Assume a Coaching Style: Enhancing Patient Independence

1. C-O-A-C-H

2. C-O-A-C-H Connect tasks with vision and priorities Observe normal routine Assume a coaching style Check backwards plan Highlight progress with data (“I can”)

3. KEY POINT Patients need us to assume different coaching styles depending on the situation, and the patient’s level of independence

4. ASSUME A COACHING STYLE

5. THE “I DO” PATIENT • After multiple open ended questions, patient is unable to name a first step to the task • Patient is in a fragile state with limited or no support system • The task involves a highly bureaucratic system Model the skill while the patient watches

6. “I DO” EXAMPLE You are at a patient’s home with the intention of making a cardiology appointment. When you sit down by the phone, the patient states she lost the cardiologist’s phone number, and she doesn’t have the internet at home. Then, the following dialogue takes place: CHW: “What would you normally do in this kind of a situation?” Patient: “ I just wouldn’t make the appointment, or I’d have to wait until I went to another doctor’s office and ask them for the number.” CHW: “In the past, it’s worked for you to use other people to get the information you need. Can you think of anyone we could call right now that would have the cardiologist’s phone number?” Patient: “No. All my neighbors go to Cooper for cardiology, and I go to Lourdes.”

7. Please take out the pink “I DO” (purple sticker in corner)scenario strips. Please list examples on the right and non-examples on the left

8. You are at a patient’s home with the intention of making a cardiology appointment. When you sit down by the phone, the patient states she lost the cardiologist’s phone number, and she doesn’t have the internet at home. Then, the following dialogue takes place: HC: “What would you normally do in this kind of a situation?” Patient: “ I just wouldn’t make the appointment, or I’d have to wait until I went to another doctor’s office and ask them for the number.” HC: “In the past, it’s worked for you to use other people to get the information you need. Can you think of anyone we could call right now that would have the cardiologist’s phone number?” Patient: “No. All my neighbors go to Cooper for cardiology, and I go to Lourdes.”

9. RESPONDING TO “I DO” SITUATIONS Example • Losing things is a fact of life. Let’s look at this stack of business cards you have and see if there’s anyone we can reach out to that would have your cardiologist’s phone number.” • “On all of your medication bottles, your pharmacist’s number is listed. I bet he can help. Let’s call him.” You make the call on speaker phone while the patient listens. • Stop by, or call the pharmacist afterward and state that you are coaching X patient to self-advocacy. Ask if he/she would mind being a permanent resource to call for help if the patient gets stuck managing an aspect of her health. Non-Example • Take out your IPAD. Google the cardiologist’s phone number. Write the number down and hand it to the patient. • Once you get the cardiologist’s number say, “Great. Now that we have the number, you can take it from here. I’ll follow up with you next week to see how it went.” • Without asking ANY open ended questions, pick up the phone and call the patient’s PCP while the patient watches. • Make a judgment statement like, “You really should be more careful with important information like that.” • First, create an organization system so that the patient never loses information again.

10. “I DO” EXAMPLE Ms. Smith has liver failure, and has been readmitted 3 times since she first joined the patient panel. She lives in an apartment with her daughter. You are not sure the cause, but the relationship is very strained, and the daughter is resistant to helping her mother. You are in the hospital with her and she hands you 5 follow-up appointments she needs made. She asks you to make them for her. How do you proceed? RECALL ‘I DO’ CRITERIA • After multiple open ended questions, patient is unable to name a first step to the task • Patient is in a fragile state with limited or no support system • Task involves a highly bureaucratic system

11. Ms. Smith has liver failure, and has been readmitted 3 times since she first joined the patient panel. She lives in an apartment with her daughter. You are not sure the cause, but the relationship is very strained, and the daughter is resistant to helping her mother. You are in the hospital with her and she hands you 5 follow-up appointments she needs made. She asks you to make them for her. How do you proceed? Take out the pink “I DO” scenario strips. Please list examples on the right and non-examples on the left.

