self-management goal setting...

Self-Management Goal Setting Technique

1. Ask patient:

“Is there something you would like work on to improve your health this week?”

2. Develop a short term goal that is

a. Specific

b. Limited

c. Achievable

d. Measurable

3. Gauge the patient’s Conviction. If rated less than 7, adjust goal to something that is more

important to patient.

4. Gauge the patient’s Confidence. Adjust goal to something that patient is at least 7/10 confident

that he or she can achieve.

5. Arrange short-term follow-up, if possible with phone call, email, journaling, etc.

6. Document goal in PSL to be sure to recall goal to ask about at next visit.

Note: Confidence and Conviction are self-rated by the patient. See Background Information (page 8) for

more details about how to gauge confidence and Conviction.

This module was prepared by:

Monica M. DiMagno MD Cecilia Sauter MS RD CDE Michele Heisler MD MPA Connie Standiford MD

Self Management Goal Setting © University of Michigan Health System

During this 30-minute teaching module, you will be guiding each other through a practice session in setting a self-management goal. This can either be done in pairs, with each pair taking turns setting a goal, or as a group, with the preceptor (or resident leader) going around the room and guiding each resident (and themselves) through setting a goal. Setting a goal for our own health can help provide insight into the difficulties our patients face in self-management. Later in the clinic today, you can also practice this goal setting technique with a patient. Learning self-management technique: an exercise for small group of learners Clinicians are great at presenting information effectively. However, most have less training and practice in the skill of helping patients set a behavioral goal. The following is an exercise you can use to practice effective communication.

1. Pair up, with one person acting as the “provider” and the other the “patient.”

2. The provider ask the following question: “Is there something you would like to work on in the next week to improve your health?”

3. The provider encourages the patient by reflecting on what he thinks the patient said, or by asking questions such as “Why do you think that is?” or “What are your thoughts about that?” The provider does not offer advice or express an opinion.

4. Once a goal is stated, work with patient to make goal SLAM-able, being specific, limited, achievable and measurable (e.g., “Over the next week, I am going to walk around my block twice right after I eat lunch.”).

5. Ask the patient to rate his level of conviction about the importance of the goal and confidence that they will be able to meet the specific goal,, adjusting the goal as necessary so that both are rated at least 7 out of 10.

6. Close the loop: to practice teach back the provider can ask the patient to summarize the goal. (e.g. “To make sure we are clear would you tell me what your goal is for the next week?”)

The exercise is then repeated with the speaker and listener exchanging roles. At the end of the exercise, discuss what was learned from the experiment in each of the roles. Ask people if they would like to share the goal that they set. Demonstrate how the goals are specific, limited, achievable and measurable. Make sure each participant assesses the level of conviction about meeting and confidence that he will be able to achieve the goal. At the end of the session record the goal that each participant set for review next week. During today’s clinic, when an appropriate patient presents, the resident should work at setting a focused short term goal. Next week, review everyone’s progress at meeting his own goal. Work at troubleshooting pitfalls and especially assessing how the goal could have been structured differently (i.e. was it not specific enough or not meaningful enough.)


Background Improving Management Support in Primary Care Practice: Introduction to Six A’s Framework Objective: To help clinicians support and enhance patient motivation to change health behaviors and improve self-management of chronic illness. Skills: At the end of this module learners should be able to:

1. Describe and demonstrate the Six A’s of behavioral counseling 2. Use scaling of confidence and conviction in goal setting 3. Help a patient choose an appropriate self-management goal. 4. Describe and demonstrate the “close the loop” technique

The Six A’s Framework for Behavioral Counseling The Six A’s are: Addressing the Patient’s Agenda, Assess, Advise, Agree, Assist and Arrange

1. Address the Patient’s Agenda:

The patient expresses any concerns or areas he or she particularly wants to discuss at the office visit. Eliciting and focusing on the patient’s 1 or 2 top health concerns at the beginning of each clinical visit fosters clinical partnership, promotes the therapeutic relationship, and encourages success in improving health behaviors.

2. Assess: The clinician assesses the patient’s beliefs, behaviors and readiness to change. By asking “Is there anything you would like to do this week to improve your health?” the clinician empowers the patient and helps to pick an actionable goal.

3. Advise: The clinician provides information about a chronic illness, the health risks and benefits of change Use of “close the loop” or teach back helps to improve and ensure understanding of important instructions or plans.

