1. Hope and Action
Theory and Practice
Alan Glaseroff MD
Stanford Coordinated Care
aglasero@stanford.edu

2. A Costly Health System Failure
• Avoidable Hospital Admissions 2x more likely for asthma and diabetes in
US vs. average of 30 developed countries in Organization for Economic
Cooperation and Development
“The United States does not do well in preventing costly hospital
admissions for chronic conditions, such as asthma or
complications from diabetes, which should normally be
managed through proper primary care.”
(Organization for Economic Cooperation and Development. Expensive healthcare is not always the best
healthcare, says OECD’s Health at a Glance [Internet]. Paris: OECD; 2009 Aug [cited 2010 Jan 3)]).
vs.
2

3. Determinants of Health and Their Contribution
to Premature Death
15%
30%
5%
10%
Social
Environmental
Medical
Behavioral
Genetic
40%
Schroeder, NEJM 357; 12
3

4. Patient–Driven Care
• “Others have struggled to find a proper
definition of patient-centeredness. Three
useful maxims that I have encountered are
these:”
– “The needs of the patient come first.”
– “Nothing about me without me.”
– “Every patient is the only patient.”
Donald M. Berwick, What 'Patient-Centered' Should Mean: Confessions Of An
Extremist Health Affairs, 28, no.4 (2009):w555-w565
• New definition: Patients largely produce
their own outcomes!
4

5. Behavior Change is Key…
5

6. Why Do Our Patients Struggle?
(“strong” endorsements by physicians)
poor self-discipline
poor will-power
not scared enough
not intelligent enough
53.2%
50.0%
36.9%
16.3%
Polonsky, Boswell and Edelman, 1996
6

7. Unachievable Self-Care Plans
• Unclear
- “I’m supposed to start exercising.”
• Unrealistic
- “My doctor told me to lose 10 lbs before the
next visit.”
- “Taking care of my diabetes means I’m
supposed to eat perfectly and never cheat.”
7

8. The Overarching Approach
The patient must…
 BELIEVE SELF-MANAGEMENT IS
WORTHWHILE: The patient must feel
there is hope and benefit in doing a
good job (GOALS)
 KNOW WHAT TO DO: The patient
must have a clear and achievable plan
for self-management (ACTION
PLANS)
8

9. Time to Practice (1)
• Pair-up
• Choose roles (one person be the provider, one person be
the patient).
– You will get to switch roles
• 5 minutes for each section
• Not “role-playing” – pick something real from your life
• Follow instructions closely
9

10. Persuasion Techniques
•
•
•
•
•
•
•
•
Agree that patient should make the change
Explain why the change is important
Warn of consequences of not changing
Advise patient how to change
Reassure patient that change is possible
Disagree if patient argues against change
Tell the patient what to do
Give examples of others (other patients, peers,
celebrities) who have made similar healthy
changes
10

11. How did that feel?
11

12. “Why wouldn’t a person with
a chronic condition do
everything in their power to
live long and feel well?”
12

13. 13

14. 14

15. WHAT DOESN’T WORK
• Labeling patient as “unmotivated,”
“unwilling to change,” or “non-compliant”
• Taking sides in the patient’s ambivalence
- Giving advice
- Transmitting knowledge unasked
- Threatening bad outcomes
- “you’ll go blind if you don’t do what I
tell you.”
- Urging more willpower “
- if you would just try harder…”
15
• Caring more than the patient…

16. 16

17. Unachievable Self-Care Plans
• Unclear
- “I’m supposed to start exercising.”
• Unrealistic
- “My doctor told me to lose 10 lbs before the
next visit.”
- “Taking care of my diabetes means I’m
supposed to eat perfectly and never cheat.”
17

18. The Overarching Approach

GOALS: BELIEVE SELFMANAGEMENT IS WORTHWHILE:
The patient must feel there is hope
and benefit in doing a good job.
18

19. FACTS AND FICTIONS
1. Diabetes is the leading cause of adult
blindness, amputations and kidney failure.
True or false?
________________________________________
A. False. Poorly controlled diabetes is the leading
cause of adult blindness, amputations and kidney
failure.
19

20. Feelings Can Fuel Change

What are the patient’s feelings?





Think of a patient you’ve seen recently
Have you ever asked how he/she feels about
his/her diabetes?
What “bugs” that person the most about his/her
diabetes???
What is working for that person in their current
lifestyle? (what is the function in the
“dysfunction”)
ASK! (then listen)
20

21. Behavior Change Strategies
1. Begin with your patient’s interests
• Agenda must be personally meaningful for
the patient
• Start with questions, not information:
• “What questions should we make sure to
address today?”
• “What’s been driving you crazy about
your chronic condition?”
21

22. Behavior Change Strategies
1. Begin with your patient’s interests
2. Believe that your patient is motivated
to live a long, healthy life
• You are both on the same side
22

