BEHAVIORAL HEALTH Improving Patient Outcomes

Improving Patient Outcomes Tools for promoting healthy behavior

STEPHANIE A. HOOKER, PHD, MPH, MICHELLE D. SHERMAN, PHD,

ABPP AND ANDREW H. SLATTENGREN, DO, FAAFP

Evidence suggests that approximately 40% of the variance in health outcomes can be attributed to modifiable health behaviors, such as physical activity, dietary habits, smoking, alcohol use, and insufficient sleep. One of the ways to improve health outcomes is to address these modifiable risks and encourage patients to engage in healthier behaviors.

Primary care is an ideal setting in which to address health behaviors. Many of the top reasons patients are seen in primary care have contributing behavioral components, including hypertension, chronic pain, and diabetes. Further, primary care offers easy access to care, continuity across time and stages of health and illness, and a comprehensive approach to health, which can enhance the development of trusting, collaborative relationships between clinicians and patients. Moreover, patients whose primary care clinicians ask about health behaviors (e.g., smoking) are more satisfied with their healthcare than patients whose clinicians do not. Thus, primary care clinicians need to be able to effectively discuss behavioral risks and encourage patients to make behavioral changes.

Several brief behavioral interventions have been found to be effective in primary care settings. For example, when primary care providers help patients set small, realistic goals for engaging in physical activity, patients increase their activity levels. However, despite many practice recommendations urging clinicians to address health behaviors with patients, primary care clinicians spend, on average, less than 1% of their time doing so. This discrepancy is likely due to many factors, including perceived insufficient time and low levels of confidence in delivering effective interventions. Perhaps further contributing to these problems is that little time is devoted to training physicians in medical school or residency on how to effectively encourage behavior change and to integrate these skills within their practices. Thus, there is a significant need for comprehensive curricula to train clinicians to use brief, behavioral interventions to address modifiable health risks.

Change that Matters: Promoting Healthy Behaviors

To address the gap in comprehensive curricula, our multidisciplinary team at the University of Minnesota’s North Memorial Family Medicine Residency program and Broadway Family Medicine clinic created Change that Matters: Promoting Healthy Behaviors, a 10-module curriculum. This program teaches primary care clinicians brief, evidence-based interventions for common behavioral health topics, including alcohol use, chronic pain, depression, healthy eating, medication adherence, physical activity, sleep, social isolation, and stress. The development of the curriculum was co-led by two psychologists (Dr. Hooker and Dr. Sherman), and included input from professionals from multiple disciplines, including family medicine (faculty and residents), public health, nutrition, and pharmacy.

Each module includes three components:

• Didactic training, including slides that outline the importance of the behavior, assessment questions, evidence-based interventions, and practice of key skills

• Electronic health record templates, including a documentation template to guide clinicians through how to deliver the intervention (assessment and goal-setting guide) and an after visit summary

• Interactive patient handouts, available in English and Spanish, that guide the clinician and patient through a discussion about the topic, encourage goal setting, and problem solve potential barriers

A key theme that runs through all modules is the idea that patients are encouraged to draw upon their values and sense of meaning in life to find motivation to make changes. Research suggests that when patients connect their reasons to change to the deeper “why” (e.g., to be able to spend more quality time with family), they are more likely to maintain those changes.

The entire curriculum is available for free to download from the website, https://changethatmatters.umn.edu. On the website, there is also a detailed Implementation Guide and printable posters for exam rooms.

Interested clinicians can download one module at a time or use a convenient 5 Tips for Addressing Health Behavior Change in Your Practice link to download the entire curriculum at once. Making and sustaining changes in health-related behaviors is difficult!

In the initial evaluation of the curriculum, feedback from family Approaching patients with a hopeful, encouraging attitude and a lot of medicine experts, resident physicians, and patients was all very positive. patience can be useful. Here are a few tips on how to talk with patients Eleven family medicine experts (physician and about health behavior change: behavioral health faculty from family medicine Take a long-term perspective. Behavior change is residency programs) reviewed the patient handouts a marathon, not a sprint. Most people take time and rated them as highly understandable and to change old habits. Often, people try to make actionable. In open-ended feedback, they stated changes to their habits after years of engaging that they liked the interactive nature of the patient Behavior change is a in the old behaviors that they want to change. materials, the use of evidence-based principles marathon, not a sprint. The strength of those habits is very strong; thus, (such as motivational interviewing and cognitive relapses are very common. For example, most behavioral therapy), diversity in pictures and patients who successfully quit smoking have tried recommendations, the visual appeal of the patient to quit at least 8 times before! It is good not to handouts, and the concrete recommendations. expect overnight transformations and recognize

