Reports From the Field

Brief Action Planning to Facilitate Behavior Change and Support Patient Self-Management

Journal of Clinical Outcomes Management. 2014 January;21(1)

References

1. Hoffman C, Rice D, Sung HY. Persons withnic conditions. Their prevalence and costs. JAMA 1996;276(18):1473–9.

2. Institute of Medicine. Living well with chro:ic illness: a call for public health action. Washington (DC); The National Academies Press; 2012.

3. De Silva D. Evidence: helping people help themselves. London: The Health Foundation Inspiring Improvement; 2011.

4. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA 2002;288:2469–75.

5. Miller W, Benefield R, Tonigan J. Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. J Consul Clin Psychol 1993;61:455–461.

6. Lorig K, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med 2003;26:1–7.

7. Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation 2010;122:406–41.

8. Lorig K, Laurent DD, Plant K, Krishnan E, Ritter PL. The components of action planning and their associations with behavior and health outcomes. Chronic Illn 2013. Available at www.ncbi.nlm.nih.gov/pubmed/23838837.

9. Schlair S, Moore S, Mcmacken M, Jay M. How to deliver high-quality obesity counseling in primary care using the 5As framework. J Clin Outcomes Manag 2012;19:221–9.

10. Lorig KR, Ritter P, Stewart a L, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care 2001;39:1217–23.

11. Jay MR, Gillespie CC, Schlair SL, et al. The impact of primary care resident physician training on patient weight loss at 12 months. Obesity 2013;21:45–50.

12. Goldstein MG, Whitlock EP, DePue J. Multiple behavioral risk factor interventions in primary care. Summary of research evidence. Am J Prev Med 2004;27:61–79.

13. Lundahl B, Moleni T, Burke BL, et al. Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient Educ Couns 2013;93:157–68.

14. Rubak S, Sandbæk A, Lauritzen T, Christensen B. Motivational Interviewing: a systematic review and meta-analysis. Br J Gen Pract 2005;55:305–12.

15. Dunn C, Deroo L, Rivara F. The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. Addiction 2001;96:1725–42.

16. Heckman CJ, Egleston BL, Hofmann MT. Efficacy of motivational interviewing for smoking cessation: a systematic review and meta-analysis. Tob Control 2010;19:410–6.

17. Miller WR, Rollnick S. Motivational interviewing: helping people change. 3rd ed. New York: Guilford Press; 2013.

18. Resnicow K, DiIorio C, Soet J, et al. Motivational interviewing in health promotion: it sounds like something is changing. Health Psychol 2002;21:444–451.

19. Doherty RB, Crowley RA. Principles supporting dynamic clinical care teams: an American College of Physicians position paper. Ann Intern Med 2013;159:620–6.

20. NCQA PCMH 2011 Standards, Elements and Factors. Documentation Guideline/Data Sources. 4A: Provide self-care support and community resources. Available at www.ncqa.org/portals/0/Programs/Recognition/PCMH_2011_Data_Sources_6.6.12.pdf.

21. Reims K, Gutnick D, Davis C, Cole S. Brief action planning white paper. 2012. Available at www.centrecmi.ca.

22. Cole S, Davis C, Cole M, Gutnick D. Motivational interviewing and the patient centered medical home: a strategic approach to self-management support in primary care. In: Patient-Centered Primary Care Collaborative. Health IT in the patient centered medical home. October 2010. Available at www.pcpcc.net/guide/health-it-pcmh.

23. Cole S, Cole M, Gutnick D, Davis C. Function three: collaborate for management. In: Cole S, Bird J, editors. The medical interview: the three function approach. 3rd ed. Philadelphia:Saunders; 2014.

24. Cole S, Gutnick D, Davis C, Cole M. Brief action planning (BAP): a self-management support tool. In: Bickley L. Bates’ guide to physical examination and history taking. 11th ed. Philadelphia: Lippincott Williams and Wilkins; 2013.

25. AMA Physician tip sheet for self-management support. Available at www.ama-assn.org/ama1/pub/upload/mm/433/phys_tip_sheet.pdf.

26. Taksler G, Keshner M, Fagerlin A. Personalized estimates of benefit from preventive care guidelines. Ann Intern Med 2013;159:161–9.

27. Centre for Comprehensive Motivational Interventions [website]. Available at www.centreecmi.com.

28. Del Canale S, Louis DZ, Maio V, et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med 2012;87:1243–9.

29. Moyers TB, Miller WR, Hendrickson SML. How does motivational interviewing work? Therapist interpersonal skill predicts client involvement within motivational interviewing sessions. J Consult Clin Psychol 2005;73:590–8.

30. Hojat M, Louis DZ, Markham FW, et al. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med 2011;86:359–64.

31. Heisler M, Bouknight RR, Hayward RA, et al. The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management. J Gen Intern Med 2002;17:243–52.

32. Miller WR, Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychother 2009;37:129–40.

33. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977;85:191–215.

34. Kiesler, Charles A. The psychology of commitment: experiments linking behavior to belief. New York: Academic Press;1971.

35. Lorig K, Laurent DD, Plant K, et al. The components of action planning and their associations with behavior and health outcomes. Chronic Illn 2013.

36. MacGregor K, Handley M, Wong S, et al. Behavior-change action plans in primary care: a feasibility study of clinicians. J Am Board Fam Med 19:215–23.

37. Gollwitzer P. Implementation intentions. Am Psychol 1999;54:493–503.

38. Gollwitzer P, Sheeran P. Implementation intensions and goal achievement: A meta-analysis of effects and processes. Adv Exp Soc Psychology 2006;38:69–119.

39. Stretcher V, De Vellis B, Becker M, Rosenstock I. The role of self-efficacy in achieving behavior change. Health Educ Q 1986;13:73–92.