23. Behavior Change Strategies
1. Begin with your patient’s interests
2. Believe that your patient is motivated to
live a long, healthy life
3. Help your patient determine exactly
what they might want to change
• Identify and respect ambivalence
• Present “the bouquet”
23

24. Time to Practice (2)
• Switch roles
• 5 minutes
• Again, no “role playing”
• Follow instructions closely
24

25. The “Journalist” Intervention
1.
2.
Zero in on an area for behavior change
Get the details
•
3.
Explore relevant beliefs (4 “importance”
questions)
•
4.
Be a journalist, listen carefully, limit questions
“Your current score? Why not lower? Why not
higher? How to bump it up?”
Summarize and feed back the total story
DO NOT OFFER ANY HELP OR ADVICE
25

26. Importance
“How do you feel about exercise now? If ‘0’
was not important, and ‘10” was very
important, what number would you give
yourself?”
0_________________________________10
not important
very important
“You rated exercise importance at 4.”
Why isn’t it a 3? (listen for the benefits)
“And what would it take to make it a 7 (listen for ideas to overcome
barriers)a 6 or 7?” (listen for the obstacles)
Rollnick et al, 26

27. Listen Well and Summarize
“It sounds like you’re inclined in two
different directions. On the one hand, you’re
somewhat worried about the possible longterm effects of your illness if you don’t
manage it well–it’s pretty scary to think about
such things. On the other hand, you’re young
and you feel fairly healthy most of the time.
You enjoy doing what you like to do, eat what
you like to eat, and the long-term
consequences seem far away. You’re
concerned, and at the same time you’re not
concerned.”
27

28. The Overarching Approach


BELIEVE SELF-MANAGEMENT IS
WORTHWHILE: The patient must feel
there is hope and benefit in doing a
good job.
KNOW WHAT TO DO. The patient
must have a clear and achievable plan
for self-management
28

29. How did that feel?
29

30. Behavior Change Strategies
1. Begin with your patient’s interests
2. Believe that your patient is motivated
to live a long, healthy life
3. Help your patient determine exactly
what they might want to change
• Identify and respect ambivalence
• Present the bouquet
4. Develop a reasonable, detailed action
plan
30

31. The “Action Plan”
Intervention
1. Don’t tell patients what to do
2. Negotiate what changes to focus on
blending your expertise and patients’ desires
3. Focus on 1 – 2 concrete actions to start
Not attitudes, numbers, or actions to stop
Not “lose 5 pounds in 2 weeks”
Instead…”Walk briskly 20 minutes 3 x/ week,
Monday, Wednesday and Friday after
lunch”
31

32. The “Action Plan” Intervention
4. Start with changes that are achievable
even if “physiologically silly”
5. Selected actions must be personally
meaningful
6. Do the first step right away
“What does this mean you’ll do tomorrow
AM?”
32

33. Implementation Intentions
• Promote cervical cancer screening
appointment
• Random assignment to experimental or
control procedure (n = 114)
• Control. Lecture about the need for
screening
• Experimental. Lecture plus:
- “You’re more likely to go for a cervical
smear if you decide when and where
you’ll go. Please write in when, where
and how you’ll make appointment.”
Sheeran and Orbell, 2000
33

34. % attending screening appointment
The Power of Implementation
100
90
80
70
60
50
40
Lecture
Lecture plus implementation plan
Sheeran and Orbell, 2000
34

35. How did it feel?
35

36. Behavior Change Strategies
1. Begin with your patient’s interests
2. Believe that your patient is motivated
to live a long, healthy life
3. Help your patient determine exactly
what they might want to change
4. Develop a reasonable, detailed action
plan
5. Stay alert for common obstacles
36

37. Patient Self-Management Barriers
1. ……
2. ……
3. ……
4. ……
5. ……
6. ……
7. ……
37

38. Patient Self-Management Barriers






Social devastation
(poverty, homelessness, lack of
access to health care services, etc)
Lack of information
Cultural disconnect
Low functional health literacy
Relative lack of life skills
Anxiety/disease-specific
distress/depression
38

39. PAM – what the patient brings to the
problem
The Patient Activation Measure® (PAM®)
assessment gauges the knowledge, skills and
confidence essential to managing one’s own
health and healthcare.
Level 1
Level 2
Starting to
take a role.
Building
knowledge
and
confidence
Level 3
Taking
action
Level 4
Maintaining
behaviors
39

40. Address Health Literacy
• Assess patients’ recall or
comprehension of recommendations
(aka “close the loop”)
• D. "So . . . let's make sure. What
medications are we going to change?"
• P. "I think we're going to stop this one (is
it metformin?) . . . and I'm going to take
glipizide twice a day. . . I think that's the
green one.“
• Develop strategies to overcome this barrier
(case management, phone contacts, etc)
Schillinger et al, 2003
40

41. Take-Home Messages
• Almost everyone would prefer to live a long,
healthy life
• Our patients are not unmotivated to selfmanage effectively
• The problem is that self-care is tough
• Our patients face many obstacles to good
self-care
• Simple behavior change strategies are likely
to help
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