Primary care physicians increasingly are assessed on patient outcomes even though many outcomes are determined largely by the patient, not the physician. But physicians sometimes struggle with motivating patients to make health-enhancing changes.
A research study(www.annfammed.org) published in the March/April issue of Annals of Family Medicine identified five strategies that may help. The strategies show promise in supporting patient activation, which has been shown to be associated with outcomes including better self-management and clinical indicators, fewer hospitalizations and lower health care costs.
The study, "Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels," defined patient activation as having the knowledge, confidence and skills to take care of one's health and health care.
Using data from an accountable care organization, researchers aggregated data on change in the patient activation measure (PAM) scores for 7,144 patients to the primary care clinician level. The patients all had two PAM scores between 2010 and 2012, with their baseline scores being below the highest of four levels of scores.
- A study reported in Annals of Family Medicine identified five promising strategies that may help physicians influence patients to make health-enhancing changes.
- The five strategies reported by the top-performing physicians were emphasizing that patients own their own health; partnering with patients; identifying small steps to improve health; scheduling frequent follow-up visits to cheer successes and solve problems; and showing care and concern.
- The researchers will conduct a follow-up study of a larger sample with a goal of developing training for clinicians.
Researchers ranked clinicians based on the change in their patients' scores. They then conducted in-depth interviews with 10 of the clinicians whose patients' scores increased the most and 10 of those whose patients' scores increased the least. The interview transcripts were analyzed to look for strategies the clinicians used to support patient lifestyle behavior change.
"We found the top-performing clinicians most frequently reported using five strategies when they worked with patients on behavior change," lead researcher Jessica Greene, Ph.D., associate dean for research and a professor at the George Washington University School of Nursing, told AAFP News.
The five key strategies were:
- Emphasizing patient ownership. The top-performing clinicians described emphasizing that patients own their health, Greene said. "One clinician told her patients, 'I'm here to coach you, not to make you better. You make yourself better; I can't do that for you.'"
- Partnering with patients. The top performers described working with patients to co-create goals and strategies for behavior change and to solve problems, Greene said. "These clinicians acknowledged that they don't know their patients' lives outside the clinic and that patients can best decide which goals and strategies are most appealing or feasible."
- Identifying small steps. The top performers helped patients identify small steps toward change, initially setting the bar low so the patient could achieve the goal, said Greene. "The patient then had some confidence when the bar was set a little higher for the next step." Many of the top performers said they would ask a patient who resisted change to identify just one small change. "The patient almost always could describe one thing they could do to get healthier," said Greene.
- Scheduling frequent follow-ups. Following up with patients frequently was part of the coaching role the top performers assumed. Some had patients come in for face-to-face visits, while others used their electronic medical record system to communicate with patients, said Greene. "A few said they felt a tension about asking a patient to make frequent follow-up visits because they didn't want the patient to have to spend more money."
- Showing care and concern. "Some of these top-performing clinicians told patients they wanted them to be healthy enough to play with their grandchildren," Greene said. "The clinicians wanted patients to make changes so their lives would be better, not just change to please the clinician."
Very few of the bottom-performing clinicians reported using these five strategies with patients, said Greene. When these clinicians did report one of these strategies, they rarely described it in as much detail as the top-performing clinicians did.
The strategy most of the bottom performers described was telling patients the consequences of bad behaviors. "I think these clinicians were doing this from the right place, trying to help spark change in people," said Greene. "Since we didn't hear this strategy from many of the top performers, it's probably not an effective strategy, but we don't really know that from this study."
Most of the clinicians in both groups reported relying on team members, such as hypertension nurses, to support behavior change.
Greene noted that the top performers described counseling and education as a crucial part of their work, while most bottom performers reported that it was a smaller component.
Top performers also seemed more optimistic about their patients, while the less successful clinicians expressed more frustration with their patients, Greene said. "It seems that once you start giving up on patients, it's hard to get them to be healthier. Maintaining a positive approach and focusing on successes seem to be helpful."
Greene and her research team will conduct a follow-up study with a larger provider sample. If that study validates the five key strategies, then the next step would be to develop training to help clinicians learn how to apply the strategies, she said.
The current study showed that both the top- and bottom-performing clinicians used trial and error and tweaked their approaches to support behavior change. "This underscores the importance of training in this area, because some folks figure out effective ways to support patients in behavior change while others don't," Greene said. "They shouldn't have to figure it out on their own."
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