Behavioral Tools To Better Glucose Control: We Seem To Be Missing - - PDF document

Behavioral Tools To Better Glucose Control: “We Seem To Be Missing Something”

Lawrence Fisher, Ph.D., ABPP Professor Emeritus Department of Family & Community Medicine UCSF

Disclosures

No conflicts of interest!

Patient Management Of Diabetes Ain’t Easy!!! (an understatement) Relationship Between Adherence And HbA1C (with adjustments)

50 Adherence (%) 40 30 20 10 80 70 60 100 90 8.4 8.0 7.6 7.2 6.8 6.0 5.6 4.0 6.4 5.2 4.8 4.4 Adjusted HbA1c

*Metformin plus a sulfonylurea was used as the reference group for the index ODM regimen. A1C indicates glycosylated hemoglobin; ODM, oral diabetes medication. Rozenfeld et al. Am. J. Manag. Care 2008; 14:71–5

Percentage of Patients Achieving ADA Treatment Targets

10 20 30 40 50 60 70 80 90 100

A1c BP Chol

All three % reaching ADA target Casagrande et al. 2013

Percentage of Patients Achieving ADA Treatment Targets

10 20 30 40 50 60 70 80 90 100

A1c BP Chol

All three % reaching ADA target Casagrande et al. 2013 18.8%

Our Logic Model

Long &

Healthy Life

Our Logic Model

Long &

Healthy Life Disease Progress/ Compli

Our Logic Model

Long &

Healthy Life Diabetes Numbers (ABC)

Our Logic Model

Long &

Healthy Life Diabetes Numbers (ABC) Actions & Behavior

Long &

Healthy Life Diabetes Numbers (ABC) Actions & Behavior

Education, Dosing, Prompts, Packaging, Co-pays

Our Logic Model

Long &

Healthy Life Diabetes Numbers (ABC) Actions & Behavior

Education, Dosing, Prompts, Packaging, Co-pays

MI, Action Plans

Our Logic Model

Long &

Healthy Life Diabetes Numbers (ABC) Actions & Behavior

Education, Dosing, Prompts, Packaging, Co-pays

MI, Action Plans

Our Logic Model

Results Of MI Trials

Results Of MI Trials

(It Get’s Worse)

Long &

Healthy Life Diabetes Numbers (ABC) Actions & Behavior

Education, Dosing, Prompts, Packaging, Co-pays

MI, Action Plans

Our Logic Model

Efficacy Of Action Planning

% of subjects 79% 56% 53% DeWalt et al, 2009

Long &

Healthy Life Diabetes Numbers (ABC) Actions & Behavior

Education, Dosing, Prompts, Packaging, Co-pays

MI, Action Plans

What Are We Missing?

A Qualitative Study

§ 20 adults with T2DM in primary care. § Varied by age, gender, ethnicity. § A1C > 8.0 § 30-45 minute semi-structured interview. What is it like for you to have DM?

What is it about DM that drives you crazy? What do you do to take care of your DM? What are the very good reasons you have for not doing what you feel you should do to take care of your DM? Has this changed over time since you were first diagnosed?

Recognizing The Tug-Of-War

ON THE ONE HAND: Want to be healthy.

Want to participate. Want to lose weight. Want to exercise. Want lower HbA1c. Don’t want compls.

Recognizing The Tug-Of-War

ON THE OTHER HAND: No real benefit. Not sure they really work. Reminds me I’m sick. Meds are unnatural. I can do it myself (control). Failure. Ashamed (self-blame). Distrustful. Hopeless. Afraid. Can’t manage it.

Karter, et al., Diabetes Care, 2010; Fisher, et al., Pt. Educ. Counseling, 2012, Rosebaum, NEJM, 2015.

“Common Feeling Scenarios” (Based On Expectations & Beliefs)

• Hopelessness
• Overwhelmed
• Demoralized
• Frightened
• Angry
• Ashamed
• Embarrassed
• Distrustful
• Self-critical
• Why me?
• Avoidant
• Self-blaming
• Guilty

The Eventual Outcome: “Diabetes MEH!”

The belief that diabetes care efforts are really just not worth the effort (diabetes apathy).

Something Is Missing In The Logic Model

We have been focusing on behavior, actions, prompts, co-pays, dosing, and education.

ON THE OTHER HAND: No real benefit. Not sure they really work. Reminds me I’m sick. Meds are unnatural. I can do it myself (control). Failure. Ashamed (self-blame). Distrustful. Hopeless. Afraid. Can’t manage it. PATIENTS TELL US ABOUT THEIR FEELINGS, BELIEFS, EXPECTATIONS Long &

Healthy Life Diabetes Numbers (ABC) Actions & Behavior

Education, Dosing, Prompts, Packaging, Co-pays

MI, Action Plans Feelings, Beliefs, Expectations

Feelings, Beliefs & Expectations DRIVE Behavior

The Missing Link

Long &

Healthy Life Diabetes Numbers (ABC) Actions & Behavior

Education, Dosing, Prompts, Packaging, Co-pays

MI, Action Plans Feelings, Beliefs, Expectations

Feelings, Beliefs & Expectations DRIVE Behavior

The Missing Link

§ A focus on behavior & education is necessary but not sufficient. § How to integrate patient feelings/ beliefs/expectations into self-management support interventions?

