Coaching Patients If I could choose just one thing

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1 Coaching Patients If I could choose just one thing Patty Fredericks, MS Essentia Health Heart and Vascular Wellness Program Coaching Patients If I could choose just one thing Patty Fredericks, MS Essentia Health Heart and Vascular Wellness Program 1

2 ARS Q1: On a scale of 1-10, how confident are you that you can motivate and inspire patients to make and sustain healthy behavior changes? 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ARS Q2: Have you ever felt like this? 1. Most of the time 2. Frequently 3. Rarely 4. Never 2

3 ARS Q3: advice is a primary catalyst for change in patient behavior. 1. Medical professional 2. Family 3. Partner 4. Friend 5. Clergy Medical professionals influence change in behavior Research supports that physician advice is a primary catalyst for change and can lead to sustained behavior change. Kreuter, MW (2000). How does physician advice influence patient behavior? Evidence for a priming effect. Archives of Family Medicine (2000), 9(5): ) A health & wellness professional s belief in a client s ability to make behavior change can influence outcome. Bandura A. (1997) Self-efficacy: The exercise of control. New York: W.H. Freeman & Co. 3

4 My hope for today is to discuss ways to: elicit change talk improve listening skills help patients find their motivation Principles of Motivation People are more motivated to change when it is based on their own decisions and choices, rather than an authority figure telling them what to do. Deci (1980) Self-determination theory Example: People with self-efficacy believe they are more capable of initiating or sustaining a desired behavior. The expert approach diminishes self-efficacy and sends the subtle message You are not in charge. Joos, S.K., and Hickman, D.H. (1990) How health professionals influence health behavior: Patient-provider interaction and health care outcomes. 4

5 People know what to do, but not how to fit it into their lifestyle. Example: Only 1 in 20 adults engage in five top health behaviors: 1. regular exercise 2. healthy fat intake 3. five servings per day of fruits and vegetables 4. moderate alcohol use 5. avoiding tobacco use Berrigan D et al (2003) Patterns of health behavior in US adults. Prev Med. Emphasizing facts, fear, and force (3 F s) does not motivate change. Example: Change or die! Telling people who are lonely and depressed that they re going to live longer if they quit smoking or change their diet and lifestyle is not that motivating. Ornish, D. (2010) How to transform your lifestyle and your life. Huffpost healthy living. 5

6 Relationships, repetition, and reframing (3R s) do work. Deutschman, Alan. (2007) Change or Die: The three keys to change at work and life. New York: Harpers Collins Publisher. Example: Joy of living! i Convince them they can feel better, not just live longer. (Dean Ornish) Relationship (express support) Repetition (repeat until it sticks) Reframing (reframe to see things in a new way) Ornish, D. (2010) How to transform your lifestyle and your life. Huffpost healthy living. Wait for the patient to be in a change frame of mind. Example: I can do it. I want to do it. I will do it. 6

7 Principles of motivation summary: Initiating change (health coaching) is not telling people what to do. It is working collaboratively with patients to both educate on what changes need to happen, but also giving them skills and confidence to be able to make those changes. Huffman, M. (2007) Health Coaching: A New and Exciting Technique to enhance Patient t Self-Management and Improve Outcomes. Home Healthcare Nurse; 25(4): Strategies to Support Change 7

8 #1 Invite patient to tell their story. Tell me what bothers you most. Tell me what is hardest for you. Tell me what you re most distressed about. Tell me what you most want to change. #2 Listen. If you re talking, you re not listening. Prepare for the surprise and increase in trust when silence allows for listening and thinking. 8

9 #3 Use open-ended questions to determine what is most important. What concerns you about... What is your disease preventing you from doing now? What would most improve your quality of life? Tell me what you most want to change. What would you like to explore today? #4 Reflect back. Provider: What is your disease preventing you from doing? Patient: I would really like to be able to do more things with my grandchildren Provider: It sounds like you want to be able to be more active. Could I suggest some things that you could do to help with that? Provider: What are all the things you are doing now to keep you healthy and well? Patient: I sleep well at night, eat fruit with my meals, take my meds at the right time, and I ve cut back on donuts at work. Provider: What I am hearing tells me that you value your health. 9

10 #5 Share facts after determining what is important. Diagnostic values can pinpoint areas of concern and validate the need for behavior change. # 6 Choose a wellness behavior to work on. Which wellness behavior are you ready to make a goal to work on? Physical Activity Healthy Eating Stress Smoking Sleep Alcohol Play Relationships Meds 10

11 # 7 Identify the motivator. Ask an unexpected question: What do you love about smoking? What s at stake if you don t stop smoking? Identify benefits: What is the best experience you have had with How might exercising lead you to What will motivate you to People are more persuaded by what they hear themselves say than by what someone tells them. Self-Perception theory: Bem, 1972 # 8 Reflect back (again). Provider: You obviously value spending time with your children and exercise is necessary to decrease arthritis pain. Patient: I don t have time to exercise. None of my friends or spouse do either! Provider: I hear you saying that you don t have time to exercise and that none of your friends or spouse do either. Patient: That s true, except for one of my friends who is an avid runner. I don t know how he does it! Provider: Instead of adding a new activity to your day, how could you incorporate more exercise in the activities that you already do? Patient: Well, I could walk instead of drive to get the paper at the end of the driveway. 11

