A behaviour change and lifestyle pathway for discussion with agencies and stakeholders in b

1. Discussion draft for Hertfordshire Health Behaviour Change Care Pathway
(Version 2.0, February 2013)
The evidence base for changing health behaviour is developing quickly. Brief interventions in primary care (by practice nurses
and GPs) can motivate people to change, providing referral onwards is speedy. This pathway seeks to join this up with
community interventions people can be signposted into, and support primary and secondary prevention
1st Line – Brief Intervention
2nd Line – Behaviour Change
Opportunistic brief advice by
GP, pharmacist or practice
nurse
Discuss primary or main goal
then refer appropriately
1. Identify health issue of
concern (and follow
appropriate pathway for
that, e.g. obesity)
2. Assess motivation to
change
3. If motivated, refer on
4. If not motivated,




Raise awareness of
risks.
Offer written information
on healthy eating and
physical activity.
Raise again in 3 months.
Offer information
prescription
Smoking
is primary,
main or
only goal
Refer to
smoking
cessation
service
Weight
loss,
healthy
living or
CVD risk
is main or
primary
goal
Refer to
ifestyle
Service
3rd Line - Activity
4th Line – Specialist
If fall into 1st or
subsequent line category
of advice within Obesity
Care Pathway refer to
Healthy Adults
Programme, provided
there are no
contraindications and if
co-morbidities or person
has BMI over 30, GP has
assessed and supports
referral.
For patients with comorbidites
Patients who are diabetic or
have coronary heart
disease or a history of heart
problems must have referral
from appropriate primary
care team or secondary
care to participate in
programme.
Behaviour change
programme to be developed
in partnership with specialist
services
Patients with highly complex psychological or emotional
issues (e.g. depression or eating disorder.)
If not already in contact with such services, refer to psychology
or primary care mental health team
If referral has come from such a service, Health Trainer to
agree programme in consultation with that service.

2. Schematic of Behaviour Change/Health Trainer Support
Source or
referral to health support front line (e.g. health
trainer/leisure service/health advocate)
1
Initial Contact with front line
2
Assessment – Goal Setting
Primary Goal
Agree communication with GP/Referrer and how
often
3
Enabling the client
Arrange referral
Facilitate attendance
Signposting / Providing
information
Work with Client
HT activity
Boosting Motivation
Confidence Building
Addressing Ambivalence Barriers
Problem Solving
Goal Setting
“Secondary Goal”
Specialist Service
4
5
Sustaining Change
Encouragement, Understanding and Support
Review against Primary Goal
6
1.
2.
3.
4.
5.
6.
Sources of referral need to be identified
Location of contact needs to be agreed
Assessment forms and questionnaires to be completed
Referrals to and from specialist services need to be in place
HTs must record their work with clients using data capture system
Progress reviews need to be supported by a practice supervisor and „time-bound‟
Hertfordshire Behaviour Change Pathwa