Here's how to move patients toward health
Here's how to move patients toward health
The key is to understand their readiness
Most case management interventions assume that because patients have medical conditions, they will understand the necessity of complying with treatment plans. However, patients aren't always ready to take the action necessary to regain and maintain their health.
"People in general are bad at regular routines," says Mark L. Robbins, PhD, a fellow in clinical and health psychology at the Cancer Prevention Research Center at the University of Rhode Island in Warwick. "We vary in our readiness, or motivation, to change. If case managers and physicians understand their patients' stage of readiness, they can guide their interventions and increase their chances for success."
Robbins and his colleagues at the University of Rhode Island have applied the Transtheoretical Model of Health Behavior Change to several health situations, including health promotion and substance abuse programs. (For an example of how the model was applied to increase breast cancer screening in a health maintenance organization, see p. 107.) The model includes these five stages:
1. Precontemplation. The patient is not ready to act and has no intention of acting in the next six months. "These patients may avoid reading, talking, or thinking about the changes they need to make," Robbins says. Pressuring them to change probably will backfire. Instead, encourage them to think about change and read about their condition.
2. Contemplation. The patient is thinking about taking action and intends to start in the next six months. These patients feel unprepared to change. They aren't confident that they will succeed. Robbins suggests case managers help patients weigh the pros and cons of their treatment plan and encourage them to take small action steps.
3. Preparation. The patient is getting ready to take action and is practicing the behavior. These patients are more confident and are most likely to benefit from traditional disease management programs, Robbins says. Encourage patients to plan adequate time, energy, and support for change and help them set goals, he says.
4. Action. The patient recently has started to change behavior and has consistently made changes for less than six months.
5. Maintenance. The patient has changed behavior consistently for six months or more. Patients in both action and maintenance stages may benefit from stimulus controls, Robbins says. For example, beepers to help patients remember to take their medications might be useful.
Of course, patients change over time. "Patients shift their motivations and when they shift they need different interventions to encourage positive actions. The model allows us to look at an entire patient population and deliver materials that make sense to each individual," he says. What makes this tailoring possible is new computer technology. "We can easily deliver different interventions for anyone who sits down at a computer.
Gigi Spicer, RN, BSN, nursing director of the kidney transplant program at Henrico Doctor's Hospital in Richmond, VA, recently tested one stage-based model developed by University of Rhode Island researchers to encourage weight loss and improve nutrition in overweight adolescents. The computer model simulated a scenario in which an adolescent had gone to McDonald's. The model reviewed the patient's past issues and evaluated the patient's progress. "It was amazing," she says. "The computer models make tailored messages possible even for large groups."
However, the model doesn't often the solution to the complex issue of improving compliance, cautions Christopher J. Combs, PhD, clinical psychologist with Temple University Hospital in Philadelphia. "The problem is that we can't control the stage our patients are in when they need medical interventions, and we don't always have enough time to change their stage of readiness," he says. "If you need a transplant, you need a transplant, and you are in the stage of readiness you are in."
Yet Spicer believes in the model, and Henrico Doctor's Hospital hopes to begin a pilot project to improve compliance in its transplant patients. "I believe the model of health behavior change holds the key to readjusting models of care so that they are more successful. Using the model gives me a conceptual framework to plug things into. It helps me understand what to do and why."
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