12. RESPONDING TO “I DO” SITUATIONS Example • “Ok. I’ll call while I’m here with you. I am always happy to help with whatever you need, but I want to make sure you have a long term support in place after I leave to help you. Do you feel comfortable if I brainstorm with your daughter? ” • Update the patient’s care plan to note that outside supports will be necessary to get to “you do” before the intervention is finished. • If the patient agrees, propose a meeting with patient's daughter to discuss care options Non-Example • Wait until you’re back in the office to make all of the appointments. Write them all down, and give them to the patient the next time you see her. • Make a judgment statement like, “You really need to learn to do this for yourself. I am not always going to be here.” • Close your body language • Check your watch

13. THE “WE DO” PATIENT • Patient starts the task, but gets stuck at an intermediary step, and can’t finish • Patient has a system in place, but it’s ultimately ineffective • Do the skill together, while filling in the gaps when the patient gets stuck

14. “WE DO” EXAMPLE You are at Jose’s home on a Monday afternoon. Almost immediately when you walk in the door, he tells you he is sure he has a podiatry appointment this week, but can’t remember the date or time. You watch him call the podiatrist’s office, but as soon as he is placed on hold, he becomes very agitated and hangs up the phone. He says, “I can’t stand it when they put me on hold like that. I’m not going to that appointment.” Take out the orange “WE DO” scenario strips. Please list examples on the right and non-examples on the left.

15. RESPONDING TO “WE DO” SITUATIONS Don’t expect Jose will make it through the entire skill in one home visit! More often then not, “we do” takes MULTIPLE visits of active prompting before the patient achieves ‘you do’ Examples • “In the hospital, you said that you wanted to be the kind of dad that runs around with your kids, and isn’t sick all the time. I know healing your foot wound is important to you so you can be the kind of dad you want. Why don’t you call back on speaker phone and I’ll sit here with you while you’re on hold?” • During the hold, when the patient becomes agitated, you’re going to actively prompt him with techniques: • “Healing your foot wound is important to you. Take deep breaths with me. Don’t hang up.” • Turn the phone on speaker. Ask the patient if he would like to watch some TV while you wait in order to make the experience less frustrating. • When finished successfully, ask: “What worked for you this time? What could you use in the future to stay on the phone during holds?” • Schedule multiple practice sessions of waiting on hold before graduation to make sure the patient achieves ‘you do’ for this skill Non-Examples • Call back on speakerphone, and make the appointment while the patient listens. • Instruct the patient to call the podiatrist back without reorienting to his vision/priorities

16. THE “YOU DO” PATIENT • Patient consistently completes the task, but lacks confidence and requires reinforcement • Allow the patient to lead on problem solving & completing the skill • Support and acknowledge strengths

17. “YOU DO” EXAMPLE Bernard calls you after he takes his insulin out of the refrigerator. He tells you the name of the insulin, and describes that it’s usually clear, but now he sees “little floaty things in it.” LPN: “You are really paying attention to your medication! Who would you call next if I didn’t pick up the phone?” Bernard: “Well, I guess I could walk to the pharmacy. It’s only a block away. I could show them the bottle.”

18. Bernard calls you after he takes his insulin out of the refrigerator. He tells you the name of the insulin, and describes that it’s usually clear, but now he sees “little floaty things in it.” LPN: “You are really paying attention to your medication! Who would you call next if I didn’t pick up the phone?” Bernard: “Well, I guess I could walk to the pharmacy. It’s only a block away. I could show them the bottle.” Take out the yellow “YOU DO” scenario strips. Please list examples on the right and non-examples on the left.

19. RESPONDING TO “YOU DO” SITUATIONS Example • “That’s a great idea. Please give me a call back after you visit the pharmacy to let me know how it goes.” Non-Example • “Hold on, let me ask one of our nurses. There are three sitting right here.” • “Great idea. Good luck, Bernard. You’re doing great. See you next week.”

20. EXAMPLES Get your paddles ready!

21. 1) One of your patients is a diabetic who is also an amputee. She needs to arrange transportation to get to one of her appointments. When you ask her how she’s arranged appointments in the past, she doesn’t remember. After re-framing the question a few times, the patient is still unable to provide an answer. How do you proceed? A)“I can help you. I'll call logisticare and put the phone on speaker so you can become familiar with the process and the information that's needed to make the reservation.” B) “It sounds like arranging transportation is something you haven't done in awhile and you might need some help. Here is the number for logisticare. You can call and put the phone on speaker. If you get stuck I will be here to answer any questions you may have.” C)” It sounds like you've probably arranged transportation in the past. Here is the number for logisticare. I'll call you tomorrow to make sure you've made the reservation?” I DO

22. 2) One of your patients who suffers from severe anxiety wants to apply for assistance to help pay her utilities. She needs to apply in-person at a office and bring the necessary documentation. When you review the process with her at a home visit, she says that she understands and has all the necessary paperwork, but she is worried about driving on busy roads to a new place. The patient does have access to a vehicle. She asks you for help. How do you proceed? A)“It sounds like you have all of your paperwork together, but you are worried about driving to a new place. Let's talk about the route you'll take to get there and I can call you tomorrow to see how it goes. “ B) “It sounds like you have all of your documentation together, but you are worried about driving to a new place. I can drive to the office and you can follow me so that you won't have to worry about directions.” C)“It sounds driving to a new place will be a challenge for you. I'll call a cab for you and meet you at the office.” WE DO

