1 / 44

USUAL INTERVENTION: Health professionals try to convince give information and “ advices” :

USUAL INTERVENTION: Health professionals try to convince give information and “ advices” : WHY patient must change … WHAT must change… HOW to change… !. Learning Dynamics. Introducing a practical clinical tool facilitating the mentorship of patients in modifying behaviours

bswain
Download Presentation

USUAL INTERVENTION: Health professionals try to convince give information and “ advices” :

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. USUAL INTERVENTION: Health professionals try to convince give information and “advices”: WHYpatient must change… WHATmust change… HOW tochange… !

  2. Learning Dynamics Introducing a practical clinical tool facilitating the mentorship of patients in modifying behaviours Structuring the clinical tool in an intervention platform that would be universally applicable to any behaviour change and may be used by anyhealthcare professional who is part of the healthcare team Formatting the clinical tool to fit in a (realistic) short 3-minute intervention

  3. “BEHAVIOUR CHANGE” 1) EVALUATION “Stage of Change”GOAL (Prochaska) “Conviction – Confidence”TARGET (Miler Rollnick) 2) INTERVENTION: “MOTIVATIONAL INTERVIEWING” (Negotiated Approach)

  4. EVALUATION: Stages of change 10 – 20%% 5 – 10 %% 20 - 30% 50%

  5. EVALUATION STAGE: “What would you think about…? (Have you thought about …?) Taking your pills more regularly? Losing some weight? Changing your eating habits…? Doing more physical activities Quitting smoking?”

  6. STAGES OF BEHAVIOURAL CHANGE EXERCISES: 1. 2. 3. 4. 5. 6. “I have tried walking every day. The temperature is horrible in Quebec! Do you think a stationary bike or a treadmill would be better?” “I’ve lost 3 pounds in two months! On bad weather days, I go walking at the shopping mall…” “I am always alone; all my children live far away. Smoking is all I have left…!” “My grandfather died at the age of 94. He drank like a fish and smoked like a chimney!” “It’s not good to smoke, but if I quit, I gain weight. I’m replacing one problem with another!” “Drinking Scotch may not be good for my high blood pressure but It relaxes me coming back from work.”

  7. ADVANTAGES FOR USE IN PRACTICE: • 1) STARTING POINT OUTCOME • (next Stage) • 2) TARGET:TARGET: • Barriers • ADVANTAGES Strategies • 3) MEASURE (success failure) Immediate, Future • 4) Determine « READYNESS »: Optimal use of Professional Consultation, Rx…

  8. “BEHAVIOUR CHANGE” 1) EVALUATION “Stage of Change”GOAL(Prochaska) “Conviction – Confidence”TARGET (Miler Rollnick) 2) INTERVENTION: “MOTIVATIONAL INTERVIEWING” (Negotiation Approach)

  9. INTERVENTION’S TARGET: “CONVICTION”: Recognizing the benefits of changing a behaviour. “If you decided to… how would that benefit you?” “CONFIDENCE”: Sense of our ability to modify a behaviour. “If you really decided to… do you think you could do it?”

  10. Conviction:“How would that benefit you…?” HIGH:Positive - Emotional - Personal 10 6 CONVICTION MOYENNNE:ABSTRAIT (CONNAISSANCES) AVERAGE:Abstract (Knowledge) « Ma santé serait meilleure, je vivrais plus vieux… Mon risque de maladie diminuerait, mon risque d’infarctus serait plus petit, Mon taux de cholestérol serait meilleur. » 3 LOW:Absent or Abstract «May be… »  0 Adapted Keller V et al. JCOM 1997. , Miller WR et al. Guilford Press, 1991.

  11. “Confidence” “If you really decided to…do you think you could?” LOW:Powerless feeling HIGH:Unwavering confidence CONFIDENCE Adapted Keller V et al. Journal of Clinical Outcomes Management 1997.Miller WR et al. Guilford Press, 1991.

  12. Integration of the models

  13. Integration of the models

  14. CASE STUDY #1: Marc 60 YO 1) Myocardial infarction 2005 ( Angioplasty LAD) 2) Dyslipidemia 3) COPD: cough++ Shortness of breath 5/6 Medication: AAS 80, Atenolol 50, Atorvastatin 40 Combivent inh. PRN Stable clinical condition Stopped ROH 4 years ago. Smokes since age 12. Never made real attempt to stop.

  15. CASE STUDY #1: Marc 60 YO STAGE Professional: “What do you think about quitting smoking?” Marc:“I will stop smoking eventually but I’m not ready yet.” CONVICTION Professional: “If you decided to quit smoking, how would it benefit you?” Marc:“My health would be better.” CONFIDENCE Professional: “Do you think you could do it?” Marc: "Hey, I quit drinking 4 years ago. I know I could do it if I set my mind to it."