4. Agree: The patient and the clinician collaboratively select a health related goal. Make the goal Specific, Limited, Achievable and Measurable (SLAM), while selecting a goal that the patient is both convinced is important and confident he/she can achieve.

5. Assist: The physician can assist the patient to identify personal barriers and resources. Help by drawing from prior experiences to troubleshoot obstacles, finding needed resources and materials, and teaching helpful management techniques

6. Arrange: Arrange for follow up to reinforce effective patient self-management behaviors and to respond to changing challenges. Record the Self Management Goal just set and agree upon an appropriate follow-up interval, using any available support resources for aid in timely review of goal progress.


Problem: In chronic illness most of the treatment has to be carried out by the patient him or herself. The reality of a chronic disease is that the patients have both the right and the responsibility to make self-management decisions on a daily basis. Self-management is what people do every day: decide what to eat, whether to exercise, if and when they will monitor their health or take their medications. Since much of the self-management in chronic diseases requires lifestyle changes, many patients feel that the clinician’s recommendations are intrusive. On the other hand, many clinicians feel frustrated because they can not get their patients to follow their recommendations (Rubin RR, Anderson RM, Funnell MM, 2002). As a result it is critical that physicians have an understanding of strategies they can use to support their patients’ self-management efforts. This understanding is based on three fundamental aspects of chronic illness care: choices, control and consequences. The choices that patients make each day often have a greater impact on their outcomes than those made by health professionals. In addition, patients are in charge of their self-management behaviors, they are in control of which recommendations they choose to implement or ignore. Finally, because the consequences of these decisions accrue directly to patients, they have both the right and the responsibility to manage their health in the way that is best suited to the context and culture of their lives. The evidence shows that good clinician communication improves patient adherence to treatment recommendation, self-care, satisfaction and health outcomes. To be effective, however, the clinician must recognize that the collaborative approach leads to better outcomes. The clinician is the expert in the disease while the patient is the expert in his or her own life, including knowing what works and does not work. Patients are more likely to follow medical recommendations and have better health outcomes when they participate more in treatment decisions and are more satisfied with their physician’s communication skills. It is estimated that only 20% of health care involves professional advice, 80% is self-care. Physicians need to have familiarity with techniques used to assist patients in self-management. Everyone self-manages; the question is whether the choices they make improve health-related behaviors and lead to improved clinical outcomes. (Bodenheimer et al. Helping Patients Manage their Chronic Conditions. California Healthcare Foundation, 2004. www.chcf.org) Self Awareness All clinicians bring their own beliefs, values, experience and personalities to the patient relationship. Clinicians naturally have varied attitudes about motivating behavioral change. Some feel pessimistic or cynical about patients’ ability to change their behavior. While these clinicians are no less aware of the importance of a healthy therapeutic relationship and work at showing respect and empathy, negative attitude can erode possible successful outcome and undermine their efforts. Maladaptive motivational tactics have been explicitly taught by some and implicitly learned by many. Some clinicians feel unprepared and untrained to successfully counsel patients to change behaviors. Some attitudes include; scaring into change, using guilt to move into change, feeling overwhelmed to assist with change, and some clinicians do not feel it is their role. Other clinicians are motivating, “you can do this, let me help.” Assessing the clinician’s beliefs and skill level is important. How convinced is the clinician that it is important for him/her to counsel patients about behavior? How confident is this clinician that he/she has the skills to enact this role successfully? Many feel that they will open a “Pandora’s box” of emotional and psychosocial pathology that they feel ill-equipped to deal with. However, when prepared, clinicians are a powerful motivator. It is helpful for the clinician to try to objectively assess his attitude and skill level. One way to self-assess is to apply the conviction/confidence assessment to one’s own outlook:

How convinced am I that I am able to motivate patients to change behavior? How confident am I that I can help patients change their behavior?


http://www.chcf.org/

When the clinician determines where the biggest challenge lies, be it in conviction or confidence, he can then in turn ask the question, what would it take to make me more convinced? What would it take to make me more confident? Like all other skills, practice helps. Trying out the relationship building skills on a small scale, perhaps trying one phrase out with each patient can be less overwhelming and may result in a palpable change in the interview. Experiencing such successes builds this confidence. Clinicians assist patients in identifying issues that the patient wants to work on, the approaches that might be helpful and the impact these approaches have on their disease and quality of life. Engaging patients in collaborative care requires that health care providers learn new skills. The triad of goal-setting, action-planning and problem-solving, is central to improving chronic disease behaviors and outcomes.

