Mad*Pow's Jamie Thomson, Experience Design Director, and Olga Elizarova, Senior Behavior Change Analyst share their experience and findings from the ImageinCare project.

1. ImagineCare
Empowering Patients with
Behavioral Science and Technology
Jamie Thomson Experience Design Director
Olga Elizarova Senior Behavior Change Analyst

2. 1. What is Behavior Change Design?
2. Behavior Change Design within ImagineCare
3. Results & Takeaways
TONIGHT’S TALK
Mad*Pow is a design agency that strives to
help people improve their health and wellness,
meet their financial goals, learn, and connect.

3. WHAT IS BEHAVIOR CHANGE DESIGN?
What is Behavior Change Design?

4. A set of processes and activities that
are applied to design an intervention
that aims to change a defined and
modifiable behavior.
WHAT IS BEHAVIOR CHANGE DESIGN?

5. Designing Systems of Interventions
Mad*Pow Behavior Change Design Process
What are we trying to achieve?
How to achieve it?
WHAT IS BEHAVIOR CHANGE DESIGN?
System Outcomes &
Target Population
Behavioral Outcomes
for Individuals
Performance Objectives
for Individuals
Behavioral
Determinants
Design of
Product, Messages,
Materials, Activities
Implementation
& Adoption
Intervention
Functions & Behavior
Change Techniques

6. Behavior Change Design
within ImagineCare
BEHAVIOR CHANGE DESIGN, APPLIED

7. CONTEXT

8. Imagine a hospital that doesn’t want people to visit.
Not because we don’t care…
…but because we do.
CONTEXT

9. What are we trying to achieve?
“The Triple Aim” of Improving the US Health Care System
Better care
Patient satisfaction
Clinician satisfaction and minimal
burden
Better value
Reduced need for high-cost care
(ER, Inpatient) through
management and prevention
Correct level of care delivered
when care is needed (ER vs
Urgent Care vs PCP)
Reduced need for medications
Better health
Reduced mortality
Chronic conditions under
control, or where possible, in
remission
Improved quality of life for
patients
STEP 1: SYSTEM OUTCOMES & TARGET POPULATION

10. Impact of condition – frequency in population, cost per capita
Available evidence about interventions & outcomes
Feasibility of interventions – technology, cost, logistics, burden
Overlap in conditions and behavioral objectives
STEP 1: SYSTEM OUTCOMES & TARGET POPULATION
Who can help us achieve those outcomes?
ImagineCare chose to focus on people with health conditions that offered the greatest
potential impact on the system outcomes, based on:

11. Hypertension
CHF
COPD
Diabetes
Depression
Medication adherence
Self monitoring
Dietary changes
Physical activity
Stress & psych health
STEP 1: SYSTEM OUTCOMES & TARGET POPULATION
Target population & behavior categories
ImagineCare’s pilot conditions and related modifiable behaviors

12. Hypertension
CHF
COPD
Diabetes
Depression
Medication adherence
Self monitoring
Dietary changes
Physical activity
Stress & psych health
STEP 1: SYSTEM OUTCOMES & TARGET POPULATION
For sake of example…
We’ll use hypertension self monitoring to show how the behavior change design process plays out

13. STEP 2: BEHAVIORAL OUTCOMES FOR INDIVIDUALS
What behaviors have an impact on system outcomes?
What’s the behavior?
How often should it occur?
Are there any exception cases or
special circumstances?
Why does the behavior impact
outcomes?
RESEARCH QUESTIONS
• Help doctor and patient determine whether
treatments are working
• Identify hypertensive crisis in the moment so
patient can seek emergency care
• Increase patient awareness and engagement with
care – halo effect can improve other behaviors
WHY?
Patients with uncontrolled blood pressure should
measure their blood pressure once per day against a goal
recommended by their physician, and take appropriate
action based on readings.
BEHAVIORAL OUTCOME

14. STEP 3: PERFORMANCE OBJECTIVES FOR INDIVIDUALS
What tasks are performed as part of the behavior?
What do they need to do
differently to achieve desired
change?
How should the behavior
typically play out, start to finish?
Any required resources?
Does anyone else need to be
involved?
Where should it occur?
What barriers may exist? How
can barriers be addressed?
RESEARCH QUESTIONS PERFORMANCE OBJECTIVES FOR MONITOR BP DAILY
• Recognize importance of monitoring BP
• Set goal for behavior and outcome
• Obtain BP cuff & learn to use
• Measure BP daily
• Compare reading to goal & take appropriate action
• If not measuring daily – identify barriers,
problem-solve, adjust as needed