  16. INTEGRATED MODELS

  17. INTEGRATED MODELS

  18. CASE STUDY #2: Edith Patient 43 years old referred for gain of weight of 60 pounds in 3 years without changing eating habits. Clinical and lab evaluation disclose no endocrine problem. She was physically very active (gym 5 days a week) up to the buying of a small trucking business 3 years ago. She did not change significantly her eating habits. She stopped all physical activities since 3 years, waking up at 5.30, she’s at work at 7.00 AM and works non stop till 7.00 PM. Back home she eats and go bed early being totally exhausted. (3000 calories = 1 pound)

  19. CASE STUDY #2: Edith STAGE Professional:“Have you thought about integrating physical activity Into your daily routine?” Edith:“Yes, I’d like to be more active. I should be able to do more in about 6 months, by then we might be able to hire somebody to help with my work.” CONVICTION Professional:“What good do you think it would do you to become physically active?” Edith:“I could finally lose the weight that I’ve gained over the past 3 years. I used to work out 5 times a week. I was in shape and had a lot more energy. Those were the good old days.” CONFIDENCE Professional: “If you decided to get in shape now, do you believe you would be able to do it?” Edith:“It’s impossible to do it right now. I have no help.”

  20. INTEGRATED MODELS

  21. INTEGRATED MODELS

  22. Simultaneous multiple behaviours interventions: • Catalytic behaviours: Physical activity • 2Effect of simultaneous interventions: • POSITIVE: • - physical activity + diet, • - physical activity +smoking cessation • NEGATIVE: • - diet: low salt (HBP) + • low calory (obesity) • - Simultaneous alcool and smoking cessation • 3 Behaviour and pharmacology • MedicationAdherence

  23. Intervention DIRECTIVE mode of communication when patient says: “YES BUT….” Patient convinces himself of the opposite! «MOTIVATIONAL INTERVIEWING» Provoke perception of BENEFITS (CONVICTION) Followed by solutions for BARRIERS (CONFIDENCE) WITH « OPEN - ENDED QUESTIONS »

  24. INTERVENTION: increase « CONVICTION » 1 MOTIVATE: Provoke expression of benefits that are: POSITIVE - PERSONNAL - EMOTIONAL «  How would it benefit you, If you decide to…  ?» REFORMULATE - REINFORCE - REFOCUS 2 INFORM: Of the advantages if needed (with empathy). CONCLUDING INTERVIEW: Information, Questions, Exercises…

  25. INTERVIEW CONCLUSION: CONVICTION Pre-Contemplation to Contemplation: • INFORMATIONS:(verbally or documentation) - reinforce Cognitive Conviction (4 - 6/10) • QUESTIONS:“How does it benefit…?” - reinforce new stage: Cognitive Conviction (Contemplation) - initiate travelling toward Affective Conviction (Preparation) WHAT IF BARRIERS….?

  26. INTERVENTION: « CONVICTION » « How DOES it benefit you…? » BARRIER… ? “How WOULD it benefit You…? “How COULD it benefit You…? BARRIER…? «BYPASS» : depersonalise « How could it benefit to SOMEBODY else…? » BARRIER… ? Give pertinent informations (with empathy)…

  27. CONVICTION INTERVIEWCONCLUSION: • CONTEMPLATION to PREPARATION: • QUESTIONS:“How does it benefit…?” • provoque expressionAFFECTIVEConviction (7 – 9/10) • POSITIVE - EMOTIVE - PERSONNAL… • OR • CONFIDENCE: • Barriers, Strategies….

  28. CASE STUDY #1:Marc 60 YO 1) Myocardial infarction 2005 ( Angioplasty LAD) 2) Dyslipidemia 3) COPD: cough++ Shortness of breath 5/6 Medication: AAS 80, Atenolol 50, Atorvastatin 40 Combivent inh. PRN Stable clinical condition Stopped ROH 4 years ago. Smokes since age 12. Never made real attempt to stop.

  29. CASE STUDY #1: Marc 60 YO STAGE Professional: “What do you think about quitting smoking?” Marc:“I will stop smoking eventually but I’m not ready yet.” CONVICTION Professional: “If you decided to quit smoking, how would it benefit you?” Marc:“My health would be better.” CONFIDENCE Professional: “Do you think you could do it?” Marc: "Hey, I quit drinking 4 years ago. I know I could do it if I set my mind to it."