Individual interviews at Broadway Family that it may take a long time for patients to reach Medicine Clinic with 20 residents and 20 patients yielded similarly positive their goals. themes. Resident physicians felt more self-confident in their ability to discuss Focus on and celebrate small changes. Setting small goals is a great way behavioral issues with their patients. One resident stated, “I feel more like to build patients’ confidence that they can change. It is not uncommon for I’m going to be able to plant a seed or make a difference in empowering people to choose an initial goal that is actually their long-term goal. For somebody...it makes me feel more confident and sort of less tied to outcomes, example, when some people join a gym to increase their physical activity, more like seeing it as an on-going long process.” Similarly, patients felt more they set a goal of going to the gym 5 days a week. If they were not exercising empowered to make changes and take ownership of their health. One patient at all prior to making that change, the goal of 5 days a week may become noted, “There’s things I can do before we jump to like medication [for sleep]….kind of refreshing to know that, you know, there’s things I can do.” Improving Patient Outcomes to page 164

Do you have patients with trouble using their phone due to a hearing loss, speech or physical disability?

Contact the Telephone Equipment Distribution Program for easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Website: mn.gov/deaf-hard-of-hearing

The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.

3Improving Patient Outcomes from page 15

an almost insurmountable challenge. However, if that person was to set an Then, review the logs with patients at subsequent visits. Physicians can initial goal of going 2 times a week, and they master that small goal, they can look for patterns in behavior: What was happening when things were consider increasing the number of times per week over time. Further, even going well? When the patient was struggling? small changes can have a big impact. Exercising This discussion and shared reflection can provide 2 times a week compared to 0 times per week is a helpful opportunity to learn what is working associated with improved fitness and ultimately and what is not. These data are vital for helping increased longevity. patients set new small goals and continue to work Maintain a spirit of hope. Sometimes patients Primary care is an ideal setting in on making changes. and clinicians can get frustrated when progress which to address health behaviors. Encourage patients to reflect on their values to seems slow or nonexistent, especially when there enhance motivation for making behavior change. are lapses in behavior. Look for and celebrate Learn about what is really important to your changes that may not be initially observable patients – for some, this may be family, intimate or measurable, such as an improved ability to relationships, or friendships, and for others, it could problem solve or increased motivation to change. be work, spirituality, or community involvement. Reframe any setbacks as temporary and opportunities to learn how to Whatever their values, encourage patients to make a connection to those improve going forward. If you believe in your patients, they may believe a deeper values and why they want to make the changes for their health. Perhaps little more in themselves, too. a patient wants to better manage her chronic pain so she can volunteer at Continue the discussion across visits. Keeping in line with the first an organization that is important to her. Another patient may want to quit tip, the discussion about behavior change should continue across visits. smoking because he wants to limit his child’s exposure to tobacco. Keeping in At the initial visit, encourage patients to keep track of their progress, mind the bigger reason for making those changes can motivate people when such as on paper, a calendar, or a specific tracking log (e.g., sleep diary). the day-to-day task of making the changes gets difficult. Technological methods also exist, such as smartphone apps or wearable matter; encourage patients to use whatever method works best for them. devices that can track some behaviors. The mode of tracking does not Improving Patient Outcomes to page 174

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3Improving Patient Outcomes from page 16 Michelle D. Sherman, PhD, ABPP, licensed clinical psychologist who is Board Certified in Couple and Family Psychology. She is a Professor at the University Conclusions of Minnesota in the Department of Family Medicine and Community Health Nearly everyone can benefit from making some change to their behavior and Director of Behavioral Health at the North Memorial Family Medicine to improve their health. Change that Matters: Residency Program. She is editor of Couple and Promoting Healthy Behaviors is a comprehensive Family Psychology: Research and Practice. curriculum to help clinicians learn how to deliver brief behavioral interventions in practice and is available for free on the website, https:// Andrew H. Slattengren, DO, FAAFP, is an changethatmatters.umn.edu. If you have 40% of the variance in health Assistant Professor at the University of Minnesota in suggestions for other topics or other questions outcomes can be attributed to the Department of Family Medicine and Community about implementing the materials in your modifiable health behaviors. Health and Associate Program Director of North practice, Dr. Hooker and Dr. Sherman are Memorial Family Medicine Residency. He is the available for consultation. They can be reached current President of the Minnesota Academy of Family via email at stephanie.a.hooker@healthpartners. Physicians. com or sherman@umn.edu, respectively.

Stephanie A. Hooker, PhD, MPH, is a licensed clinical health psychologist and Research Associate at HealthPartners Institute, Bloomington, MN. She is also an Adjunct Assistant Professor in the Department of Family Medicine and Community Health at the University of Minnesota. Her research examines behavioral influences on health and well-being, with an emphasis on developing and testing brief, theory-based interventions.

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