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Tips & Tools to Optimize Brief Action Planning

Tips & Tools to Optimize Brief Action Planning. Supporting Patient Self-Management. Dr. Rahul Gupta. Learning Objectives. Review process & purpose of Brief Action Planning (B.A.P. ) Navigate common challenges through learning 3 key tips/tools

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Tips & Tools to Optimize Brief Action Planning

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  1. Tips & Tools to OptimizeBrief Action Planning Supporting Patient Self-Management Dr. Rahul Gupta

  2. Learning Objectives • Review process & purpose of Brief Action Planning (B.A.P.) • Navigate common challenges through learning 3 key tips/tools • Explore a case study illustrating B.A.P. and tips/tools in action • Practice tools to develop comfort and skill

  3. “ Everyone has a doctor in him or her, we just have to help that doctor in its work. The natural healing force within each of us is the greatest force in getting well.” -Hippocrates (460-377 B.C.)

  4. Brief Action Planning • Is a self-management support tool based on the principles and practice of Motivational Interviewing: “…a collaborative, person-centred form of guiding to elicit and strengthen motivation for change.” www.motivationalinterview.org • B.A.P. is: Structured, Patient-Centered and Evidence-InformedReims et al, 2013

  5. KEY POINT of Brief Action Planning: Building Self-Efficacy Higher self-efficacy is associated with making increasingly ambitious goals and better outcomes. Bodenheimer. Goal-Setting for Behavior Change in Primary Care. PtEducCouns 2009;76(2):174-80. Bandura . Self-Efficacy: Toward a Unifying Theory of Behavioral Change. Psychological Review 1977;84(2)191-215.

  6. The Spirit of Motivational Interviewing • Collaboration Health care professional and patient are equal; Avoid the expert role • Evocation Ideas for change come from the patient • Autonomy Respect the patient’s right to change or not to change • Compassion Interaction is grounded in caring with the patient’s best interest in mind Dr Bill Miller, Nov 2010 updated from Miller & Rollnick, Motivational Interviewing, 2002

  7. What’s Going on Here

  8. “Is there anything you would like to do for your health in the next week or two?” Behavioral Menu Elicit a Commitment Statement SMART Behavioral Plan “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” If Confidence <7, Problem-Solve Barriers “Would you like to check in with me to review how you are doing with your plan?” Follow-up

  9. Common Challenges with B.A.P.

  10. Tips & Tools to Overcome Challenges

  11. Case StudyVisit 1 (Nov 22, 2013) 23 year old female diagnosed with fibromyalgia and depression at age 14. Mother died of stomach cancer when she was age 16. Seen by multiple rheumatologists, never feels believed Has been on amitryptiline, duloxetine, gabapentin, pregabalin, cyclobenzaprine in past and none have helped. No meds for 2 years. Frustrated, crying a lot, in constant pain “everywhere” On disability, fatigued, can’t stay asleep Initial PHQ Nov 2013: 18 (very difficult)

  12. Case Study-continuedVisit 1 (Nov 22, 2013) • Is there anything you would like to do for your health in the next week or two? • Patient starts crying even louder: “what’s the point, it will just lead to more pain and frustration!!”

  13. Group Question: What would you do?

  14. Tip # 1: Mindful Listening • Mindfulness: “On purpose, attending to the present moment, nonjudmentally” • Often caught in own mind chatter, remembering past experiences with this patient, thinking about what to say next, worried about time • May be (knowingly or unknowingly) judging patient • Technologies may be competing for our attention Beckman et al.. The Impact of a Program in Mindful Communication on Primary Care Physicians. Academic Medicine; 87(6): 815-819

  15. Tip # 1: Mindful Listening • Listen actively • Use reflective statements to demonstrate empathy and understanding • Check for accuracy • Attend to non-verbal communication • Mindful Listening has potential to improve experience, expectations and outcomes Pollack KI et al. Physician empathy and listening association with patient satisfaction and autonomy J Am Board Fam Med 2011 Nov-Dec, 24(6) Koyama. The subjective experience of pain: where expectations become reality. ProcNatlAcadSci 2005; 102(36):12950-5

  16. Reflective Statements “I’m really tired of coping with my chronic pain and I can’t live like this any longer” • Repeat: direct re-statement • Rephrase: saying the same thing in slightly different words • Sounds like you are pretty exhausted, and have had enough. Is that accurate?” • Paraphrase: make a guess at the meaning, usually adding something that was not said directly • “It sounds like mentally you are in a lot of pain too, is that fair to say?” Miller & Rollnick, Motivational interviewing: Preparing people for change (2nd ed.).2002. The Guilford Press.

  17. Group Exercise- Reflective Statements “I feel so tired and depressed, it’s hard to get myself out of the house”. • Repeat: direct re-statement • Rephrase: saying the same thing in slightly different words • Paraphrase: make a guess at the meaning, usually adding something that was not said directly Miller & Rollnick, Motivational interviewing: Preparing people for change (2nd ed.).2002. The Guilford Press.

