At each clinical encounter there should be a conversation that ensures the patient will be supported in developing and refining their care plan and health related goals, within this process there may be individual choices and decisions to be made ,which may involve the use of shared decision making tools (SDM).
These processes will result in a number of actions and goals, many of which will be dependent upon the person’s current level of confidence, knowledge and skills as how able they are to carry out the various agreed activities.
These may range from taking control of choosing when care is provided in the home to treatments or lifestyle related options.
Clinicians will require consultation skills to be able to communicate in a way that helps;
- Identify a person’s current level of activation/engagement
- Support people to develop a care plan
- Make informed choices
- Set appropriate goals
- Check the person’s confidence and ability in following through
- Ensure access to appropriate support if needed
The following process may be needed to support this:
- Single record of care plan
- Ability to track and follow up on goals
- Access to own records
- Ability to send people test results prior to communication
- Enable communication with clinician- via electronic/web mediums
Along with effective systems that will:
- Send out of results prior to consultations
- Ensure people have access to their records
- Have a way of recording people’s preferences, agreed goals and follow up
- Have access to tools to enable people to track progress, set and track goals
- Have access to telephone and web based support to help peoples through early stages of behaviour change
- Identify options to interact via text, email etc. with clinical teams
- Set up online support groups and forums and ways to record goals and track progress
- Access care plans
- Provide electronic records
- Access web tools
- Access SDM tools
- Utilise text communication
- Utilise email communication
The following have been identified as providing skills for clinicians to support behaviour change.
The Three Enablers
These enablers were identified through the Health Foundations clinician development programme. Review of research indicates that the core consultation skills to support people to self-manage are:
- Joint agenda setting
- Goal setting-confidence rating/exploring ambivalence
- Goal follow up
Care planning is a proactive intervention based on clinical priorities and what is important to the individual (or of equal importance). These are identified in dialogue between the patients, the health professional and relevant carers. The additional support needs and follow up (in intervals between care planning consultations) are determined during the care planning process itself.
Care planning is a proactive process. The care plan is the record of the interactions and can be used to:
- Ensure that the patients goals are followed up
- Record key activities
- Sharing of goals and activities across the system, for example in the case of integrated care teams
Shared Decision Making
Shared Decision Making (SDM) is a process in which health professionals encourage patient’s in selecting their appropriate health treatments or care management options. It uses evidence-based information about options, outcomes and uncertainties, together with decision support counselling and a system for recording and implementing patients’ informed preferences.
This is important because not being properly informed about their illness and the options for treatment/management is the most common cause of patient dissatisfaction (Coulter & Cleary 2001).
And because most patients want more information and a greater say in decisions about how they will be treated. Research has shown that when they do, they choose less hospital care and have better experiences.
Research shows that encouraging patients to ask three simple questions leads health professionals to provide higher quality information about options and their benefits and harms.
- What are my options?
- What are the pros and cons of each option for me?
- How do I get support to help me make a decision that is right for me?
Motivational Interviewing (MI)
It is important that training in MI is carried out by trainers who understand the health and self-management context.
MI is based on three key elements:
- Collaboration between the clinician and the patient, rather than confrontation or a must do imposition
- Drawing out the client‘s ideas and beliefs about change and building from where the patient is
- Emphasising the autonomy of the client so they develop and decide what they are going to do and take ownership
Health Coaching involves the use of motivational interviewing skills, combined with clinical knowledge that guides and prompts a patient to be an active participant in behaviour change.
Health coaching is significantly different to activities such as life coaching in that patients may not be ready or willing to change behaviour at that current time, so therefore an understanding of the nature of LTCs is essential from any training.
Developing Specific Roles
The role of the clinical team is to ensure that at the end of each consultation the patient is fully equipped with their onward journey or is referred to where they can gain the required confidence, knowledge and skills.
Consideration may be given to developing specific roles to support self-management. These may include:
- Health coaches – work on a one to one basis with patients either face to face or via telephone, often quite intensive and focused on very specific outcomes
- Wellbeing coaches – working at a higher level than health trainers- focused on people with LTCs and have additional risk factors such as smoking, obesity, anxiety and depression
• Health/self-management champions – talk to patients about their options, assess people’s levels of health literacy and help ensure referral to most appropriate support
• Volunteer co-ordinators – manages teams of volunteers who may be carrying out roles such as running courses, acting as mentors, running peer support group