15. STEP 4: BEHAVIORAL DETERMINANTS
What factors increase likelihood of success?
CAPABILITY
Physical
Psychological
OPPORTUNITY
Physical
Social
MOTIVATION
Reflective
Automatic
The COM-B Model (Michie, et al) provides a framework for identifying behavioral determinants
BEHAVIOR
Michie S, van Stralen M M, West R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions, Implementation Science, 2011;6(42). doi: 10.1186/1748-5908-6-42

16. CAPABILITY
Physical
Skills to take a BP reading
Psychological
Knowledge about what needs to
be measured, how and when
Knowledge of goal
Knowledge of what action is
appropriate based on reading
STEP 4: BEHAVIORAL DETERMINANTS
What factors increase likelihood of success?
OPPORTUNITY
Physical
Social
MOTIVATION
Reflective
Automatic
BEHAVIOR
Measure BP Daily & Take appropriate action

17. OPPORTUNITY
Physical
Having a BP cuff
Having time to measure BP
Having resources or tools that will
allow action to be taken
Social
Relationship with a clinician
Being able to openly use BP cuff
in social environment
CAPABILITY
Physical
Skills to take a BP reading
Psychological
Knowledge about what needs to
be measured, how and when
Knowledge of goal
Knowledge of what action is
appropriate based on reading
STEP 4: BEHAVIORAL DETERMINANTS
What factors increase likelihood of success?
MOTIVATION
Reflective
Automatic
BEHAVIOR
Measure BP Daily & Take appropriate action

18. STEP 4: BEHAVIORAL DETERMINANTS
What factors increase likelihood of success?
CAPABILITY
Physical
Skills to take a BP reading
Psychological
Knowledge about what needs to
be measured, how and when
Knowledge of goal
Knowledge of what action is
appropriate based on reading
BEHAVIOR
Measure BP Daily & Take appropriate action
OPPORTUNITY
Physical
Having a BP cuff
Having time to measure BP
Having resources or tools that will
allow action to be taken
Social
Relationship with a clinician
Being able to openly use BP cuff
in social environment
MOTIVATION
Reflective
Having a goal
Having motivation to take action
Social support & accountability
Automatic
Emotional reaction to condition
and behavior

19. STEP 5: INTERVENTION FUNCTIONS & BEHAVIOR CHANGE TECHNIQUES
Education
Persuasion
Incentivization
Coercion
Training
Restriction
Environmental Restructuring
Modeling
Enablement
PRIMARY INTERVENTION FUNCTIONS
What are the primary functions of the intervention?

20. STEP 5: INTERVENTION FUNCTIONS & BEHAVIOR CHANGE TECHNIQUES
PERFORMANCE OBJECTIVES
Recognize importance of monitoring BP
Set goal for behavior and outcome
Obtain BP cuff & learn to use
Measure BP daily
Compare reading to goal & take appropriate action
If not measuring daily – identify barriers, problem-solve, adjust as needed
BEHAVIORAL DETERMINANTS
Skills to take a BP reading
Knowledge about what needs to be measured, how and when
Knowledge of goal
Knowledge of what action is appropriate based on reading
Having a BP cuff
Having resources or tools that will allow action to be taken
Having a goal
Having motivation to take action
Having time to measure BP
Social support & accountability
Emotional reaction to condition and behavior
Education
Persuasion
Incentivization
Coercion
Training
Restriction
Environmental Restructuring
Modeling
Enablement
PRIMARY INTERVENTION FUNCTIONS
What are the primary functions of the intervention?

21. STEP 5: INTERVENTION FUNCTIONS & BEHAVIOR CHANGE TECHNIQUES
PERFORMANCE OBJECTIVES
Recognize importance of monitoring BP
Set goal for behavior and outcome
Obtain BP cuff & learn to use
Measure BP daily
Compare reading to goal & take appropriate action
If not measuring daily – identify barriers, problem-solve, adjust as needed
BEHAVIORAL DETERMINANTS
Skills to take a BP reading
Knowledge about what needs to be measured, how and when
Knowledge of goal
Knowledge of what action is appropriate based on reading
Having a BP cuff
Having resources or tools that will allow action to be taken
Having a goal
Having motivation to take action
Having time to measure BP
Social support & accountability
Emotional reaction to condition and behavior
Education
Persuasion
Incentivization
Coercion
Training
Restriction
Environmental Restructuring
Modeling
Enablement
PRIMARY INTERVENTION FUNCTIONS
What are the primary functions of the intervention?

