Following up on health action plans

In the rush of a busy office practice, time to have important conversations with patients is often lost to the “tyranny of the urgent,” professional agendas, and feeling overwhelmed. Team-based care can ease this burden. Family physicians have to balance addressing acute problems, preventive care, and chronic care with what the patient chooses for self-management. Learning to collaboratively set the agenda with each patient is essential to managing time and decreasing time-management anxiety. 8 , 9

While rooming the patient, the clinical assistant should initiate agenda setting. In some practices, this will be the nurse, and in others, a medical assistant. In addition to acknowledging the documented reason for the visit, the assistant should ask, “Is there something else you want to discuss with us today?” This question should be repeated until the patient has nothing to add. For the subset of patients who have lists that are obviously too long for a single visit, the assistant can add, “We may not be able to do a good job on all of these problems in one visit, so let's pick the ones that are most important to you.” Clinical assistants should also ask whether there are any refill requests or forms the patient needs to have completed.

After greeting the patient and re-establishing rapport, the physician should acknowledge and confirm the agenda. For example, “I see that you have several things you want to discuss today, and Christine tells me that your ongoing low-back pain is most important to you. Have we missed anything more important?” A more detailed description of collaborative agenda-setting can be found in an earlier issue of Family Practice Management. 10 This important technique helps to organize time used in an office visit and protect time for self-management. A large study8 testing this method found that patients and physicians were less likely to bring up new “oh by the way” issues in the closing moments of the appointment. On average, visits with trained physicians were 90 seconds shorter compared to control physicians (while this finding falls shy of statistical significance, P = 0.1, it has clinical significance). Saved time can be devoted to creating viable care plans with patients.

Create a collaborative care plan

Research suggests that problem-solving and creating a goal and a feasible action plan improves outcomes 11 for problems such as diabetes, 12 weight loss, 13 and depression. 14 , 15 We call this a collaborative care plan. Effective problem-solving emphasizes patient centeredness and avoids the clinician imposing goals and plans on the patient. “Building a collaborative care plan” presents the steps in goal setting and action plan development with tips, suggested questions, and examples of patient responses. Every interaction does not require using every step. A flexible approach is needed based on the clinician's experience, the nature of the goal, and the patient's pre-existing problem-solving skills. Adopting a patient-centered approach to enhance patient self-management represents a major challenge in clinician attitude and behavior (the table below summarizes differences between provider-determined versus patient-determined goals).

BUILDING A COLLABORATIVE CARE PLAN, STEP BY STEP

1. Help the patient focus on a specific goal. Tip: Make it the patient's goal more than yours. Script: “Can you think of a goal to improve your health? We want to help you.” Example: “Weight control.”
2. Brainstorm activities to accomplish the goal. Tip: Ask the patient to list some possible ways to achieve the goal. Hold back sharing your suggestions and let the patient identify ideas first. Script: “What are some different ways you can accomplish your goal? List anything that comes to mind.” Example: “Consult a nutritionist; exercise more; snack less; eat less chocolate; use smaller portions.”
3. Choose an activity. Tip: Help the patient choose one activity. Too many choices may be overwhelming and less feasible, increasing the risk of failure. Script: “These are all good ideas, but I suggest you start with one activity.” Example: “Exercise.”
4. Focus the activity. Tip: The more specific the activity, the more likely it will be accomplished. A second round of brainstorming may help determine the activity most likely to be adopted. Script: “Can you think of one kind of exercise that you are most likely to accomplish?” Example: “Walking.”
5. Identify how often or how long the activity will occur. Tip: Help the patient be specific but realistic. If he or she is too ambitious, counsel the patient to set a less ambitious goal at the outset and then increase frequency or duration. Script: “How often will you exercise?” Example: “Three times a week for 15 minutes.”
6. Identify when the activity will take place. Tip: The patient may need a little time to ponder when it is feasible to do the activity. Script: “When would you like to take a walk?” Example: “Mondays and Tuesdays during my lunch hour and on Saturday mornings.”
7. Consider barriers. Tip: Identifying barriers helps the patient refine the plan, increasing feasibility and probability for success. Script: “What barriers can you foresee that might prevent you from reaching your goal?” Example: “I might not walk if it is raining or if I feel lonely and want company.”
8. Assess confidence on a scale of 1 (low) to 10 (high). Tip: Rating one's confidence helps identify social or psychological barriers. Once named, these barriers may have less power. Script: “How would you rate your confidence if 1 is the lowest chance of success and 10 is a sure thing?” Example: “I think my confidence is a 7.”
9. Identify ways to increase (or sustain) confidence Tip: Having patients think about ways to increase confidence helps reduce the influence of all barriers. Script: “What can you do to increase your confidence? How can we help you?” Example: “Maybe it would be helpful to talk about this with my husband and coworkers. They could walk with me sometimes.”

Once a realistic action plan has been developed, printed, and given to the patient, follow-up can be arranged. It is critical to include this step; regular, early follow-up is highly correlated with the patient's likelihood to complete the plan. 11 Often follow-up is offered by other members of the medical team, as will be discussed below. A sample of a collaborative care plan that an EHR might produce is shown below. A template can be downloaded.

SAMPLE COLLABORATIVE CARE PLAN

Teamwork: Use of teamlets

The “teamlet” model, 5 which involves physicians and clinical assistants working together in a flexible way that includes collaborative care planning, can provide better care for larger patient panels. 16 The assistant, often a medical assistant or licensed practical nurse (LPN), starts this process by initiating agenda setting as described above. He or she can then introduce self-management as a potential agenda item by asking for and documenting a patient's health care goal. Depending on the flow of the day, the assistant can continue working through the problem-solving steps with the patient. This work is documented in the EHR, and the physician completes the action plan where the clinical assistant stopped.

Planned follow-up is critical for improving health outcomes. 11 The clinical assistant plays an equally important role in the follow-up of patients' action plans by checking on goal accomplishment in the agenda-setting phase of the visit. For example, “I can see that last time you were in, you planned to begin walking for 20 minutes in the mornings twice a week. How has that been going for you? Should we protect time to discuss this today?” Clinical assistants can be trained to empathize with patients and normalize behavior change challenges. The assistant can help patients revise goals and encourage them to address challenges with the physician: “I am glad you brought up these challenges. They are common, and we want to help. I will let Dr. Smith know (pointing to the EHR note), and I encourage you to bring it up.”

Training

Physicians, medical assistants, LPNs, and other members of the health care team can be trained in problem-solving counseling. We propose a two-step training protocol for teamlets.

In step one, a medical assistant and a physician who regularly work together role-play using agenda-setting and problem-solving skills with one another. It works best when the participants focus on a real behavior they want to change and take time after each role-play to debrief, reflect on their own experience, and give feedback.

Step two is to practice with real patients. Plan a practice clinic in advance. Schedule patients in expanded time slots – a 20- to 25-minute appointment in a 50- to 60-minute slot. Both teamlet members see the patient, taking turns observing one another and practicing selected agenda-setting and problem-solving skills. Allow time at the end of the appointment to debrief. Integrate this practice cycle a few times a week until your teamlet feels comfortable with its skill. Although this takes time and decreases office revenue, the increased efficiency and skill mastery is well worth the cost. A recent pilot study 17 of teamlets using problem-solving skills showed dramatic differences in patient interactions compared to control teamlets. It is unlikely that team members will learn new skills without protected time for practice.