  30. CASE STUDY #1:Marc 60 YO « INCREASE CONVICTION » Physician: “If you decided to stop smoking… what good do you think it would do you?” Patient : “I’d be healthier.” Medicine : “What benefits would you enjoy by being healthier?” Patient : “I wouldn’t cough as much or be as short of breath.” Medicine : “What other activities would you like to do if you weren’t so short of breath?” Patient : “My life would be completely different. The other day, for instance, I tried to play with my grandchildren, but I had to stop after 30 seconds because I was out of breath. Also I could also go out and take trips.” Reinforcement : “It would indeed be wonderful to be less short of breath and to do the things you enjoy most in life.”

  31. INTEGRATED MODELS CONCLUDING INTERVIEW: Questions to reinforce new stage or switch on “right”, (Barriers and strategies) to address Confidence and pass to Action

  32. INTERVENTION: increase « CONFIDENCE » 1 « If youreally decide to… do you think you could do it? » 2 « What would prevent you from…? » « BARRIERS» 3 « How do you think you can..? » « STRATEGIES » Build on earlier SUCCESSES

  33. CASE STUDY #2: Edith Patient 43 years old referred for gain of weight of 60 pounds in 3 years without changing eating habits. Clinical and lab evaluation disclose no endocrine problem. She was physically very active (gym 5 days a week) up to the buying of a small trucking business 3 years ago. She did not change significantly her eating habits. She stopped all physical activities since 3 years, waking up at 5.30, she’s at work at 7.00 AM and works non stop till 7.00 PM. Back home she eats and go bed early being totally exhausted. (3000 calories = 1 pound)

  34. CASE STUDY #2: Edith STAGE Professional:“Have you thought about integrating physical activity Into your daily routine?” Edith:“Yes, I’d like to be more active. I should be able to do more in about 6 months, by then we might be able to hire somebody to help with my work.” CONVICTION Professional:“What good do you think it would do you to become physically active?” Edith:“I could finally lose the weight that I’ve gained over the past 3 years. I used to work out 5 times a week. I was in shape and had a lot more energy. Those were the good old days.” CONFIDENCE Professional: “If you decided to get in shape now, do you believe you would be able to do it?” Edith:“It’s impossible to do it right now. I have no help.”

  35. CASE STUDY #2: Edith Increase confidence 1) Provoke expression of BARRIERS by the patient: Physician: “What prevent you from starting to exercise?” Edith:“It’s impossible to do it right now. I get up at 5:30 a.m. and work until 7:00 in the evening. During the day, I don’t have a spare moment. We don’t have the money right now to hire someone to help out. Physician: “I see that you are extremely busy. Would you still like to look more closely at whether something could be done so that you can get back to how you used to feel when you were exercising?” Edith: “We can still do that but I already get up at 5:30 a.m. and work until 7:00 p.m. I cannot get up any earlier.”

  36. CASE STUDY #2: Edith INCREASE CONFIDENCE 2) Provoke expression of SOLUTIONS by the patient: Physician: “Your days are very long. Do you think you would be less effective at work if we could find 20 minutes in the day to give to yourself as a gift to get you back in shape? You certainly deserve it.” Edith: “That might be possible. I already have gym equipment in the basement, including a treadmill.” Physician: “Than would it be possible to cut your day by 20 minutes in the afternoon and take this time to wind down on your treadmill?” Edith: “Yes, that wouldn’t be too difficult.” Physician: “Would you be willing to make the decision today to give yourself 20 minutes every afternoon and use your treadmill? We will revisit this during the next visit. Edith:“Yes, that’s fine… I’ll start tomorrow. We’ll see what becomes of it.”

  37. INTEGRATED MODELS CONCLUDING INTERVIEW: Negotiate an Action (even partial)

  38. Simultaneous multiple behaviours interventions: • Catalytic behaviours: Physical activity • 2Effect of simultaneous interventions: • POSITIVE: • - physical activity + diet, • - physical activity +smoking cessation • NEGATIVE: • - diet: low salt (HBP) + • low calory (obesity) • - Simultaneous alcool and smoking cessation • 3 Behaviour and pharmacology • MedicationAdherence

  39. 3 Minute Empowerment and Royal College Physicians

  40. Take Home messages: • Efficacious, targeted, personalised approach for behaviour change require determination of: • STAGE of change, • GOAL (next stage) • TARGET of intervention (Conviction, Confidence). • FEW SECONDS..! • 2) Traditional DIRECTIVE (professional centered) approach • (information + directives), leading to the “YES BUT…” syndrome, should be avoided.

  41. Take Home messages: 3) Motivational Interviewing (patient centered communication technique) reinforce and accelerate the movement along the path of change. “ASK DONT TELL!” Small step for the physicians Big step for the patients…!

  42. « INITIATE A BEHAVIOURAL CHANGE IN 3 MINUTES; BREAK THE BARRIERS » PALM   DOCUMENTS TO GO  www.lemieuxbedard.com/emc

More Related