22. STEP 5: INTERVENTION FUNCTIONS & BEHAVIOR CHANGE TECHNIQUES
Which techniques are best suited to perform these
functions, to influence the behavioral determinants
and performance objectives?
We choose techniques and strategies from a large toolkit of theories and frameworks
Self Determination Theory – a theory of motivation concerned with supporting our natural or
intrinsic tendencies to behave in effective and healthy ways. Conditions supporting the
individual’s experience of autonomy, competence and relatedness are argued to foster the
most volitional and high quality forms of motivation and engagement.
Social Cognitive Theory – describes a dynamic, ongoing process in which personal factors,
environmental factors, and human behavior exert influence upon each other. According to
SCT, self-efficacy, goals, and outcome expectancies are the three main factors that affect the
likelihood that a person will change a health behavior.
Behavioral Economics & Game Mechanics – human decisions are strongly influenced by
context, including the way in which choices are presented to us.

23. STEP 5: INTERVENTION FUNCTIONS & BEHAVIOR CHANGE TECHNIQUES
Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane J, Wood CE. (2013). The Behavior Change Technique Taxonomy (v1) of 93 hierarchically clustered techniques: building an international
consensus for the reporting of behavior change interventions, Annals of Behavioral Medicine, 2013;46(1): 81-95. doi: 10.1007/s12160-013-9486-6
Identity
13.1. Identification of self as role model
13.2. Framing/reframing
13.3. Incompatible beliefs
13.4. Valued self-identify
13.5. Identity associated with changed
behavior
Schedules consequences
14.1. Behavior cost
14.2. Punishment
14.3. Remove reward
14.4. Reward approximation
14.5. Rewarding completion
14.6. Situation-specific reward
14.7. Reward incompatible behavior
14.8. Reward alternative behavior
14.9. Reduce reward frequency
14.10. Remove punishment
Covert learning
16.1. Imaginary punishment
16.2. Imaginary reward
16.3. Vicarious consequences
Self-belief
15.1. Verbal persuasion about capability
15.2. Mental rehearsal of successful
performance
15.3. Focus on past success
15.4. Self-talk
Goals and Planning
1.1. Goal setting (behavior)
1.2. Problem solving
1.3. Goal setting (outcome)
1.4. Action planning
1.5. Review behavior goal(s)
1.6. Discrepancy between current behavior
and goal
1.7. Review outcome goal(s)
1.8. Behavioral contract
1.9. Commitment
Feedback and Monitoring
2.1. Monitoring of behavior by others without
feedback
2.2. Feedback on behavior
2.3. Self-monitoring of behavior
2.4. Self-monitoring of outcome(s) of
behaviour
2.5. Monitoring of outcome(s) of behavior by
others without feedback
2.6. Biofeedback
2.7. Feedback on outcome(s) of behavior
Social Support
3.1. Social support (unspecified)
3.2. Social support (practical)
3.3. Social support (emotional)
Natural Consequences
5.1. Information about health consequences
5.2. Salience of consequences
5.3. Information about social and
environmental consequences
5.4. Monitoring of emotional consequences
5.5. Anticipated regret
5.6. Information about emotional
consequences
Comparison of behavior
6.1. Demonstration of the behavior
6.2. Social comparison
6.3. Information about others’ approval
Associations
7.1. Prompts/cues
7.2. Cue signaling reward
7.3. Reduce prompts/cues
7.4. Remove access to the reward
7.5. Remove aversive stimulus
7.6. Satiation
7.7. Exposure
7.8. Associative learning
Repetition and substitution
8.1. Behavioral practice/rehearsal
8.2. Behavior substitution
8.3. Habit formation
8.4. Habit reversal
8.5. Overcorrection
8.6. Generalisation of target behavior
8.7. Graded tasks
Comparison of outcomes
9.1. Credible source
9.2. Pros and cons
9.3. Comparative imagining of future
outcomes
Reward and threat
10.1. Material incentive (behavior)
10.2. Material reward (behavior)
10.3. Non-specific reward
10.4. Social reward
10.5. Social incentive
10.6. Non-specific incentive
10.7. Self-incentive
10.8. Incentive (outcome)
10.9. Self-reward
10.10. Reward (outcome)
10.11. Future punishment
Regulation
11.1. Pharmacological support
11.2. Reduce negative emotions
11.3. Conserving mental resources
11.4. Paradoxical instructions
Antecedents
12.1. Restructuring the physical environment
12.2. Restructuring the social environment
12.3. Avoidance/reducing exposure to cues
for the behavior
12.4. Distraction
12.5. Adding objects to the environment
12.6. Body changes
Shaping Knowledge
4.1. Instruction on how to perform the
behavior
4.2. Information about antecedents
4.3. Re-attribution
4.4. Behavioral experiments

