Creating Practical Active Care Plans

Creating practical active care plans
A framework using behavioral economics + design thinking

Education
● BS, Kinesiology - San Diego State University
● DC, Doctor of Chiropractic - Palmer College
● MBA, General Management - Cornell SC Johnson College of Business
● MS, Healthcare Leadership - Weill Cornell Medical College
Experience
● One Medical - On-site employer healthcare
● ACA Quality & Assurance - Committee member
● Orthology - UnitedHealth funded physical medicine clinics
● Adjunct faculty at Palmer College of Chiropractic
Background

Why this method?
Communicating with patients effectively is imperative to the delivery of
high quality healthcare. In the world of physical medicine we give active
care advice to help our patients navigate the world after their
appointments.
Structuring advice while using basic design thinking and behavioral
economics themes, we can methodically streamline our communication,
improve outcomes, and deliver patients a fantastic consumer centered
healthcare experience.
-Isaac Borowiec, DC, MBA, MS © 2019

Practical active care is more than an exercise.
Home exercises
● Personal workouts
● Rehabilitation
exercises
Active care
Daily routines
● Picking up objects
● Lifting children
Learned habits
● Laptop posture
● Sit-to-stand posture
Created and compiled by: Isaac Borowiec, DC, MBA, MS ©
Take a broad
approach to what
you consider active
care to fully
encompass moments
of the day that can
impact patient
recovery.

Structuring advice helps patients understand solutions.
● Lifting heavy objects
● Bending + twisting
● Gentle walking
● Standing more than sitting
● Standing rather than sitting
● Extension exercises
● Thoughtful functional movements
Things NOT to do
Things OKAY to do
Things to HEAL faster
Chronic low back pain
CONDITION
Consider how you
phrase advice to
patients and how
they perceive
options for their
recovery pathway.

Designing a patient centered active care plan:
Design
thinking
Behavioral
economics
Patient
centered
Built for
outcomes
Identify root goal Patient
● Plan makes sense
● Plan is realistic for patient
● Built for outcomes
● Focused on habits rather
than ﬁxed rote exercises
● Patient empowered with
knowledge to course correct
Custom ﬂexible solution
Goal: Autonomous patients which
are self-guided empowered

What is design thinking?
An iterative approach leading to
optimal solutions
Human centered process
for ideation
Intentional application
of empathy to process design
Process which creates a naturally
sustaining solution to needs
A structured thought & experiment process that helps
create optimal human centered solutions.

How to start using design thinking in clinical practice.
Use conversation to understand the
daily environment they live in and
about hindrances to their healing and
poor habits.
Use:
“how might we” language
Abductive reasoning:
A process of observation and
learning from which core needs are
identiﬁed.
Discovery process Ideate Possible Solutions
“How might we relax after work in
positions that will not hinder back
healing?”
Standard
use
Clinicalapplication

Design thinking applied to clinical practice:
Problem discovery
using
empathy with end user
(patient)
Ideation
&
Prototyping
Testing with patients
Feedback & Iterate each visit

Sample use case:
Low back pain (chronic)
New parent
Long commute
Loves to watch netﬂix
while playing with kids
Extension based rehab
&
Modifying posture during
lifting kids
Patients forgot to do
rehab exercises, but were
able to modify lifting
children
Start lunging with picking up kids, and
brush teeth in lunge position at
bathroom sink
Iterative approach

Speciﬁcally useful with non-compliant patients
Ideal exercise
prescribed and taught
in detail
Patient doesn’t ﬁnd
time for daily / weekly
exercises
Re-think what exercise is with
novel methods of implementation

Why behavioral economics?
Better self-care habits increases the
value of your care
Patient lifestyle is extremely
important to health outcomes
Improving doctor-patient
communication can improve care
and outcomes
Major health systems are
implementing behavioral
economics into practice

Behavioral Economics
Economic theory Behavioral psychology
+
How people actually act
in the real world
A library of tools best used in particular contexts to affect desired behavior change.3

Bounded reality Choice fatigue
An inventory of behavioral economics tools:
Prospect theory
Libertarian
paternalism
Rational decision
making
Heuristics +
Rules of thumb
H. Simon - 1950
Kahneman & Tversky - 1980
Thaler & Sunstein - 2008
Neoclassical economics
Thomas Rice, UCLA - 2013
Loss aversion
Nudge theory
Ideal economic decision
making Supply & Demand
Framing
Status quo
bias
Asymmetrically prefer not
to lose,
rather than gain

Choice fatigue leads to use of heuristics (rules of thumb).
Am I overloading
patients with
information on
1st visit?
How much actionable
advice to I give?
Consider framing
advice with context.
Consider adding
structure to advice.
Consider choice
fatigue and staggering
advice.
Healthcare provider

How can these strategies increase provider effectiveness?
Increase impact by
rethinking how to
communicate and
structure patient
advice.
Considering patients
may or may not follow
what we say when at
home.
How do we plan for
this uncertainty?