12 #9 Determine readiness to chanllge. Why do I really want to change the behavior (the benefits or pros )? Why shouldn t I try and change the behavior (the obstacles or cons are)? Do my pro s outweigh my con s? What would it take for me to change the behavior and overcome my con s (What s my strategy)? Miller, W.R. & Rollnick, S. (2002) Motivational Interviewing: preparing people for change. New York: Guillford press. 12

13 #10 Offer advice. Ask permission: If you re interested, I have a recommendation (an idea) for you to consider. Would you like to hear it? Offer advice: Based on my experience, I would encourage you to consider. Emphasize choice: And, I recognize it s your choice to do so. Voice confidence: I m very confident that if there comes a time when you make a decision and commitment to, you ll find a way to do it. Elicit response: What do you think about my recommendation (my idea)? #11 Identify a goal together. Explore the following questions when identifying a goal to work on: Tell me about your reasons for wanting to do that. What results are you looking for? For whom do you want to make the change (be sure it s for yourself first and not someone else)? Do you think this goal is realistic? What might get in the way? What might be a strategy to overcome obstacles? 13

14 #12 Write a prescription for the goal. specific measurable action-based realistic include a time line Good example: Walk 30 minutes after taking kids to the bus stop 5 days per week. Bad example: Exercise 5 days per week for 30 minutes. #13 Assess confidence. Provider: How would you rate the importance of this goal on a scale of 1-10? If below 7, ask: How could it become more important to you? Provider: What is your confidence level on a scale of 1 10 for achieving this goal? If below a 7, ask: How can you increase it? 14

15 Research in the field of chronic disease management confirms that if a person picks 6 or lower on the confidence scale, he/she is not confident to succeed. In that case, re-evaluate the goal and make changes so the client will feel confident in their ability to achieve it. Miller, W. R. & Rollnick, S. (2002) Motivational Interviewing: preparing people for change. New York: Guillford Press. To increase confidence: Start with a high confidence activity Small steps Example: Decrease soda from 3 cans per day, to 1. Avoid all or nothing Deploy strengths Foster positive emotions and resilience Identify potential obstacles and come up with strategies to overcome them. 15

16 # 14 Use humor and smile frequently. # 15 Close the conversation positively. Show appreciation: Thank you for your willingness to talk with me about. Support self-efficacy: I m confident you can realize your goal to. Or, I m confident that if and when you make a firm decision to, you will find a way to do it. Show that you care: What was the best part of our session for you today? 16

17 # 16 Acknowledge progress and challenges from last visit. What is the best thing that has happened since we last met? Tell me about a time when you felt alive and engaged? Let s review the prescription you were working on Rehab is difficult. I see you completed all physical therapy visits and the report indicates you ve made good progress. Excellent! What goals do you have going forward? ARS Q4: On a scale of 1-10, how confident are you that you can motivate and inspire patients to make and sustain healthy behavior changes? 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 17

18 Essentia Heart and Vascular Wellness Program (218) Self- or provider-referred. 1-year lifestyle l track program for $400/yr or $35/month. 3-month lifestyle track program for $200. Insurance will cover lifestyle track program if first seen by our nurse practitioner or cardiologist. Staff includes nurse practitioner, exercise physiologists, certified wellness coaches, dietician, diabetes educators, nurses and smoking counselors. References 1. Kreuter, MW. (2000). How does physician advice influence patient behavior? Evidence for a priming effect. Archives of Family Medicine; 9(5): Bandura, A. (1997). Self-efficacy The exercise of control. New York: W.H. Freeman & Co. 3. Deci (1980) Self-determination theory 4. Joos, S.K., and Hickman, D.H.(1990). How health professionals influence health behavior: Patient-provider interaction and health care outcomes: K. Glanz, F.M. Lewis, & B.K. Rimer (eds.), Health behavior and health education: Theory, research and practice. San Fransisco: Jossey-Bass. 5. Berringer, D et al (2003). Patterns of health behavior in U.S. adults. Prev Med; 36(5): Deutschman, Alan. (2007) Change or Die: The three keys to change at work and in life. New York: Harpers Collins Publisher. 7. Ornish, D. (2010) How to transform your lifestyle and your life (part one). Huffpost healthy living. 18

19 continued Huffman, M. (2007) Health Coaching: A new and exciting technique to enhance patient self-management and improve outcomes. Home Healthcare Nurse; 25(4): Bem (1972). Self-Perception theory Miller, W.R. & Rollnick, S (2002) Motivational Interviewing: preparing people for change. New York: Guillford Press. whitepaper@wellcoaches.com Wellcoaches coach training manual. 19

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