Doing What Works - Effective Brief Strategies for Care Managers - - PowerPoint PPT Presentation

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Doing What Works - Effective Brief Strategies for Care Managers

Suzanne Daub, LCSW The National Council for Behavioral Health suzanned@thenationalcouncil.org

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Webinar Goals

> Improve our effectiveness when providing care management services. > Expand our repertoire of brief strategies by considering evidence based

methods.

> Integrate into treatment planning > Apply brief strategies to challenging case examples.

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Does Care Management Ever Feel Like This?

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Effective and Brief Strategies

 The 5 As  Motivational Interviewing  Transtheoretical Model: Stages of Change  Behavior Change Strategies

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What are the 5 A’s?

> Sequential steps designed to facilitate behavior change and self-

management of symptoms

> First applied to smoking cessation but found to have utility with other

behaviors

> Consumer-centered approach that engages consumer in process > Not a theory but a set of “how to” guidelines that can be used by all team

members

Whitlock, Orleans, Pender & Allan, 2002 Karmody, K.A. 2008, The 5As of Self-Management (healthcarecommunities.org)

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ASSESS :

Beliefs, Behavior & Knowledge

ADVISE :

Provide specific Information about health risks and benefits of change

AGREE:

Collaboratively set goals based

• n consumer’s interest and

confidence in their ability to change the behavior

ASSIST:

Identify personal barriers, strategies, problem-solving techniques and social/ environmental support

ARRANGE :

Specify plan for follow-up (e.g., visits, phone calls, mailed reminders)

• 1. List specific goals in

behavioral terms

• 2. List barriers and

strategies to address barriers

• 3. Specify follow-up plan
• 4. Share plan with

consumer, team and consumer’s social support network

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Benefits of 5As Approach

> Consistent with Motivational Interviewing, Stages of Change, CBT

interventions, etc.

> Also models for consumer and team members a way to “think” about

behavioral change that demystifies our work

> Identifies areas for feedback in consultation with PCP and care team > Components of model are important at all stages of care

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Motivational Interviewing (MI)

Collaborative vs. expert approach Person centered Elicit consumer’s motivation for change (the consumer’s reasons) Ambivalence- two (or more) conflicting views about behavioral

change (think about what the consumer will have to give up to do what we are asking)

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Motivational Interviewing

Increasing Change Talk

Desire: Why would you want to make this change? Ability: How would you do it if you decided? Reason: What are the three best reasons? Need: How important is it? and why? Commitment: What do you think you’ll do?

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Transtheoretical Model

Stages of Change:

Precontemplation Contemplatiion Preparation Action Maintenance Relapse

Major Contributors: Prochaska & DiClemente

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Stages of Change

Basic research has generated a rule of thumb for at-risk

populations: 40% in precontemplation, 40% in contemplation, and 20% in preparation

Be aware of your (and team members) reactions at each stage of

change

Stage-Matched Interventions

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Matching Intervention to Stage of Change

NOT READY: Pre-contemplation Contemplation

Karmody, K.A. 2008, The 5As of Self-Management (healthcarecommunities.org)

> Neutrality > Build rapport > Raise awareness > Tailor psychoeducation to

readiness level

> Indicate readiness to help > Identify benefits/costs of

change

> Praise previous efforts

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Matching Intervention to Stage of Change

READY Preparation Action

> Collaborative problem

solving

> Identify and reinforce small

steps taken (be a cheerleader!)

> Develop action plan > Encourage support

networks

> Look for ways to increase

self-efficacy

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Behavior Change Strategies

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Symptom Monitoring

Use a Rating Scale: “On a scale of 0 – 10 where 0 = no symptoms and 10 = worst symptoms ever, where are you now”?

Helps the consumer develop a sense of self efficacy

• ver symptoms

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Establish Importance

1 2 3 4 5 6 7 8 9 10

Not Unsure Somewhat Very Important Important Important Use an Importance Ruler: What goals are important to the consumer NOW? (may differ from PCP’s goals)

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Establish Readiness

1 2 3 4 5 6 7 8 9 10

Not Unsure Somewhat Very Ready Ready Ready & Trying Use a Readiness Ruler: how ready is the consumer to take action?

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Establish Confidence

Use a Confidence Ruler: how confident is the consumer that he or she can change the behavior?