  18. Example Case: Reflective Statements “What’s the point, it will just lead to more pain and frustration!!” • Rephrase: “ Sounds like you are afraid to feel disappointed again, is that right?” • “Yes, I’ve heard this all before and it never changes things” • Paraphrase: “So you are feeling like you have no control over your future?” • “Yes!”…(patient starts to calm down) …“but I haven’t given up” • “I can appreciate it is not fun to feel no control. Would it be ok if I share a few ideas that have worked for others when they feel powerless, to see if that generates ideas for you?” • “OK.”

  19. Case StudyVisit 1 (Nov 22, 2013) • “Would it be ok if I share a few ideas that have worked for others, to see if that generates ideas for you?” • OK. • You could work on this “Control worksheet” to generate some ideas, you could join a support group for people like you, or review some online resources.

  20. Tip # 2: Use “Control Worksheet” • When patients focus on things outside their control, stress increases & resourcefulness declines • Exercise involves shifting attention to areas where patient DOES have some control, even if minor • Builds hope, and orients patient to possibilities Bodenheimer. Goal-Setting for Behavior Change in Primary Care. PtEducCouns 2009;76(2):174-80

  21. THINGS I DO HAVE CONTROL OVER: What I put into my body Asking for help How I react when in pain THINGS I DON’T HAVE CONTROL OVER: Family history What is covered by MSP When my pain acts up CONTROL WORKSHEET *Once both lists have been generated, encourage them to shift attention to list on right

  22. Case StudyVisit 1 (Nov 22, 2013) • She chose the Control Worksheet, and one example explored • NOT IN CONTROL: Food at boyfriend’s place • IN CONTROL: Bring her own food, stock up his place • She planned to work on worksheet further at home • Given pain diagram to fill out • “When would you like to follow up?”: 14 days • TIME for visit #1: 35 minutes

  23. THINGS I DO HAVE CONTROL OVER: What I put into my body Asking for help How I react when in pain Bring her own food, stock up his place THINGS I DON’T HAVE CONTROL OVER: Family history What is covered by MSP When my pain acts up Food at boyfriend’s place CASE STUDY: CONTROL WORKSHEET

  24. “Is there anything you would like to do for your health in the next week or two?” Behavioral Menu SMART Behavioral Plan Elicit a 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 “Would you like to check in with me to review how you are doing with your plan?” Follow-up

  25. Case StudyVisit 2 (Dec 13, 2013) • “How did it go with your plan?” • Did in fact go through control worksheet, and wrote in her journal++! • Did not do pain diagram • “Some movement is great, what did you learn?” • “While can’t control pain, can pace myself differently” • “While can’t control others actions, can prepare for triggers ahead of time” (hunger, traffic, fatigue) • “While can’t stop pain, can stretch & build strength”

  26. Case StudyVisit 2 (Dec 13, 2013) • Is there anything she would like to do for her health in the next week or two? • “Stop over-doing it with her knitting projects”

  27. “Is there anything you would like to do for your health in the next week or two?” Behavioral Menu SMART Behavioral Plan Elicit a 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 “Would you like to check in with me to review how you are doing with your plan?” Follow-up

  28. SMART Behavioral Plan Action Planning is “SMART”: • Specific, stated in positive • Measurable • Achievable • Relevant • Timed Locke & Latham. Building a Practically Useful Theory of Goal Setting & Task Motivation. American Psych, 2002;57, 705-717Frederickson & Branigan. Cognition and Emotion, 2005;19, 313-332. Bodenheimer. Goal-Setting for Behavior Change in Primary Care. PtEducCouns 2009;76(2):174-80

  29. Group Question: Quality of goal? “Stop over-doing it with her knitting projects” Frederickson & Branigan. Cognition and Emotion, 2005;19, 313-332.

  30. Positive Psychology • “…the scientific exploration of the conditions and processes that lead to optimal health and performance.” • Unlike traditional psychology, which focuses on pathology and finding valid methods for treating what's wrong, positive psychology emphasizes human strengths and positive experiences to improve lives • Creates conditions under which patients can flourish. www.ippanetwork.org

  31. Tip #3: Help CreatePositive Visuals “Stop over-doing it with her knitting projects” • Need to overcome negativity bias • Need to optimize power of imagination • Research suggests shifting focus to positive visuals enhances cognitive abilities and inspires action • “Broaden and Build theory” of positive emotions Frederickson & Branigan. Cognition and Emotion, 2005;19, 313-332.