23. 3) You are working with a patient who is unable to read and therefore has a lot of trouble managing her pillbox. She is HIV positive so it is very important for her to take several medications daily. When you visit her at home, the patient admits that she hasn’t been taking her medication. When you ask her how she’s remembered to take medicine in the past, she is unable to provide an answer. How do you proceed? A)“It sounds like you've taken your medication on time in the past and are comfortable with contacting your pharmacist. Do you have any questions before you make the call? I can follow up with you tomorrow to see how the phone call goes.? “ B)”It sounds like you are familiar with taking your medication. Why don't you contact your pharmacist while I'm here and put the phone on speaker. I can help you if you have any questions.” C) “It sounds like remembering to take your medication is challenge. I can help you. I'll call your pharmacist and put the phone on speaker to see if we can come up with a plan to help you remember.” I DO

24. 4) One of your patients needs to pay their electric bill. You meet them at the PSE&G office in Camden in the morning to help them through the process, but it is extremely busy when you get there. After talking with your patient, she says that she doesn’t feel like waiting and will come back later in the afternoon after the rush is over. Later that day, the patient calls you and says that she is getting ready to leave to pay her bill. You review what she needs and she has everything in order, but she asks if you can meet her at the office. How do you proceed? A) It sounds like going to the PSE&G office has been a challenge/frustrating/etc. I can help you.” B) “It sounds like you’re familiar with paying your bill at the PSE&G office, but you might need some help. I can help you.” C)“It seems like you have all your documentation in order. I think you will be fine going yourself. I’ll give you a call later to see how it goes.” YOU DO

25. 5) You are working with a patient who gets several medications delivered to her home monthly from Miguel’s pharmacy. At a home visit (a few days before her medication is scheduled to arrive), she states that she’ll be unable to afford her medication this month because she needed to buy school supplies for her son. She states that she wants to the ask the pharmacy if she can pay a portion of her bill and pay the rest back later, but she’s worried that Miguel will say no and she’ll be viewed as a poor customer. How do you proceed? A) “It sounds like paying for several medication has been a challenge/frustrating/etc. I can help you.” B)“It sounds like you’re familiar with Miguel’s pharmacy but you might need some help speaking to the staff. I can accompany you to the pharmacy and help fill in any gaps that may come from the conversation.” C)“It sounds like you’ve spoken to the staff at Miguel’s pharmacy before. Do you have any questions about the process from last time? WE DO

26. 6) One of your patients is enrolled in the MANNA food delivery program and gets food delivered every Tuesday morning. Your patient calls you on Tuesday afternoon saying that he missed his food delivery because he was at a Dr.’s appointment and is unsure what to do. When you ask the patient if he’s ever contacted MANNA in the past, he says that he contacted them recently about his change of address. How do you proceed? YOU DO A)“It sounds like you're familiar with contacting MANNA, but you might need some help. I can help you. If you want to call MANNA while I'm here and put the phone on speaker, I can help if you need me.” B) ”You’ve contacted MANNA before. I think you will do fine calling yourself. Give me a call when you’re finished” C)“It sounds like contacting MANNA will be challenging for you. I can call for you while I'm here..”

27. 7) You are at a home visit with a patient and they explain to you that they have run out of pain medication. When you last were at a visit with this patient and their PCP two weeks ago, they were prescribed a month’s supply. This patient has a history of opiate addiction and IV drug use. However, they have been sober for a few years. When you ask the patient about his pain levels, he describes that his pain has been higher than normal which is why he’s been taking more medication. You have noticed at previous appointments that the patient will ask the doctor some questions concerning things other than his previous addiction. He has said to you, however, that he is worried that the doctor will think he’s addicted again. He asks you for help. How do you proceed? WE DO

28. 8) One of your patients is primarily Spanish-speaking and usually has her son translate for her at Dr.’s appointments. She has an appointment coming up in a couple of weeks, but she’s unsure of what to do since her son will be away on vacation. When asked what she’s done in the past if her son has been unavailable, she says that her son has always gone with her. What should you do? I DO

29. 9) You have been working with a patient for a couple of months. Because of your coaching, he is now able to navigate the prescription refill process with ease every month. At the next home visit, the patient tells you that his dog chewed all of his medication bottles and his refills aren’t due for another two weeks. How do you proceed? WE DO