1 2 3 4 5 6 7 8 9 10

Not Unsure Somewhat Very Confident Confident Confident

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Mood Monitoring Form

www.tiny.cc/moodmonitor

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Teach The Relaxation Response

The Relaxation Response is a state of deep rest that changes the physical and emotional responses to stress. When the Relaxation Response is elicited: Metabolism decreases Breathing slows down Heartbeat slows down Blood pressure decreases Blood vessels open up Stress hormones decrease If practiced regularly, it can have lasting effects

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Two Essential Steps to Elicit the Relaxation Response

• 1. Repetition of a word, sound, phrase, or muscular activity.
• 2. Passive disregard of everyday thoughts that inevitably come

to mind and a return to repetition.

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Fostering Strengths and Resiliency

> Consumer’s strengths provide a foundation that interventions can be built

upon and helps build rapport

> Are we being less effective by primarily focusing on consumer’s deficits,

symptoms, and/or chief complaint?

> Positive Psychology: Focus on strengths may have a lasting impact on

mood, self-perception, perceived control, and coping.

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Practical Ways to Foster Strength and Resiliency

Make a checklist of strengths Make a list of Pleasurable Activities Strengthen social ties and “service to others” Promoting positive thinking/optimism (personal

hope that one’s life can be better)

Catch it! Check it! Change it! Connecting With that Which Is More than Self Promoting restful sleep, exercise, healthy diet

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Treatment Planning Principles for Care Managers

Consumer Driven Based on Diagnosis &Assessment & Readiness Focus is Changed based vs. Time based Conveys to consumers that Care Manager is invested in their

improvement

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Treatment Planning Principles for Care Managers:

• Small incremental changes can make a BIG difference
• Small change plans solve your documentation woes
• Apply the rapid cycle change principles:
• Plan
• Do
• Study
• Act

Support makes a big difference Celebrate SUCCESS!!!!

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• Mr. A is a 54 year old Caucasian
• man. He presents in crisis

having recently lost his sales job, health insurance and car. He is fearful that he will loose his home as well. Mr. A has a BMI over 30; DM poorly controlled with Metformin (HbA1C >10) and has been hypertensive for 6 years.

Managing Diabetes

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What Stage of Change is Mr. A in?

> Precontemplation > Contemplation > Preparation > Action > Maintenance

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• Mr. A is a 54 year old Caucasian
• man. He presents in crisis having

recently lost his sales job, health insurance and car. He is fearful that he will loose his home as well.

• Mr. A has a BMI over 30; DM

poorly controlled with Metformin (HbA1C >10) and has been hypertensive for 6 years.

Care Management Strategy: Applying the 5 As

• 1. Assess: his immediate needs
• 2. Assess: his beliefs/thoughts about

his physical health

• 3. Advise: Raise awareness about

impact of stress on physical health

• 4. Agree: Most pressing needs
• 5. Assist: Management of immediate

needs

• 6. Arrange: returning to work on

relaxation once immediate needs are stabilized.

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• Ms. T is a 73 year old African

American woman. She is a retired teacher with chronic back pain, HTN, and a history of multiple hospitalizations for

• CAD. She is depressed, has

stopped going to church, misses her PCP appointments and takes her HBP medications “on her own terms.”

Managing Heart Disease

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What Stage of Change is Mrs. T in?

> Precontemplation > Contemplation > Preparation > Action > Maintenance

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Desire: Why would you want to make this change? Ability: How would you do it if you decided? Reason: What are the three best reasons? Need: How important is it? and why? Commitment: What do you think you’ll do?

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Using MI to Increase Mrs. T’s Change Talk

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Smoking Cessation

• Mr. J is 65 years old and has smoked for 40 years.

He is chronically depressed. He is 5 years clean from drug and alcohol addiction and is finally welcomed back into his family and is getting to know his grandchildren for the first time in their

• lives. His doctor has told him that if he doesn’t

quit smoking, he will die. He is certain that if he gives up cigarettes, he’ll pick up drugs.

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What Stage of Change is Mr. J in?

> Precontemplation > Contemplation > Preparation > Action > Maintenance

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• Mr. J is 65 years old and has

smoked for 40 years. He is chronically depressed. He is 5 years clean from drug and alcohol addiction and is finally welcomed back into his family and is getting to know his grandchildren for the first time in their lives. His doctor has told him that if he doesn’t quit smoking, he will die. He is certain that if he gives up cigarettes, he’ll pick up drugs.

Care Management Strategy: Applying the 5 As 1. Assess 2. Advise 3. Agree 4. Assist 5. Arrange

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Suzanne Daub, LCSW Senior Integrated Health Consultant suzanned@thenationalcouncil.org

Questions?

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