Putting it together
Design
thinking
Behavioral
economics
Patient
centered
Built for
outcomes
Custom ﬂexible solution

Case # 1
Low back pain
New Parent

Chronic low back pain for a new parent
Busy task ﬁlled
home life
Current default
habits
Pain on ﬂexion
Needs mobility
● Active care makes sense
● Identify dual-use time
○ common positions
(design thinking)
● Identify poor habits
● Retrain movement patterns
○ Squat (bending)
○ Lunge
○ House chores (dishes)
● 1-3 exercises max to do with
child on the ground as a game
(choice fatigue)
Custom solution

The role of iterative active care plans:
Prone extensions
Cat-Camel
Bird-dogLunge or Squat
Out
Considering
behavioral
economics, limit
choices of exercises
to approximately 3,
then graduate
patient from easiest,
and insert harder
exercise.
This iterative design
helps to simplify
advise and keep
active care simple
and realistic for
patients over the
course of care.

New Parent’s customized tool box:
● 3 core exercises
● Practice child
‘put down’
New Parent
● Pain free
movement
● Avoid Lifting
heavy objects
● Make every bend
a lunge or squat
● Practice child
‘put down’
Home exercises Daily routines Learned habits

Case # 2
Low back pain
Computer
engineer

Chronic LBP pain for computer engineer:
When is
standing more
practical than
sitting?
What
constraints can
we work around?
Cue - Response
for posture
hacks
Pre-programed
responses for
aches / pains
Pain on extension &
needs mobility
● Active care realistic at work
● Identify micro moments for
breaking poor habits
● Identify and distinguish
between ideal & poor
positions (design thinking)
● Retrain movement patterns
○ Seated posture
○ Build in variability hacks
○ Build in posture hacks
● 1-3 exercises max to do with
child on the ground as a game
(choice fatigue)
Custom solution

The role of posture hacks
Pre-set plan of what to do when CUE (ache) is
activated
Posture aches are cues to DO SOMETHING
RESPONSE to cue should decrease
discomfort so it reinforces better behavior
CUE
RESPONSE

Computer engineer’s custom tool box:
● 3 core exercises
● Practice posture
hacks
New Parent
● Pain free
movement
● Find ways to
stand more
● Walking more
than sitting
● Avoid positions
of long term
ﬂexion
● Flights and travel
● Turn posture
ﬁxes into habits
Home exercises Daily routines Learned habits

Research and references
1. Nudge: Improving Decisions About Health, Wealth, and Happiness R. H. Thaler and C. Sunstein, New Haven: Yale University Press, 2008
2. The Behavioral Economics of Health and health care Thomas rice Annu. Rev. Public Health 2013 34:431-47
3. Changing the default on employer-based retirement programs so that employees must opt out of participation rather than in has greatly
increased employee participation in these programs. See J. J. Choi, D. Laibson, B. C. Madrian et al., "For Better or for Worse: Default Effects and
401(k) Savings Behavior," from D. Wise, Perspectives on the Economics of Aging (Cambridge, Mass.: National Bureau of Economic Research, June
2004).
4. Effect of a Game-Based Intervention Designed to Enhance Social Incentives to Increase Physical Activity Among Families, The BE FIT
Randomized Clinical Trial. Mitesh S. Patel, MD, MBA, MS1,2,3,4
; Emelia J. Benjamin, MD, ScM5,6,7
; Kevin G. Volpp, MD, PhD1,2,3,4
; et al
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2655242
5. The Power of Habit: Why we do what we do, in life and business, Charles Duhigg, New York, Random House, 2012
6. The Pyramid Principle: Logic in Writing and Thinking, Barbara Minto, Prentice Hall, 3rd edition 2010

Creating Practical Active Care Plans

Recommended

Recommended

More Related Content

Similar to Creating Practical Active Care Plans

Similar to Creating Practical Active Care Plans (20)

Recently uploaded

Recently uploaded (20)

Creating Practical Active Care Plans