Don't give up on patient self-management

A patient had achieved fairly good diabetes control but wanted to start tackling his weight, recalled Liz Castillo, a health coach at San Francisco General Hospital's Family Health Center. The 30-something patient suggested that he try boosting his water consumption.

“His action plan was to drink three bottles a day instead of one,” said Ms. Castillo, who agreed with the patient's suggestion.

Ms. Castillo works with nearly 150 diabetic patients and said that this exchange exemplifies the type of team approach that some time-pressed physicians have been adopting as they grapple with how best to help patients improve their health.

The underlying concept, frequently dubbed patient self-management, is not new. Various techniques have been developed to connect with patients, from motivational interviewing to collaborative goal-setting to tools like the “5 A's.”

But doctors can be understandably reluctant to embark on the sorts of convoluted and thorny discussions needed to encourage a patient to cut back on snacks or cigarettes, said Thomas Bodenheimer, MD, FACP, co-director of the Center for Excellence in Primary Care at the University of California, San Francisco.

Instead, doctors can opt to conduct the initial screening, assessing a patient's interest in health change, Dr. Bodenheimer said. Then they can refer patients to trained coaches, such as Ms. Castillo, to help support and spur on that initial spark, he said.

Albeit worthwhile, such efforts can be time-consuming and daunting. Ms. Castillo, who meets with patients for as long as 30 minutes each time, can sometimes persevere for a year or longer without any seeming progress, Dr. Bodenheimer said. “Then all of a sudden, something happens, and they begin to engage,” he said. “What happens is not always clear.”

A different mindset

To connect with patients, doctors may have to adjust their own mindset from the more paternalistic approach that permeated their medical training, said James Webster, MD, MACP, professor of medicine at Northwestern University's Feinberg School of Medicine.

The idea was that physicians “would just tell patients what to do, and that was that,” said Dr. Webster, a member of the expert panel that developed the American Medical Association's (AMA) Resource Guide to Patient Self-Management Support. (See sidebar, “Additional resources.”) “That was one of my disappointments after graduating,” he noted wryly. “I would give all of this wonderful advice, and people wouldn't always take it.”

Along with a resource list, the AMA guide details various intervention techniques, with appendices at the back outlining specifics, such as the 5 A's: assess, advise, agree, assist and arrange. Although the specifics may differ, the techniques share common themes, including an interactive, collaborative approach.

In short, health professionals who don't meet patients halfway risk shutting down progress, said Damara Gutnick, MD, an ACP Member and clinical assistant professor of medicine and psychiatry at the NYU Langone School of Medicine in New York City.

“If somebody tells you what to do, your natural response is to resist,” said Dr. Gutnick, who provides primary care at Bellevue Hospital and uses a technique called motivational interviewing while working with ambivalent patients with poorly controlled chronic disease and/or persistent unhealthy behaviors such as overeating and smoking.

Moreover, she added, “Just because I'm the expert doesn't mean I'm the expert on you.”

Gauging interest

To sort out which patients could benefit, watch for red flags, such as increasing weight or blood pressure, said Connie Davis, MN, ARNP, a geriatric nurse practitioner in British Columbia, Canada, who trains health professionals in motivational interviewing.

Alternatively, a clinician could ask patients verbally or in a pre-visit questionnaire to rate their own confidence in handling a specific health challenge, such as blood sugar control, she said.

Tone and language are critical in evaluating a patient's willingness to change, Dr. Gutnick said. Rather than telling patients they should quit smoking, a doctor could instead ask if they could name any benefits of cutting back. In that way, the doctor gains insight into that individual's personal motivators, Dr. Gutnick said.

She added that when patients hear themselves speak out loud their personal reasons for change, they are much more likely to move in the direction of change than when the doctor says the reasons out loud, probably because the reasons that are most important to the individual get more “airtime.” This leads to an opportunity for patient self-reflection.

“They might say, ‘My clothes won't smell and I'll have more money,’” she said. (Dr. Gutnick has made a video about motivational interviewing, “Mr. Smith's Smoking Evolution,” which is online. )

What if the patient isn't forthcoming? In that scenario, the doctor should ask permission to express her own worries, thus showing respect for the patient's autonomy, Ms. Davis said.

If an expanding waistline is the issue, the doctor might tick off a few concerns, such as potential strain on the patient's heart and joints, before asking for the patient's feedback. It's essential that any conversation about health change be framed as a partnership, Ms. Davis said. “They could say, ‘Most of this is going to be in your hands. We'd like to help. What would you like to do next?’”

This is the first question of Brief Action Planning (BAP), which is a highly structured, patient-centered, evidence-informed, self-management support tool based on the principles of motivational interviewing. It is organized around three core questions and five skills delivered with the spirit of motivational interviewing. More on this, including a video interview explaining it, can be found at the Centre for Comprehensive Motivational Interventions website.

Given time constraints, doctors could handle the initial phase of this conversation, checking on the patient's interest. When the timing seems right, the patient could be referred to a nurse, social worker or other trained staffer for a more detailed discussion and related action plan, according to patient self-management experts. Alternatively, the practice's medical assistant could get a quick reading on the patients' mindset as they settle them into the exam room before the doctor's arrival, Ms. Davis said.

“Some of them are really chitty-chatty about social stuff. They could be chitty-chatty about health stuff,” she said. During that stretch, she said, the medical assistant could ask, “Is there something you would like to do for your health in the next week or two?”