  32. Case Example: Visit 2 (continued) “Stop over-doing it with her knitting projects” • “How would you prefer to manage your creative work periods?” • “Chunk it into manageable times.” • “What would that look like, as a starting place for the next 2 weeks?” • “15 minutes knitting, then 5 minute movement break • “Maximum 3 hours per day.” • “What will this give you?” • “A sense of productivity.” Frederickson & Branigan. Cognition and Emotion, 2005;19, 313-332.

  33. Help Create Positive Visuals • If patients speak in “negative” terms, then help them flip their stated problem into a visible “positive” outcome.

  34. Example Questions: Positive Visuals Help them flip their stated problem or negative visual into a visible “positive” outcome. • What would you RATHER have/feel? • What do you want MORE of? • What would having ______ look or feel like? • What would _____ bring you?

  35. Group Exercise: Positive Visuals • DEPRESSION OR CHRONIC FATIGUE “I don’t want to feel so depressed and tired any more” • CHRONIC DISEASE “I have no control over my diabetes or the number of meds I’m on” • CHRONIC PAIN “I want to feel less pain”

  36. “Is there anything you would like to do for your health in the next week or two?” Behavioral Menu SMART Behavioral Plan Elicit a 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 “Would you like to check in with me to review how you are doing with your plan?” Follow-up

  37. Case StudyVisit 2 (Dec 13, 2013) “Chunk creative work into manageable times” • “So can you repeat your plan?” • “I will knit for 15 minutes then take a 5 minute movement break, and repeat this patternfor a maximum 3 hours per day, so that I can feel more productive” • “When shall we follow up?”: 3 weeks • Also agreed to complete PDI • Time for visit #2: 20 minutes

  38. Case StudyVisit 3 (Jan 10, 2014) • “How did it go with your plan?” • 15/5 felt too short, so went to 25/5 or stopped if pain 7/10 • Also had decided to increase movement. Walked 2x in week. Tried to stretch in AM, but found her pain/mood upon waking “got in the way” • Pain/fatigue has increased overall, but feeling happier and productive • Has filled out pain diagram and PDI (55)

  39. Case Study-continuedVisit 3 (Jan 10, 2014) • “So what’s next?” • “Not get so thrown off by triggers”.

  40. Case StudyVisit 3 (Jan 10, 2014) “Not get so thrown off by triggers”. • “How would you rather handle things?” • “Be more prepared for stressors”. • “What would you like to do in the next 1-2 weeks?” • “Trips to Vancouver- bring food, protect sleep routine. In AM- have uplifting music ready to play. Day- maximum 1 appointment per day . Walk in nature 3x per week”. • How confident are you that you can do all this?” • “5/10”

  41. “Is there anything you would like to do for your health in the next week or two?” Behavioral Menu SMART Behavioral Plan Elicit a 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 “Would you like to check in with me to review how you are doing with your plan?” Follow-up

  42. Case StudyVisit 3 (Jan 10, 2014) “Be more prepared for stressors”. • How confident are you that you can do all this?” • “5/10” • “What would you need to tweak to be at least 7/10 confident?” • “Only expect to stretch in AM if pain < 5/10. Walk 2x/wk”. (revised plan re-stated) • “F/U?”: “3 weeks” • Time for visit #3: 20 minutes

  43. Case StudyVisit 4 & 5 (Jan 31 & Feb 21, 2014) • Still lots of challenges (fatigue, mood, triggers) • Experiencing wins: • Trips to Vancouver much more restful • Mood more even through the day (less crying) • Walking & knitting routines successful • Pain is the SAME…but more optimistic for future, feeling stronger, and responding to pain with + self-talk (Visits 10 minutes each)

  44. Case StudyVisit 6 (March 14, 2014) • “Never felt this not depressed in adult life!” • PDI score now 39 (from 55, in Jan 2014) • PHQ9 score down to 7 (from 18, in Nov 2013) • “Successfully finishing goals is leading to more motivation” • “When setbacks happen, I know it’s not a catastrophe” • “No overall change in pain, but trusting my body more” • “More energy now- want to walk, get stronger” • “More support in relationship through communicating needs”

  45. Case Study-continuedVisit 6 (March 14, 2014) • “What’s next?” • “Reinforce patterns- firm resolution for exercise, 30/5 time chunks, build confidence in eventual work” • Visit 10 minutes

  46. “Is there anything you would like to do for your health in the next week or two?” Behavioral Menu Elicit a Commitment Statement SMART Behavioral Plan “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” If Confidence <7, Problem-Solve Barriers “Would you like to check in with me to review how you are doing with your plan?” Follow-up

  47. Case Highlights: Using B.A.P. • Can break B.A.P. segments over several visits • Focus on building relationship & self-efficacy • Visit lengths and frequency reduce over time

  48. Optimizing B.A.P. BAP: • Learn basic structure well • Prioritize relationship over algorithm or outcomes • Protect your own time & energy Tips & Tools to deal with challenges: • Mindful Listening • Use Control Worksheet • Help Create Positive Visuals

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