30. 10) A patient you are working with has to fill out a new patient packet for a specialty appointment since she’s never been seen there before. At a home visit, the patient says she hasn’t filled out the packet because it’s too long and overwhelming. When you ask her how she’s filled out forms like this is the past, she said that her daughter normally fills in the places she gets stuck. She asks for your help. What do you do? WE DO

31. 11) You have been working with a patient who suffers for schizophrenia for several months. Due to his condition, you’ve found that he often mistrusts the advice of others. You have connected them with a local pharmacy that packs and delivers pillboxes on a weekly basis. During a home visit, you notice that the patient has taken a certain medication out of the box and put them into a single slot. When you ask the patient why, he responds by saying that those pills make him “too tired.” When you discuss the possibility of discussing this side effect at his next follow-up appointment, he implies that he doesn’t trust the doctor and that he thinks he’s being overmedicated anyway. How do you proceed? I DO

32. 12) You are working with a patient who is able to schedule transportation for her medical appointments. On the day of her appointment, the patient calls you saying that her ride is late, and she is unsure of what to do. How do you proceed? YOU DO

33. 13) You are at a patient’s home discussing upcoming specialty appointments. The patient doesn’t want to forget about scheduling the appointment, so he calls to make the appointments while you are there. While he’s on the phone, you can tell that he’s frustrated with being on hold and also displays annoyance with the receptionist who is attempting to schedule the appointment and ends up hanging up. The patient asks you if you can make the appointments for him. How do you proceed? WE DO

34. 14) You are working with a patient who has been prescribed an anticoagulant and her PCP has ordered regular blood draws to test the patient’s “blood thickness.” You know the patient hasn’t gotten their blood drawn in a month, thus posing a health risk. This patient has verbalized that she hates “getting stuck” every week and she don’t see the point of the test. When you discuss the situation further, the patient admits that the doctor never explained the point of the test to her. When you ask the patient if she would be comfortable asking the doctor about the purpose of the test, she says she is afraid that the Dr. will be upset with her. In the past, you have noticed that the patient completely shuts down at PCP visits, and doesn’t ask her doctor any questions during the visit. How do you proceed? I DO

35. 15) One of your patients needs to get blood work drawn before one of her specialty appointments. A week before her urology appointment, you ask the patient if he’s gone to the lab and he says no. When you discuss why he didn’t get his bloodwork done, he says that last time he went, he got lost at the Cooper complex and the blood work didn’t end up showing anything anyway. When you reframe the question, he says that he reiterates that getting lost at Cooper was really frustrating. How do you proceed? WE DO

36. 16) A patient who suffers from pancreatitis has health insurance, but it does not cover prescriptions. Therefore, she cannot afford an expensive medication to treat her pancreatitis. When asked if she’s had a conversation with her doctor about prescription assistance or if cheaper options are available, she says that she’s doesn’t feel like her doctor listens to her and she doesn’t want to bother him anyway since he always seems so busy. When you re-frame the question, she says that she “doesn’t want any favors.” How do you proceed? I DO

37. 17) You are working with a diabetic patient who is also socially isolated. When on a home visit, you discuss diabetes self management classes as an opportunity for her to learn more about her condition and interact with others. She says she likes the idea, but she’s nervous that she’ll be judged based on her bad habits. How do you proceed? WE DO

38. 18) You are visiting a patient at home for the first time and you learn that she has a lot of upcoming appointments. When you ask how the patient keeps tracks of appointments, she remarks that she keeps them all in her head and admits that this isn’t a good system. She asks for ideas as to how she can better keep track of her appointments. How do you proceed? WE DO

39. EXCEPTIONS: WHEN NOT TO COACH You and a fellow staff member coach arrive at a Pedro’s home. He says he is having chest pain, and appears very distressed. He has a phone in his hand, and tells you he is calling 9-1-1. You know that chest pain has resulted in many ER visits for Pedro in the past. Often, when goes to the emergency room, they do an entire work up, only to find that he is experiencing acid reflux. Pedro is in the “experimental” group for the Coalition’s randomized controlled trial, and you know readmissions and ER visits detract from the results. How should you proceed?

40. “You are the expert of your body. I will wait with you until the ambulance gets here.” Immediately call the RN manager, and inform them of the situation Update the patient’s care plan to note that we need to work with him on recognizing emergency symptoms vs. regular symptoms of his chronic disease Non-Example “You told me you wanted to stay out of the hospital. Do you really need to go to the ER?” “Before you call 9-1-1, let me call the nurse and see if she can talk to you.” EXCEPTIONS: WHEN NOT TO COACH Example

41. EXAMPLES Use the folders to separate the examples into two piles (COACH or EXCEPTIONS)