Goal Driven Treatment (Introduction to the Transformation for

Health Model)

RHP 12 Learning Collaborative Package Two (Topic One)

Participants will be able to describe the transformation for health model using the theories of Brazilian Philosopher Paulo Freire

Participants will identify the stages and sequences of the transformation for health model

Participants will describe the practical implementation of the model in a chronic disease management program.

Participants will describe implementation of self efficacious behaviors

Participants will demonstrate implementation of survey tools utilized in the transformation for health

Objectives

Determinants of Health Status (from expert

consensus; Shi; Blum)

Health Status (100%)

Genetics (10%)

Medical Care (10%)

Environment (40%)

Behavior (40%)

Physical

Barriers

Financial

Education/Literacy

Nutrition & Exercise

Lifestyle choices

Employment

“An approach is needed to help patients change or adopt healthy behaviors – by

themselves, not for them by others” (Paulo Freire)

Transformation for Health

Chronic Care Model

Transformation for Health Framework

Transformation for Health Logic Model Phase One

Issue Traditional Patient Education Self-Management Education

What is taught? Information and technical skills about the disease

Skills on how to act on problems

How are problems formulated? Problems reflect inadequate control of the disease

The patient identifies problems he/she experiences that may or may not be related to the disease

Relation of education to the disease

Education is disease-specific and teaches information and technical skills related to the disease

Education provides problem-solving skills that are relevant to the consequences of chronic conditions in general

What is the theory underlying the education?

Disease-specific knowledge creates behavior change, which in turn produces better clinical outcomes

Greater patient confidence in his/her capacity to make life-improving changes (self-efficacy) yields better clinical outcomes

What is the goal? Compliance with the behavior changes taught to the patient to improve clinical outcomes

Increased self-efficacy to improve clinical outcomes

Who is the educator? A health professional A health professional, peer leader, or other patients, often in a group setting

Constructs

Cognition (Critical Consciousness)

Intention (Self-Efficacy & Social

Support)

Decision (Barriers and Facilitators for

Goal Setting)

Transformation (Self Guided Evaluation & Goal Modification)

Implementation

“CONSCIENTIZATION” – awakening of critical consciousness, which is…

A critical element of “LIBERATORY EDUCATION”, which then leads to…

PRAXIS – action needed for transformational behavior

Cognition Phase

The first and most important step in the Transformational Process: facilitating the patient’s movement from Pre-consciousness to Critical Consciousness….

Critical Consciousness

MAGIC CONSCIOUSNESS A person simply faces facts and attributes to them a superior

power by which he is controlled and to which he must submit – characterized by fatalism. Que sera, sera

NAÏVE CONSCIOUSNESS The person sees cause and effect as an unchanging established

fact which can be deceiving – a person with naïve consciousness considers himself superior to facts, in control of facts, and thus free to understand them as he pleases.

CRITICAL CONSCIOUSNESS A person who has reached the critical consciousness thinks of

things and facts as they are objectively in reality; it is integrated with reality. Critical understanding leads to critical action.

Stages in critical consciousness

THE NATURE OF HEALTH CARE RECEIVER

Limited knowledge – naïve consciousness Different competencies and skills in self-care and care

of others Adherence skills to comply with treatment plan varies

along a range or continuum Self-defeating and dysfunctional life styles may be

present driven by individual and family forces Limited internal and external resources Limited knowledge of internal and external resources

FACILITATING CRITICAL CONSCIOUSNESS

THE NATURE OF HEALTH CARE PROVIDER Specialized knowledge – expertise Plenty of experience, frequently of a technical nature Clinical skills vary along a range or extent Level of compassion for others vary along a range or

extent Works within a context of limited time and resources to

support task achievement Works within a practice setting that frequently may not

be particularly supportive or compassionate Applicable community resources are fragmented and/or

unknown

FACILITATING CRITICAL CONSCIOUSNESS

Creating an environment where patients open up to you as a provider◦How do you do this?

Find out what patient expects from you as a provider

What patients needs? Get on the patient’s level – language barriers Find out what patient is willing to do Starts out with the very first encounter – phone,

face-to-face Identify with the patient – start where the patient is,

relationship-building

Facilitating Critical Consciousness

How do you do this when you do not speak the same language as the patient?

How do you do this when the patient is hostile or uncooperative?

How do you do this when the patient is in denial?

Facilitating Critical Consciousness

Creating an environment where patients open up to you as a provider

Individual’s motivational system is awakened by critical consciousness

Capacity for the transformative process is assessed

Development of self-efficacy to begin changing lifestyles and behaviors

Intention Phase

Actualization of decision to change

Acceptance of responsibility

Acceptance of consequences and outcomes

Decision Phase

Direct involvement in the health care process

Requires a great deal of critical awareness or awakening

Requires relationship building

Transformation Phase

Transformation for Health Logic Model Phase Two

Implementation

Motivational Interviewing

Self-Efficacy Enhancement

Identification of Social Support

Promotion of Effective Use of Social Support

Avoidance in Goal Setting: Identify

Barriers and Facilitators

Facilitation of Evaluation of

Outcome

Guidance in Modification of Goals if Outcomes Not Met

Social Learning Theory

SELF-EFFICACY

What is Self-Efficacy

Choice behavior Effort expenditure and persistence Thought patterns and emotional

reactions Humans as producers rather than

simply foretellers of behavior

How does self efficacy affect behavior

Mastery experienceVicarious experience Social persuasion (including verbal persuasions)

Physiological states

SOURCES OF SELF EFFICACY INFORMATION

Self-Efficacy for Managing Chronic Disease 6-Item Scale

Self-Efficacy for DiabetesMeasure of Patient Adherence (MOS)

Self-Efficacy Measurement Tools

Transformation for Health Logic Model Phase Three

Behavoiral Outcomes

Apprehension of realities and

readiness to change

Enhanced Self-efficacy for health behavior change

Intention to Adapt Positive Changes

Effective use of social support in behavior change

Realistic goal setting for behavior

change

Maintenance of Goals

Continued Positive Behaviors

STAGES OF CHANGEPROCHESKA & DICLEMENTE

Transtheoretical Stages of ChangeProchaska & DiClemente

permanent exit

maintenance

resumed use pre-contemplation

contemplation

preparation

action

preparation

Adapted Stages of Change

Not thinking about change

Thinking about change

Preparing for change

Taking action

Maintaining change

Return to old habits

Change become permanent

Ruler Scale

How important is it to you to change this? 0…..1…..2…..3…..4…..5…..6…..7…..8…..9…..

10 Not at all

Extremely

How confident are you that you can change this?

0…..1…..2…..3…..4…..5…..6…..7…..8…..9…..10

Not at all Extremely

Transtheoretical Model

For individuals to progress, they need: A growing awareness that the advantages (the

“Pros”) of changing outweigh the disadvantages (the “Cons”)—the TTM calls this decisional balance

Confidence that they can make and maintain changes in situations that tempt them to return to their old, unhealthy behavior—the TTM calls this self-efficacy

Strategies that can help them make and maintain change—the TTM calls these processes of change. The ten processes include

Progression Through the Stages

Consciousness-Raising Dramatic Relief Self-Reevaluation Environmental Reevaluation Social Liberation Self-Liberation Helping Relationships Counter-Conditioning Reinforcement Management Stimulus Control

Strategies

Goal Driven Treatment

Constructs Implementation

Behavioral Outcomes

Targeted Goals Met

SELF EFFICACY TOOLS

Thank you!