The Six A’s Framework for Behavioral Counseling The six A’s were introduced by the NCI to be applied to assist patients with smoking cessation. The USPSTF Counseling and Behavioral Interventions Work Group recently recommended adopting it as a unifying conceptual framework for evaluating and describing health behavioral counseling efforts in primary and general health care settings. Patient and provider communication affects both patient behavior and patient outcomes (Skolund) The Six A’s are: Address the Patient’s Agenda, Assess, Advise, Agree, Assist, Arrange.

1. Address the Patient’s Agenda:

Before explicitly assessing possible barriers to effective patient self-management, it is essential to give the patient a chance to express any concerns or areas he or she particularly wants to discuss at the office visit (address the agenda). The DAWN study showed very clearly that patients with diabetes have an initial and continuing distress related to diabetes. Patients would like more help from their providers to address these issues, but very few receive this help. Studies have found that many physicians fail to elicit patients’ concerns, which impedes the development of an effective partnership. Because of the multiple self-management behaviors required in chronic disease management, often it is best to assess the patient’s own agenda to help decide where to focus first. By asking: “What is the hardest or causing you the most concern about caring for your diabetes at this time? What would you like us to do during your visit to help address your concern?” the clinician allows the patient to set the agenda (Diabetes Concern Assessment From, Anderson RM, Funnell, MM, MDRTC, 2005).

Effectively building a relationship and eliciting patient concerns and feelings are crucial building blocks for self-management support, especially with patients who are less motivated or ready to take action (Heisler M, 2005). Useful skills are open-ended inquiry, reflective listening, expressing empathy and clarification.

2. Assess:

The next step is for the clinician to assess the patient’s beliefs, behaviors and readiness to change. In effective assessments, the physician identifies problematic self-management areas and whether the problems stem from:

• lack of understanding of medical recommendations (knowledge deficit) • lack of agreement with recommendations • barriers to performing a mutually agreed-upon self-care behavior.


It is well-documented that patients are better satisfied and more likely to feel committed to an action when they feel they have been able to express concerns and propose actions in their own words. Almost everyone would like to change something. Let them pick the “something.” It is important to assess how convinced a patient is that a behavioral change is important (their Conviction) and what their skill levels are to achieve that change (their Confidence). Patients may not be ready to develop an action plan in one area; but may be ready to work on another problem that is more meaningful to them. By asking “Is there anything you would like to do this week to improve your health?” the clinician allows the patient to work on something that is currently relevant to them, thus increasing the likelihood that the patient will follow through and succeed.

3. Advise:

Once the clinician has identified the patient’s readiness to work on a specific action plan, they can now provide information. Here the clinician can increase the awareness of the importance of a specific action plan. Patients also need to be aware of the different options and choices they have available. Being familiar with the patient’s priorities and health beliefs makes collaborative development of the action plan easier.

As many as 50% of patients leave the physician office visit without understanding what the physician said. Asking patients to restate information you have just told them is called “closing the loop” or teach back.

(With permission from Heisler M, 2005)

For example:

“To be sure that I was clear, please tell me in your own words your understanding of why you should take this medication”

Closing the Loop: Interactive Communication to Enhance Recall & Comprehension

Re-AssessPatient Recall &Comprehension

Adherence

New Concept:Health Information,

Advice, or Change in Management

Provider Explains New Concept

Patient Recalls and Comprehends

AssessPatient Recall & Comprehension

Clarify & Tailor Explanation

4. Agree:

Next the patient and the clinician collaboratively select a health-related goal. First, it is important to help the patient identify the problem, come up with a list of ideas to solve the problem and collaboratively pick one and try it for a couple of weeks. The patient agrees on a specific and


achievable action plan to move toward attainment of the goals. One easy question to start this process is to ask:

“Is there anything you would like to do this week to improve your health?” It is sometimes helpful to have a menu of options for the patient to choose from such as: physical activity, healthy diet, reducing stress, taking medications, checking sugars. A bubble chart can help avoid emphasizing one area over the other.

It is crucial for the clinician to help the patient set a. “SLAM”-able goal which is Specific, Limited, Achievable and Measurable. Short term goals and very specific goals are more effective than long term and general goals. Achieving a goal, even if small, increases self-efficacy and confidence that one can improve one’s life e.g., success begets success. Increased self-efficacy is associated with improved health related behaviors and better clinical outcomes. The clinician’s role is not to try to force change. The clinician is essential in tailoring advice to the patient needs and assisting to match them to the patient’s conviction (importance) and confidence (skills). Scaling conviction and confidence is a useful tool in letting the patient identify success and assess possible barriers.

