Making Brief Action Planning Work for You Coaching

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.

Patient

Condition specific skills and information Self-management ß education Condition specific skills and information

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 Self-Management Support • Information and technical skills are taught • Information is diseasespecific • Assumes that knowledge creates behavior change • Goal is compliance • Health care professionals are the teachers • 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 selfefficacy and self-reliance • Teachers can be professionals or peers Bodenheimer et al JAMA 2002; 288: 2469

Stepped Care for Self-management Support Expert Techniques Advanced Techniques (MI, PST, Care Mgr, Group, etc. ) Self-management Support Basics: Goal Setting, Action Planning, Problem solving, Follow up Patient Role in Self-management Cultural Humility Health Literacy

Making Brief Action Planning Work for You— Coaching Staff for Successful Self Management Kristin Yeoman, MD, MPH, Clinical Consultant LCDR Gwenivere Rose, MS, RD, USPHS, Program Director Indian Health Service, Chinle Service Unit , Diabetes Program

Chinle Service Unit Facilities Chinle Comprehensive Healthcare Facility Pinon Health Center Tsaile Health Center

Demographics 298, 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 Team Ghad ni eełíí Yucca Team Tsá’ásze’ Sage Team Tsááh Juniper Team Ghád Each Clinical Team Includes: Nursing Assistants, Health Techs (MAs), Medical Support Assistant, Nurses and Providers Other Teams and Groups To Be Trained: —Pinon and Tsaile Health Center Team, CHRs, Special Diabetes, PHNs, Wellness Center, Dietitians, etc.

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

Behavioral Menu Brief Action Planning (B. A. P. ) “Is there anything you would like to do for your health In the next week or two? ” Behavioral Menu SMART Behavioral Contracting Elicitation of Commitment Statement “How confident (on a scale from 0 to 10) do you feel about carrying out your plan? ” If Confidence <7, “Problem Solve” Barriers “When would you like to check in with me to review how you are doing with your plan? ” Steven Cole, et. al.

MY HEALTH PLAN • 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 things that will let me know I am successful with my 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)? : Nutrition I 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. Exercise I 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. Medications I 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.

Documentation of SMS Education 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.

Roles and Sequencing Morning Huddle 1. HT prints out icare template 2. Review all pts, decide what preventive care to focus on General Translation by either NA or HT, whoever is available NA rooms pt 1. Greets patient 2. Vital signs 3. Determines chief complaint 4. Determines and does appropriate GPRA screenings 5. Performs POC testing (a 1 c etc) 6. Writes exams/tests that pt needs from prescreening onto PCC 7. Provides and briefly discusses menu of options; tells them we’re trying something new 8. Empanels patients 9. Has pt sign release of information, send it to appropriate facility for records Nurse 1. Greets patient 2. Provides follow-up on action plan 3. Take phone calls re med refills, questions 4. Leader of PI projects, reviews data and determines where to improve 5. Team leader for SMS; helps with coaching, monitoring education codes etc 6. Sees pts in f/u HT sees pt 1. Greets patient 2. Gives immunizations 3. Provides education based on menu of options 4. Makes action plan 5. Determines appropriate f/u 6. At follow-up session provides feedback on previous action plan 7. Reviews plan agreed on by pt and provider to ensure pt understanding 8. Make f/u appt if MSA can’t do it 9. Send pt to lab if needed Provider sees pt 1. Greets patient 2. Evaluates chief complaint 3. Follows up chronic medical problems 4. Orders labs/exams needed on pt 5. Discusses pt’s choice on menu of options 6. Provides pt education 7. Provides teach back 8. 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

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 Mc. Garvey, Salay, Kobernick, Tamra Begay off 8 am-12 noon 1 -5 pm Monday 4/4 Tuesday 4/5 Wednesday 4/6 Caroline and Lanora with Henrietta (Rountree provider) Cassandra Friday 4/8 Coaching in observation room: 10 -11 nursing assistants Ivan Duane Debriefing with Henrietta/Brenda: 8: 15 Kristin Caroline and Lanora (Rountree provider): Kristin, Shirley Thursday 4/7 Debriefing with Henrietta/Brenda 8: 15 Gwenivere

B. A. P. Monitoring Patient Project Response to the Question: “Is there anything you’ve been thinking about doing to improve your health? ” Pt (date) Demographics, diagnosis (age, gender) Category of Response to Question One (fill in brief details or comments) 2/8/2011 Healthy, Makes a Plan Doesn’t need a plan 1 45 male, diabetes 2 80 female, heart disease 3 30 male, high blood pressure 4 5 6 Needs more information, not interested, not familiar with taking on role in self-management Very challenging situation, very complex life or social situations says you’re the nurse, I just do what you tell me Has some memory loss. Might have to work with daughter Exercise at gym

Contact Information • Kristin Yeoman, 928 -674 -7452, kristin. yeoman@ihs. gov • Gwenivere Rose, 928 -674 -7080, gwenivere. rose@ihs. gov Corn Pollen Path Garden Harvest