderate
3-Sometimes
Current Concerns
4 - Not at all
Self-Assessment Components, Cont.
I take my medications as prescribed
I follow the fluid and diet restrictions
I exercise as recommended
I weigh myself daily
I can recognize symptoms of a “flare-up” and
who to call
I avoid alcohol
I avoid tobacco and illegal drugs
0 - Never
1 - Rarely
2Occasionally
3 - Most of
the Time
Instructions: Please put an X to indicate your
answer for your behaviors. If you are a returning
patient, please indicate your answer since last
visit.
4 - All of the
Time
Vital Behaviors for Renal Transplant
I take my medications as prescribed
I follow the fluid and diet restrictions
I exercise as recommended
I weigh myself daily
I can recognize symptoms of a “flare up” and
who to call
I avoid alcohol
I avoid tobacco and illegal drugs
0 - Never
1- Rarely
2Occasionally
3 - Most of
the Time
Instructions: Please put an X to indicate your
answer for your behaviors. If you are a returning
patient, please indicate your answer since last
visit.
4 - All of the
Time
Vital Behaviors for LVAD
I take my medications as prescribed
I follow the fluid and diet restrictions
I exercise as recommended
I weigh myself daily
I can recognize symptoms of a “flare up” and
who to call
I avoid alcohol
I avoid tobacco and illegal drugs
0 - Never
1 - Rarely
2Occasionally
3 - Most of
the Time
Instructions: please put an X to indicate your
answer for your behaviors. If you are a returning
patient, please indicate your answer since last
visit.
4 - All of the
Time
Vital Behaviors for Heart Transplant
Outcomes
• The Self-Assessment incorporates each patient’s analysis of their
behaviors and symptoms into their clinic visit. This makes the clinic
visit patient-centric, drives the decision-making of the clinician, and
quickly identifies clinical social work referrals.
• Early identification of specific areas needing intervention
•
Medical Adherence:
o Self-Care: Identifies gaps in patient’s understanding
o Physical Functioning: Identifies areas for medical intervention
o Mood and Current Concerns: Identifies potential obstacles to
adherence
Outcomes
• Self-Assessment Changes Dynamics of Patient/Provider
relationship:
o Eliminates need for each staff member to grill patients
on their behaviors - Patients have already quantified
their behaviors, answered the hard questions and are
prepared for a conversation re: their behaviors.
o Allows staff members to be in “Motivational
Interviewer” and “Educator/Consultant” role rather
than in Authoritarian role. Praise positive behaviors,
problem-solve and teach to improve other scores.
“Medical Notebooks”
Assists the patient with the Can I do it question by:
o Providing structure to help patients be organized with
their relevant medical directions, calendar of
appointments, relevant health information, etc.
o Creates one place for family members and caregivers
to look to help the patient be adherent
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“Medical Notebooks,” Cont.
o Creates relevant, current information to show to ER and
other health providers (Many of our patients are treated
in at least 2 medical systems)
o Patients now have necessary documents for travel
o Provides one place for all staff members to place
educational material and “homework” for patients
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Self-Assessment Scores: Analysis, cont.
o Patients do not generally “offer up” how they are
beginning to lapse in their Vital Behaviors. If staff do not
ask, patients often won’t tell.
o Patients often assume that if staff do not keep asking,
that specific behavior is no longer important.
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Self-Assessment Scores: Analysis
• Initial analysis:
o Patient’s Self-Assessment Scores increase on the
following visit
o As with any behavior, many patients regress in
adherence – this is “normal”
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LVAD Medical Notebook - Organization
•
•
•
•
•
•
•
•
•
•
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Front pocket of notebook = Labs & Rx “To Do”
Business card holder
Calendar
Medications
Coumadin
Instructions
Labs
Dressings
Daily Recordings
Medical Problem List
LVAD Notebook Org., Cont.
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•
•
•
•
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Emergency Guide
Contact List (Emergency contacts, family)
Healthcare Directives
Nutritional Information
Questions for M.D. (Add blank paper)
Heart Failure & Transplant Notebooks Org.
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•
•
•
•
•
•
•
•
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Front pocket of Notebook = For labs & Rx “to do”
Business card holder
Calendar
Medications
Clinic Worksheets
Labs
Diagnostic Reports
Medical Problem List
Contact list
Heart Failure & Transplant Notebook, Cont.
• Healthcare Directive
• Nutritional Information
• Questions for M.D. (with blank paper)
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Medical Notebook Given to Patient
• Presented as a gift – each notebook is personalized
• Patient instructed by SW or RN on how to use
• Patient asked to bring the notebook to all of their medical
appointments
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Medical Notebook Given to Patient, Cont.
• Staff assists patient in keeping notebook up-to-date
• Staff teaches the patients how to read their labs and
follow along with staff & keeps information current
• Staff writes or has patient write appointments in the
calendar
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LVAD to Heart Transplant Patients
• When an LVAD patient receives a Transplant, staff reorganizes their notebook for them with the new tabs.
• When the notebook is thinned, staff asks if the patient
wants to keep the outdated information or obtains
permission to safely dispose of their confidential
information.
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Medical Notebook Analysis
• Effectiveness was observed by patient, their family and staff
behaviors
• Physicians, RN Coordinators were involved in the
organization of the notebooks
• All new LVAD & Transplant patients are presented with their
Medical Notebook as part of their pre-discharge teaching by
the RN Coordinators
• With our patients who were given implants before this tool
was developed or with our Heart Failure patients, our policy is
that any staff member can offer a notebook to one of our
patients.
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Medical Notebook Analysis
• Patients, patient’s caregivers and staff “love” this tool
• At least 90% of the patients bring the notebook to their
appointments and use the notebook to show staff their
current medication lists, daily recordings, etc.
• Staff updates patient’s notebooks with copies of recent
labs, diagnostic reports, etc.
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0 - Never
1- Rarely
2Occasionally
3 - Most of
the Time
Instructions: Please put an X to indicate your
answer for your behaviors. If you are a returning
patient please indicate your answer since last
visit.
4 - All of the
Time
Create Your Own Self-Assessment
References
• American Heart Association. http://www.heart.org
• Miller, William, and Stephen Rollnick. Motivational
Interviewing: Helping People Change. 3rd ed. New York:
Guilford Press, 2012. Print.
• Patterson, Kerry, Joseph Grenny, et al. Change Anything: the
New Science of Personal Success. New York: Business Plus,
2011. Print.
• Patterson, Kerry, Joseph Grenny, et al. Crucial Conversations:
Tools for Talking When Stakes Are High. Updated 2nd ed.
New York: McGraw-Hill, 2012. Print.
• Patterson, Kerry, Joseph Grenny, et al. Influencer: the Power
to Change Anything. New York: McGraw-Hill, 2008. Print.
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Contact Information
Carol M. Lee
[email protected]
916-733-7105
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