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Brief Action Planning

Brief Action Planning. Rahul Gupta MD, CCFP, ICF Certified Coach. Adapted from the work of Margie Wiebe PCCN, RN & Connie Davis, MN, ARNP. Learning Objectives. Define Brief Action Planning (B.A.P.) and describe the process

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Brief Action Planning

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  1. Brief Action Planning Rahul Gupta MD, CCFP, ICF Certified Coach Adapted from the work of Margie Wiebe PCCN, RN & Connie Davis, MN, ARNP

  2. Learning Objectives • Define Brief Action Planning (B.A.P.) and describe the process • Explore a case study illustrating how B.A.P. supports patient self-management • Practice B.A.P. to develop comfort and skill

  3. Disclosures • Coaching consultant for the Physician Health Program of BC • Designed and facilitate modules for patient self-management for Practice Support Program of BC

  4. “ 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.) (c) Gupta 2013

  5. 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

  6. What is Self-Management Support? • It is not the same as patient education • It is two-way communication that encourages interaction between the patient and health care provider • It helps the patient learn how to adopt healthy behaviours and problem-solve. The goal of self-management support is to increase the patient’s self-confidence in their ability to change their own behaviours (=Self efficacy)

  7. Think about a time when you accomplished something that challenged you… Photo by M.Wiebe

  8. When you accomplished it, how did you feel?

  9. Did that success lead to anything else? If so, what? Mt Outram, BC, photo by C Davis

  10. You Have Just Defined Self-Efficacy

  11. 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.

  12. 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

  13. What’s Going on Here

  14. The Process of B.A.P. • 3 core questions (in blue) • 5 core skills • 3 skills used regularly (in yellow) • 2 skills used as needed (in green)

  15. “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

  16. Three Questions of B.A.P. “Is there anything you would like to do for your health in the next week or two?” “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” “Would you like to check in with me to review how you are doing with your plan?” Strecher, VJ. The role of self-efficacy in achieving health behaviour change. Health Educ Quart 1986;13(1)73-91

  17. Five Skills of B.A.P. Behavioral Menu SMART Behavioral Plan Elicit a Commitment Statement Problem-Solving Follow-up

  18. “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

  19. Skill #1 Skill #1 Behavioral Menu • “Is it okay if I share some ideas from other people who are working to improve their health? “ • If yes, share two or three ideas briefly all at once. • “Maybe one of these would be of interest to you or maybe you have thought of something else while we have been talking?” Learning to say NO Exercise Pacing Daily Activities Adapted from Stott et al, Family Practice 1995; Rollnick et al, 1999, 2010

  20. Example Case

  21. Example Case 62 year old female cashier with long history of severe migraines, still debilitating 1x weekly (in bed 2 days). On long-acting opioid, sumatriptan and codeine for BTP. • Continues to miss many afternoons at work due to migraines • Low self-esteem, timid++, anxious, perfectionist • Frustrated, feels “at the mercy” of migraines, lots of incompletions • Is there anything you would like to do for your health in the next week or two?

  22. Example Case- Behavioural Menu • Is it ok to share some ideas? • You might consider working on becoming more assertive, or getting better at completing things. • Does one of these ideas interest you, or maybe you have thought of something else? • “I want to make my mornings less stressful”

  23. “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

  24. Skill #2 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. Pt Educ Couns 2009;76(2):174-80

  25. Stating Action Plans in the Positive • We are trained to focus on what’s wrong with ourselves • Preoccupation with “what’s wrong” means less focus on what allows us to flourish • The brain cannot visualize “negatives” • The brain is continually responding to pictures • Research suggests shifting focus to positive visuals enhances cognitive abilities and inspires action • Example: “I want to stop being in so much pain”. • Physician: What would you prefer to experience? • “I want to feel more comfort in my body”. • “I want to feel energetic”. Frederickson & Branigan. Cognition and Emotion, 2005;19, 313-332.

  26. Skill #2 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. Pt Educ Couns 2009;76(2):174-80

  27. Example Case: SMART goal-setting “I want to make my mornings less stressful”. • What would you prefer? • To feel more at ease in the mornings. • How will you start? • Don’t know.

  28. Example Case: SMART goal-setting “I want to feel more at ease in the mornings”. • Can I share some ideas that have worked for others? • You might pace yourself differently, or reduce your expectations. Does that trigger any thoughts? • I will not answer my phone til noon, I will say NO to unreasonable requests for my time, I will break tasks into 30 minute chunks. • What’s enough for the first 2 weeks? • 5 mornings “of ease” per week.