Sometimes patients simply aren't ready, whether for emotional or logistical reasons, Ms. Castillo said. In those cases, doctors might achieve better health results over the long haul if they're willing to temporarily set aside their clinical agenda, she said.

The doctor stepping into the exam room might be fixated on addressing the patient's worrisomely high hemoglobin A1c level, Ms. Castillo said. “And then the patient says, ‘My son is in a gang and he got beat up really bad last night.’ They just want to talk about that.”

She suggested that physicians try to meet patients where they are. “Once people feel listened to, they're more willing to compromise and they're more willing to listen to you the next time,” she said.

Constructing partnerships

Health coaches might be described by other names, including patient navigators, nurse care managers or care coordinators, said Emily Carrier, MD, a senior researcher at the Center for Studying Health System Change in Washington, D.C. She helped author a research brief about high-intensity primary care programs, published last October. These programs were often sponsored by large employers, unions or insurers, so they targeted individuals who were employed and privately insured, as well as their dependents, she added.

The brief, which studied the design of six high-intensity programs, found that primary care doctors were more interested in participating if they could identify which chronically ill and high-cost patients could most benefit. (In some cases patients are selected for these services based on standardized analyses of their previous utilization rather than their physicians' judgment, Dr. Carrier added.)

Physicians also stressed the importance of finding the best individual to assume the health coach role, with responsibilities extending beyond self-management to assisting with appointments and follow-up after hospital discharge, Dr. Carrier said.

Frequently, the practices that Dr. Carrier studied recruited health coaches from their own medical assistants.

“They were able to identify the right people by seeing how interested they were in this and what ideas they were bringing to the table,” she said. “They [the coaches] really needed to take ownership of their relationship with the patient. And really invest in that relationship and be willing to see patients through very challenging problems.”

Ms. Castillo agreed, saying a patient's interest in blood glucose control, for example, can become drowned out by other considerable life stresses. If money is scarce for food, rice and beans might be one of the few staples that a patient can afford. In one extreme example, a patient was essentially homeless, renting part of a garage, and thus lacked a refrigerator to store his insulin, Ms. Castillo said.

The San Francisco-based health coach works primarily with Spanish-speaking patients and first meets them during a “warm handoff,” with the doctor introducing Ms. Castillo and her role. That step is crucial to build trust, she said.

“Culturally they put their all into their physician. The physician knows everything. They don't ever want to go against the physician,” she said.

Taking action

Once a patient expresses willingness to address a health issue, such as weight loss, the next step is to develop an action plan, Ms. Davis said. A goal should not be lofty, but rather specific, short-term and measurable. For example, patients shouldn't just commit to losing 20 pounds. Rather, they should settle on an achievable step for the next week or two, such as cutting out snacking after dinner. Or they could decide to hit the treadmill for at least 30 minutes Monday, Wednesday and Friday mornings.

Patients also should state their goal and then rate, on a scale of 0 to 10, their confidence that it's achievable, Dr. Gutnick said. If a patient selects a number that falls below 7, the doctor or health coach should brainstorm ways to adjust the goal, including logistics, until the patient becomes more confident.

The patient might remember that she lacks child care on Monday mornings but realize that she could exercise in the afternoon those days. A confident patient is more likely to achieve that goal, thus building up emotional traction to move on to the next.

Motivational interviewing, Dr. Gutnick stressed, is a skill that takes a lot of practice and related coaching to do well. And follow-up is key. Set a day to check in, so there's a sense of accountability, she advised, and celebrate any positive steps. “The follow-up is as important as the planning,” Dr. Gutnick noted.

Practicing patience

As health coaches work with patients, they must coordinate with the doctor, so they don't inadvertently send mixed messages, Dr. Bodenheimer said. The doctor might be insisting that the patient eliminate sweets entirely, not realizing that an action plan has been developed to cut down consumption by half, he said.

Even talented medical assistants need protected time to be successful, Dr. Bodenheimer said. “We have a lot of coaches that we've trained that have not done much coaching, which is a shame,” he said.

One alternative might be to hire more medical assistants to free up the physician's time to book, and bill for, additional patients, he said. Doctors who can't spare the time of a medical assistant, Dr. Webster added, might look for support groups such as the Alzheimer's Association or available patient resources at a nearby hospital.

A practice that invests in health coaching can reap patient care benefits, Dr. Bodenheimer said. He was involved with a study, which has been accepted for publication, that showed a statistically significant difference in hemoglobin A1c levels between diabetic patients who worked with health coaches—peer coaches who also had diabetes—and those who received more traditional care.

There also might be financial payoff in terms of greater patient loyalty, thus reducing the costs of bringing new patients into the practice, Ms. Davis said. “This is a high satisfier,” she said. “These are people who are going to say really great things about you to their friends.”

Don't give up, Dr. Webster said. Doctors who keep communicating with their patients in a compassionate, non-judgmental way might be surprised to learn which exchange finally resonates, he said. He recalled one patient, a long-time smoker who had to be hospitalized for pneumonia. As Dr. Webster helped the patient into a wheelchair headed for the emergency department, he noted sadly that the patient's recovery would likely be extended by his tobacco habit.

The patient, now a non-smoker, relayed that passing comment months later, Dr. Webster said. “He said, ‘I just realized then that I had to stop smoking.’”

Small steps forward, even if it's just a bit more water consumption or fewer snacks, keep Ms. Castillo going. “It's very satisfying to see patients succeed, even in the most minimal way,” she said.