Where Do We Go From Here?

Have A Different Conversation

Our goal: To maximize the chances that patients will make clear, informed and examined decisions about the actions they will take to manage their disease. Derived from a realization that: § We do not set the agenda or make the decisions - the 93% rule. § We do not solve the problem or “get” the patient to do anything. § We are not “commanders” – we can only be “facilitators”: helping patients with their decision-making about what they want to do and what they can do.

The “Commander” Approach

The “Facilitator” Approach 8 Tips For Having A Different Conversation (addressing feelings/beliefs/expectations)

• 1. The importance of taking time (foreplay):

§ Take a breath, get ready to actively listen. § Slow the pace and rhythm of speech. § Observe the seating (desk, computer). § Be prepared to listen and allow quiet. § Not a focus on numbers, tests, treatments.

8 Tips For Having A Different Conversation

• 2. Bring feelings, worries and concerns into the

conversation because they drive the very behavior that you want to help patients change. § Ask open-ended questions. § Actively express empathy and understanding – we are in this together. § Summarize and reflect genuinely & frequently. § Overtly label feelings, concerns, worries. § Normalize feelings, beliefs, expectations. § Do not solve problems – just listen & understand.

8 Tips For Having A Different Conversation

• 3. Summarize & label both sides of problem so

that the patient can make a decision: “Sounds like on the one hand you would really like to lose some weight because you know that it would help you manage your diabetes better.” “But on the other hand the thought of dieting feels overwhelming, you have tried it before and felt like you failed and now you feel very discouraged and not hopeful about starting again.”

8 Tips For Having A Different Conversation

• 4. Decide, Pick & Plan:

§ Given all of this – “What do you want to do?” § Is this really worth the effort? § Is the timing is right (it may not be). § “Are you sure you really want to try this?” § Help them pick something small and do-able to start (e.g., walk 15 minutes twice a week). § Pick something very specific (e.g., walk from house to park and back). § Help decide when, how often, where.

8 Tips For Having A Different Conversation

• 5. Anticipate and address potential obstacles:

§ What might prevent you from walking on Tuesdays and Thursdays. § What can you do if that happens?

• 6. Provide a simple daily or weekly tracking form.

§ Provides ongoing feedback to patients. § Allows review with clinician to problem solve.

8 Tips For Having A Different Conversation

• 7. Record everything on a structured action plan

form, including the feelings/beliefs/expectations regarding completing the behavior and the reasons not to. § Copy for patient to take home. § Copy for clinician in clinical note.

My Action Plan Specific

Be specific about what the 1 or 2 things you will do and how often you will do them. Strategy 1 What you will do? How often will you do it? Strategy 2 What you will do? How often will you do it?

Measurable

How will you track your progress?

Attainable

How confident are you that you can do it? On a scale of 1-10: 0

Realistic

What will make it hard for you to reach your goal? Barriers: How you will overcome them:

Time

!

When will you start? Follow up date:

For additional resources and information visit connectiontohealth.com !

What health issue will you work on? Please add anything else related to achieving your goal here:

8 Tips For Having A Different Conversation

• 8. Schedule a follow-up:

§ Within two weeks (do not let failure persist or success go unacknowledged). § Office visit, by phone, email, etc.. § Review plan (monitoring form), feelings, beliefs, expectations, obstacles. § Expect that the plan will need to be tweaked (warn the patient beforehand!).

8 Tips For Having A Different Conversation (Including The Missing Link)

• 1. The importance of taking time.
• 2. Bring feelings, beliefs, & concerns into the

conversation.

• 3. Summarize & label both sides of the problem.
• 4. Help patient decide, pick and plan – their decision

(be very specific).

• 5. Identify & address potential obstacles.
• 6. Provide a monitoring/tracking form.
• 7. Write it all down on a structured action plan.
• 8. Schedule a follow-up contact within 2 weeks.

Take-Home Messages

§ There is missing link in our strategy to enhance behavioral management in diabetes. § Education and a focus on behavioral activities are necessary but not sufficient. § Beliefs, feelings & expectations drive behavior change. § To address them, we need to alter our strategy and our clinical stance – to bring the affective side of diabetes into clinical care. § The 8 tips provide a broad outline for how to make it happen.

THANKS FOR LISTENING

Thoughts, questions, comments??