40. Ajzen I. Constructing a theory of planned behavior questionnaire. Available at people.umass.edu/aizen/pdf/tpb.measurement.pdf.

41. Rogers RW. Protection motivation theory of fear appeals and attitude-change. J Psychol 1975;91:93–114.

42. Schwarzer R. Modeling health behavior change: how to predict and modify the adoption and maintenance of health behaviors. Appl Psychol An Int Rev 2008;57:1–29.

43. Cialdini R. Influence: science and practice. 5th ed. Boston:Allyn and Bacon; 2008.

44. Stott NC, Rollnick S, Rees MR, Pill RM. Innovation in clinical method: diabetes care and negotiating skills. Fam Pract 1995;12:413–8.

45. Miller WR, Rollnick S, Butler C. Motivational interviewing in health care. New York: Guilford Press; 2008.

46. Bodenheimer T, Handley M. Goal-setting for behavior change in primary care: an exploration and status report. Patient Educ Couns 2009;76:174–80.

47. Locke EA, Latham GP. Building a practically useful theory of goal setting and task motivation. Am Psychol 2002;57:705–17.

48. Doran G. There’s a S.M.A.R.T. way to write management’s goals and objectives. Manag Rev 1981;70:35–6.

49. Locke EA. Toward a theory of task motivation and incentives. Organ Behav Hum Perform 1968;3:157–89.

50. Locke EA, Latham GP, Erez M. The determinants of goal commitment. Acad Manag Rev 1988;13:23–39.

51. Lorig K, Homan H, Sobel D, et al. Living a healthy life with chronic conditions. 4th ed. Boulder: Bull Publishing; 2012.

52. Amrhein PC, Miller WR, Yahne CE, et al. Client commitment language during motivational interviewing predicts drug use outcomes. J Consult Clin Psychol 2003;71:862–78.

53. Ahaeonovich E, Amrhein PC, Bisaha A, et al. Cognition, commitment language and behavioral change among cocaine-dependent patients. Psychol Addict Behav 2008;22:557–62.

54. Gutnick D. Centre for Comprehensive Motivational Interventions community of practice webinar. Brief action planning and culture: developing culturally specific confidence rules. 2012. Available at www.centrecmi.ca.

55. Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults. A scientific statement from the American Heart Association. Circulation 2010;122:406–41.

56. Handley M, MacGregor K, Schillinger D, et al. Using action plans to help primary care patients adopt healthy behaviors: a descriptive study. J Am Board Fam Med 2006;19:224–31.

57. Joint Commision. Primary care medical home option-additional requirements. Available at www.jointcommission.org/assets/1/18/PCMH_new_stds_by_5_characteristics.pdf.

58. Oregon Health Policy and Research. Standards for patient centered medical home recognition. Available at www.oregon.gov/oha/OHPR/pages/healthreform/pcpch/standards.aspx.

59. Nutting PA, Crabtree BF, Miller WL, et al. Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the national demonstration project. Am Fam Med 2010;8(Suppl 1):S45–S56.

60. Stewart EE, Nutting PA, Crabtree BF, et al. Implementing the patient-centered medical home: observation and description of the National Demonstration Project. Am Fam Med 2010;8(Suppl 1):S21–S32.

may be a better fit, or referring to a more specific question may flow more naturally from the conversation such as “We’ve been talking about diabetes, is there anything you would like to do for that or anything else in the next week or two?”

Although technically Question 1 is a closed-ended question (in that it can be answered “yes” or “no”), in actual practice it generates productive discussions about change.

For example, whenever a patient answers “yes” or “no” or something in-between like, “I’m not sure,” the clinician can often smoothly transition to a dialogue about change based on that response. Responses to Question 1 generally take 3 forms (Figure 1):

1) Have an Idea. A group of patients immediately present an idea that they are ready to do or are ready to consider doing. For these patients, clinicians can proceed directly to Skill 2—SMART Behavioral Planning; that is, asking patients directly if they are ready to turn their idea into a concrete plan. Some evidence suggests that further discussion, assessment, or even additional "motivational" exploration in patients who are ready to make a plan and already have an idea may actually decrease motivation for change [17, 32].

2) Not Sure. Another group of patients may want or need suggestions before committing to something specific they want to work on. For these patients, clinicians should use the opportunity to offer a Behavioral Menu (Skill 1).

3) No or Not at This Time. A third group of patients may not be interested or ready to make a change at this time or at all. Some in this group may be healthy or already self-managing effectively and have no need to make a plan, in which case the clinician acknowledges their active self-management and moves to the next part of the visit. Others in this group may have considerable ambivalence about change or face complex situations where other priorities take precedence. Clinicians frequently label these individuals as "resistant." The Spirit of MI can be very useful when working with these patients to accept and respect their autonomy while encouraging ongoing partnership at a future time. For example, a clinician may say “It sounds like you are not interested in making a plan for your health right now. Would it be OK if I ask you about this again at our next visit?” Pushing forward to make a "plan for change" when a patient is not ready decreases both motivation for change as well as the likelihood for a successful outcome [32].

Other patients may benefit from additional motivational approaches to further explore change and ambivalence. If the clinician does not have these skills, patients may be seamlessly transitioned to another resource within or external to the care team.

Skill 1: Offering a Behavioral Menu

If in response to Question 1 an individual is unable to come up with an idea of their own or needs more information, then offering a Behavioral Menu may be helpful [44,45]. Consistent with the “Spirit of MI,” BAP attempts to elicit ideas from the individual themselves; however, it is important to recognize that some people require assistance to identify possible actions. A behavioral menu is comprised of 2 or 3 suggestions or ideas that will ideally trigger individuals to discover an idea of their own. There are 3 distinct evidence-based steps to follow when presenting a Behavioral Menu.