5. Assist:

Once a self-management goal and an action plan have been agreed on, the physician can assist the patient to identify personal barriers and resources. A useful tool in assisting the patient in identifying barriers and overcoming them is “. The clinician can also provide necessary information and support to enhance patient self-efficacy, skill mastery, and self-monitoring. Importantly, the physician should express understanding and praise and offer reinforcement.

6. Arrange for follow up:

Close follow-up is crucial to build and reinforce effective patient self-management behaviors and to respond to the changing challenges of chronic disease management. Elements of effective follow-up include: • Carefully recording the main elements of the agreed-upon action plan and potential obstacles

discussed (perhaps even in the patient’s formal problem list in the medical record) to ensure follow-up on progress to date at the next visit;

Physical activity

Healthy Diet Stress

reduction

Medications Other Check

sugars


• Scheduling a follow-up visit at an interval long enough to give the patient a chance to gain some experience in the trial of new self-management behaviors and produce some measurable changes, but short enough to be able to provide timely feedback on progress;

• Encouraging the patient to attend relevant self-management training programs or other assistance programs in the community;

• As necessary, arranging for more in-depth sessions with a dietician, health educator, or counselor; • If possible and as necessary, enrolling the patient in a telephone-based support program or case

management program to provide between-visit self-management support; • Calling or e-mailing the patient between office visits to maintain contact and offer support.

Practicing Self Management Goal Setting: Skills:

Open ended inquiry, reflective listening, expressing empathy, clarification Setting an action plan Scaling Confidence/Conviction Goal negotiation

Effectively building a relationship and eliciting patient concerns and feelings are crucial building blocks for self-management support, especially with patients who are less motivated or ready to take action. Many clinicians think of good communication as speaking to the patients in a way that ensures that the message is understood and is perceived as relevant and helpful. However, effective communication also involves listening to patients in a way that ensures that they feel understood, respected and cared for. 1. Open-ended inquiries, reflective listening, clarification and expressing empathy.

• Open ended inquiry: obtain a story and not a simple answer. Using: tell me, what and how are useful stems in reflective listening. “Tell me about something you are motivated to do.”

• Reflection is active listening and then restating what the patient has said. This indicates that that the patient has been heard, and in some cases offers to emphasize, summarize or paraphrase the patient. “Sounds like you are unsure about your commitment to get your diabetes under better control.”

• Empathy strives to understand the patient at a deeper level: emotions, thoughts, values. “I can see how upset you are about this”

• Clarification “It sounds like you are really frustrated by your glucose readings when you are working so hard to bring them down.”


2. Example of setting a “SLAM”-able action plan:

A patient chooses as his/her goal to lose weight. His goal is to lose 20 pounds in the next month. This goal is specific, limited and measurable, but not achievable. This patient can be helped to set a more realistic goal, such as losing a pound a week. The action plan is how the patient plans to meet the goal. An ambitious patient may offer to exercise every day. This goal is not very specific or limited, and likely not realistically achievable. “I will walk for 15 minutes each day after lunch” is a more SLAM-able goal.

3. Scaling confidence and conviction:

Scaling conviction (importance) and confidence (skills)

o Scaling is helpful in identifying the patients own successes and barriers that are in the way to achieve the action plan. The clinician then engages in “change talk” to determine barriers. Example of scaling and change talk follow:

o “On a scale of 0 to 10 how convinced are you that it is important to check your feet?” Patient response is a 4. Clinician: “Oh, a 4.” “I ‘m curious what led you to say 4 and not a 2”? Here the patient has a chance to recognize (self-talk) that they are not doing so badly, that in a certain sense they are better than a 2. Clinician: “What would have to happen to make it a 6”? Now the patient has a chance to think about the different barriers that are in the way. As the patient identifies the barriers the clinician can now assist with ideas, information, etc to overcome those barriers. Clinician is guiding, but not leading.

o The same approach can be used to identify their confidence. On a scale 0 to 10, how confident are you that you can regularly check your feet?”

Patient response is a 6. Clinician: ‘Oh, a 6.” “What led you to rate your confidence a 6 and not a 4? Patient evaluating his/her own success. Clinician: “What would you need to get to a 7 or 8?” Patient can identify barriers and lead the clinician in how to help in overcoming those barriers.


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