  29. Skill #2 SMART Behavioral Plan Is her plan “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. Pt Educ Couns 2009;76(2):174-80

  30. “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

  31. Skill #3 Elicit a Commitment Statement • After the plan has been formulated, the clinician elicits a final “commitment statement.” The strength of the commitment statement predicts success on action plan. Aharonovich, E. Cognition, commitment language, and behavioral change…Psychology of Addictive Behaviors, 2008;22:556-562Amhrein PC. Client commitment language during motivational interviewing predicts drug use outcomes. Journal of Consulting and Clinical Psychology, 2003;71:862-878

  32. Example Case: Eliciting a Commitment Statement • Just to make sure we both understand the details of your plan, would you mind putting it together and saying it out loud? • “Over the next 2 weeks, I will make my mornings feel more at ease. I will not answer the phone til noon, I will say NO to unreasonable requests, and I will break tasks into 30 minute segments. I will do this 5x per week.”

  33. “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

  34. Skill #4 Problem Solving • Problem solving is used for confidence levels less than 7. • Note: If the patient indicates his/her level is <7, the likelihood of a successful behavioural change is low. Rollnick, Miller & Butler. Motivational Interviewing in Health Care, 2008. The Guildford Press p60-61

  35. Skill #4 Problem Solving “A ___ (the number they chose) is higher than a zero. That’s good.” “Is there something you could do to raise your confidence?” Yes No Behavioral Menu Restate plan and repeat confidence measure

  36. Example Case: Problem Solving“I want to feel more at ease in the mornings”. • Considering a scale of 1-10, how sure are you about completing your plan? • “4/10.” • OK, 4 is better than 3! When confidence is greater than 7, people are more likely to succeed. Do you have any ideas about how you might raise your confidence to a 7 or greater? • “If I expect myself to do it even 2x per week, that feels more possible.” • How sure are you now? • “8/10.”

  37. “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

  38. Skill #5 Follow-up • Follow-up builds confidence. • Follow-up builds a trusting relationship. • Follow-up early and often with action plans. • Decrease frequency of follow-up as behavior is more secure. Artinian NT. Interventions to promote physical activity and dietary lifestyle changes for CV risk factor reduction, a scientific statement from the American Heart Association. Circulation 2010; 122: 406-441

  39. Skill #5 Follow-up “How did it go with your plan?” Success Partial success Did not try or no success Recognize success Recognize partial success Reassure that this is common occurrence “What would you like to do next?”

  40. Case Example: Follow-Up 2 weeks later • How did it go with your plan? • (with different physiology, more upbeat) “Did say NO x2, limited tasks to 30 minutes” • “In new morning ease, completed 3 different tasks for first time in a decade!”(felt sense of accomplishment) • “Had difficult few days where did not take meds on time, and migraine escalated++, still missed 2 days of work”. • What would you like to do next for your health in the next few weeks? • “Create a new response to my migraines.”

  41. Case Example: F/U 2 weeks later (cont’d) • “Create a new response to my migraines”. • What specifically would that look like? • “If migraine >4/10, take meds right away, sit quietly for 30 minutes, repeat if needed, adjust morning plan to 15 minute tasks”. • How confident are you with this plan? • “8/10 confident.” • When would you like to follow up? • “I’d like to follow up in one month.”

  42. Case Example: Follow-Up 1 month later • How did it go with your plan? • “Stayed on top of meds, gave myself permission to reduce expectations on bad days”. • “Doing things in smaller chunks, continuing to protect ease in mornings, always managed to get to work”. • 3 months later: only missed 2 days at work total, transformed relationship with son, having better family events, medication use more appropriate.

  43. 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.

  44. The client does the most talking in Brief Action Planning

  45. EXERCISE –Practicing B.A.P. • Use “Worksheet” as your guide • Divide into groups of 2 (patient & provider) • Spend 5 minutes in each role, then switch • PATIENT: Choose something real you want to do in the next week or two • PROVIDER: Use 5 minutes to practice approach

  46. EXERCISE –Practicing B.A.P. De-Brief

  47. Tips For Using These Tools • Practiceand get feedback. • Set SMART goals for yourself. • Choose easy patients to start with. • Work over multiple appointments. • Focus on the spirit of the interview.

  48. SUMMARY:Building Self-Efficacy through B.A.P. • Positive visuals broaden cognitive abilities and resourcefulness • Successful completion of goals builds self-efficacy • Communicating belief in the patient builds self-efficacy Higher self-efficacy is associated with making more ambitious goals and better outcomes. Frederickson, B. The Role of Positive Emotions in Positive Psychology. Am. Psychol. 2001 March; 56(3): 218-226 Bodenheimer. Goal-Setting for Behavior Change in Primary Care. PtEducCouns 2009;76(2):174-80 Bandura, A. (2000). Cultivate self-efficacy for personal and organizational effectiveness. In E. A. Locke (Ed.), Handbook of principles of organization behavior. (pp. 120-136). Oxford, UK: Blackwell.

  49. Questions?

  50. Resources • Center for Comprehensive Motivational Interventions www.centreCMI.ca • Patient Self-Management Module (VCH) of PSP

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