24. STEP 5: INTERVENTION FUNCTIONS & BEHAVIOR CHANGE TECHNIQUES
Goals and Planning
1.1. Goal setting (behavior)
1.2. Problem solving
1.3. Goal setting (outcome)
1.4. Action planning
1.5. Review behavior goal(s)
1.6. Discrepancy between current behavior
and goal
1.7. Review outcome goal(s)
1.8. Behavioral contract
1.9. Commitment
Feedback and Monitoring
2.1. Monitoring of behavior by others without
feedback
2.2. Feedback on behavior
2.3. Self-monitoring of behavior
2.4. Self-monitoring of outcome(s) of
behaviour
2.5. Monitoring of outcome(s) of behavior by
others without feedback
2.6. Biofeedback
2.7. Feedback on outcome(s) of behavior
Social Support
3.1. Social support (unspecified)
3.2. Social support (practical)
3.3. Social support (emotional)
Natural Consequences
5.1. Information about health consequences
5.2. Salience of consequences
5.3. Information about social and
environmental consequences
5.4. Monitoring of emotional consequences
5.5. Anticipated regret
5.6. Information about emotional
consequences
Comparison of behavior
6.1. Demonstration of the behavior
6.2. Social comparison
6.3. Information about others’ approval
Associations
7.1. Prompts/cues
7.2. Cue signaling reward
7.3. Reduce prompts/cues
7.4. Remove access to the reward
7.5. Remove aversive stimulus
7.6. Satiation
7.7. Exposure
7.8. Associative learning
Repetition and substitution
8.1. Behavioral practice/rehearsal
8.2. Behavior substitution
8.3. Habit formation
8.4. Habit reversal
8.5. Overcorrection
8.6. Generalisation of target behavior
8.7. Graded tasks
Comparison of outcomes
9.1. Credible source
9.2. Pros and cons
9.3. Comparative imagining of future
outcomes
Reward and threat
10.1. Material incentive (behavior)
10.2. Material reward (behavior)
10.3. Non-specific reward
10.4. Social reward
10.5. Social incentive
10.6. Non-specific incentive
10.7. Self-incentive
10.8. Incentive (outcome)
10.9. Self-reward
10.10. Reward (outcome)
10.11. Future punishment
Regulation
11.1. Pharmacological support
11.2. Reduce negative emotions
11.3. Conserving mental resources
11.4. Paradoxical instructions
Antecedents
12.1. Restructuring the physical environment
12.2. Restructuring the social environment
12.3. Avoidance/reducing exposure to cues
for the behavior
12.4. Distraction
12.5. Adding objects to the environment
12.6. Body changes
Identity
13.1. Identification of self as role model
13.2. Framing/reframing
13.3. Incompatible beliefs
13.4. Valued self-identify
13.5. Identity associated with changed
behavior
Schedules consequences
14.1. Behavior cost
14.2. Punishment
14.3. Remove reward
14.4. Reward approximation
14.5. Rewarding completion
14.6. Situation-specific reward
14.7. Reward incompatible behavior
14.8. Reward alternative behavior
14.9. Reduce reward frequency
14.10. Remove punishment
Covert learning
16.1. Imaginary punishment
16.2. Imaginary reward
16.3. Vicarious consequences
Self-belief
15.1. Verbal persuasion about capability
15.2. Mental rehearsal of successful
performance
15.3. Focus on past success
15.4. Self-talk
Shaping Knowledge
4.1. Instruction on how to perform the
behavior
4.2. Information about antecedents
4.3. Re-attribution
4.4. Behavioral experiments
Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane J, Wood CE. (2013). The Behavior Change Technique Taxonomy (v1) of 93 hierarchically clustered techniques: building an international
consensus for the reporting of behavior change interventions, Annals of Behavioral Medicine, 2013;46(1): 81-95. doi: 10.1007/s12160-013-9486-6

25. STEP 5: BEHAVIOR CHANGE TECHNIQUES
Selecting techniques
Having a blood pressure cuff
BEHAVIORAL DETERMINANT:
• Adding objects to the environment
SELECTED BEHAVIOR CHANGE TECHNIQUES:
Environmental restructuring
INTERVENTION FUNCTION:

26. STEP 5: BEHAVIOR CHANGE TECHNIQUES
Selecting techniques
Skills to be able to measure blood pressure
BEHAVIORAL DETERMINANT:
• Instructions on how to perform behavior
• Verbal persuasion about capabilities
• Biofeedback
• Social support (practical)
SELECTED BEHAVIOR CHANGE TECHNIQUES:
Training
INTERVENTION FUNCTION:

27. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
Patient AppSensors
Patient
Clinician Dashboard
ImagineCare Clinicians
communicate via
In-App Texts
Phone Calls
Video Calls
data processed through
Evidence-based care pathways
Rules & preferences engine
Machine learning & predictive analytics

28. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
Invitation to participate
Persuasion, Incentivisation
Material
Incentive
Large risk-bearing entities (ACOs,
self-insured employers) invite at-
risk populations to participate via
email or offline outreach
Social
Comparison
Credible
Source
During a follow-up visit at your
doctor’s office, a staff member
talks with you about
ImagineCare, a program that will
help you monitor your blood
pressure daily and encourage
and support you in the health
changes you want to make.
Social Support
(Practical)
Your college has introduced a
new program for wellness and
stress management, called
ImagineCare.
ENROLLMENT DESIGN
• From a trusted source
• Volitional
• Confidential
• Quick & simple as possible
• Mobile first
ACCESS MODEL – B2B2C
Information about
health consequences

29. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
Welcome kit
Environmental Restructuring, Incentivisation
Adding objects to the environment
(provide a blood pressure cuff)
Material Reward

30. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
Guided setup process
Persuasion, Education, Environmental Restructuring, Incentivization, Enablement
Prompts/cues;
Instructions on how to perform behavior
Prompts/cues;
Feedback on behavior;
Discrepancy between
current behavior and goal;
Social support (practical)
Social reward

31. Taking the first reading
STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
Environmental Restructuring, Training, Incentivization
Prompts/cues
Feedback on behavior;
Social reward Feedback on behavior
Instructions on how
to perform behavior
Biofeedback
Instructions on how to
perform behavior

32. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
Self monitoring via active and passive sensors
Education, Incentivisation, Enabling
Goal for the
outcome
Biofeedback
Self-monitoring
outcomes
Action planning; Prompts/cues;
Conserving mental resources
Self-monitoring
behavior

33. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
Agreeing to a care plan
Enablement, Education, Incentivisation
Goal setting (behavior -
measure BP daily)
Goal Setting (outcome -
achieve prescribed range)
Action planning;
Commitment;
Behavioral contract;
Social support (practical);
Credible source;
Restructuring the social environment

34. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
Communication, human support & triaging
Education, Enabling, Incentivization, Persuasion
Feedback on outcomes of behavior;
Social reward
Feedback on outcomes of behavior;
Problem solving
Social support (emotional);
Social support (practical)

35. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
Message design

36. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
Scenario: You’ve achieved a milestone in your health and wellness goals.
Which message would you rather receive?
A B

37. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
A B
You have a chronic pulmonary (lung) disease and the ImagineCare team can tell
you’ve been using rescue medication inhalers more often
C

38. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES
C
Branded Polo
B
White Coat
D
Casual
A
Scrubs

39. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES

40. STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES

41. RESULTS & TAKEAWAYS
Results & Takeaways

42. 2016 Pilot Results
N=2741, compared against matched control group
RESULTS
reduction in cost
of ER care
23%
Overall savings per
patient per month
$255
reduction in poorly
controlled high blood
pressure
50%
satisfaction rating for
ImagineCare Health
Navigator & RN services
95%
the national employer
health & wellness
program engagement
4x
reduction in
hospital admissions
56%
*Engagement vs. Towers Watson National Survey of employer health and wellness programs “Staying@Work Report 2013/2014, United States”

43. “I remember struggling to get 10,000
steps each day, watching my heart
rate increase with each round of 1,000
steps … my heart is grateful for
everything you have given it.”
RESULTS

44. “He was patient, he went at her speed,
he allowed her to practice…she is now
able to do this on her own!”
–Caregiver for an 89-year-old ImagineCare customer
RESULTS

45. “The term ‘hypertensive’ now
has the follow-up ‘inactive’ in
my medical record.”
RESULTS

46. RESULTS
“I owe a debt to ImagineCare and am
so appreciative of the experience and
interactions I have had with your team.
You have... quite literally... helped
change my life. Thank you for
everything!

47. Don’t just throw technology at
the problem – consider the power
of the human element.
TAKEAWAY #1

48. Take a structured, theory-grounded
approach. Start from the evidence,
and iterate from there.
TAKEAWAY #2

49. ImagineCare
Jamie Thomson Experience Design Director
Olga Elizarova Senior Behavior Change Analyst
Empowering Patients with
Behavioral Science and Technology