Behavioral Tools To Better Glucose Control: We Seem To Be Missing - PDF document

Behavioral Tools To Better Glucose Control: “We Seem To Be Missing Something” Lawrence Fisher, Ph.D., ABPP Professor Emeritus Department of Family & Community Medicine UCSF Disclosures No conflicts of interest!

Patient Management Of Diabetes Ain’t Easy!!! (an understatement) Relationship Between Adherence And HbA1C (with adjustments) 8.4 8.0 7.6 Adjusted HbA 1c 7.2 6.8 6.4 6.0 5.6 5.2 4.8 4.4 4.0 0 10 20 30 40 50 60 70 80 90 100 *Metformin plus a sulfonylurea was used as the reference group for the index ODM regimen. A1C indicates glycosylated hemoglobin; ODM, oral diabetes medication. Rozenfeld et al. Am. J. Manag. Care 2008; 14:71–5 Adherence (%)

Percentage of Patients Achieving ADA Treatment Targets 100 90 80 % reaching ADA target 70 60 50 40 30 20 10 0 A1c BP Chol All three Casagrande et al. 2013 Percentage of Patients Achieving ADA Treatment Targets 100 90 80 % reaching ADA target 70 60 50 40 30 18.8% 20 10 0 A1c BP Chol All three Casagrande et al. 2013

Our Logic Model L ong & Healthy Life Our Logic Model L ong & Disease Healthy Progress/ Life Compli

Our Logic Model L ong & Diabetes Healthy Numbers Life (ABC) Our Logic Model L ong & Actions Diabetes Healthy & Numbers Life Behavior (ABC)

Our Logic Model L ong & Actions Diabetes Healthy & Numbers Life Behavior (ABC) Education, Dosing, Prompts, Packaging, Co-pays MI, Our Logic Model Action Plans L ong & Actions Diabetes Healthy & Numbers Life Behavior (ABC) Education, Dosing, Prompts, Packaging, Co-pays

MI, Our Logic Model Action Plans L ong & Actions Diabetes Healthy & Numbers Life Behavior (ABC) Education, Dosing, Prompts, Packaging, Co-pays Results Of MI Trials

Results Of MI Trials (It Get’s Worse) MI, Our Logic Model Action Plans L ong & Actions Diabetes Healthy & Numbers Life Behavior (ABC) Education, Dosing, Prompts, Packaging, Co-pays

Efficacy Of Action Planning 79% 56% 53% % of subjects DeWalt et al, 2009 MI, What Are We Action Plans Missing? L ong & Actions Diabetes Healthy & Numbers Life Behavior (ABC) Education, Dosing, Prompts, Packaging, Co-pays

A Qualitative Study § 20 adults with T2DM in primary care. § Varied by age, gender, ethnicity. § A1C > 8.0 § 30-45 minute semi-structured interview. What is it like for you to have DM? What is it about DM that drives you crazy? What do you do to take care of your DM? What are the very good reasons you have for not doing what you feel you should do to take care of your DM? Has this changed over time since you were first diagnosed? Recognizing The Tug-Of-War ON THE ONE HAND: Want to be healthy. Want to participate. Want to lose weight. Want to exercise. Want lower HbA1c. Don ’ t want compls.

Recognizing The Tug-Of-War ON THE OTHER HAND: No real benefit. Not sure they really work. Reminds me I’m sick. Meds are unnatural. I can do it myself (control). Failure. Ashamed (self-blame). Distrustful. Karter, et al., Diabetes Care, 2010; Fisher, Hopeless. et al., Pt. Educ. Counseling, 2012, Afraid. Rosebaum, NEJM, 2015. Can’t manage it. “Common Feeling Scenarios” (Based On Expectations & Beliefs) • Hopelessness • Embarrassed • Distrustful • Overwhelmed • Self-critical • Demoralized • Why me? • Frightened • Avoidant • Angry • Self-blaming • Ashamed • Guilty

The Eventual Outcome: “Diabetes MEH!” The belief that diabetes care efforts are really just not worth the effort (diabetes apathy).

Something Is Missing In The Logic Model ON THE OTHER HAND: We have been focusing on No real benefit. behavior, actions, Not sure they really work. prompts, co-pays, Reminds me I’m sick. Meds are unnatural. dosing, and I can do it myself (control). education. Failure. Ashamed (self-blame). PATIENTS TELL US ABOUT Distrustful. THEIR FEELINGS, Hopeless. BELIEFS, EXPECTATIONS Afraid. Can’t manage it. MI, The Missing Link Action Plans Feelings, L ong & Actions Diabetes Beliefs, Healthy & Numbers Expectations Life Behavior (ABC) Feelings, Beliefs & Expectations DRIVE Education, Dosing, Behavior Prompts, Packaging, Co-pays

MI, The Missing Link Action Plans Feelings, L ong & Actions Diabetes Beliefs, Healthy & Numbers Expectations Life Behavior (ABC) Feelings, Beliefs & Expectations DRIVE Education, Dosing, Behavior Prompts, Packaging, Co-pays Where Do We Go From Here? § A focus on behavior & education is necessary but not sufficient. § How to integrate patient feelings/ beliefs/expectations into self-management support interventions?

Have A Different Conversation Our goal: To maximize the chances that patients will make clear, informed and examined decisions about the actions they will take to manage their disease. Derived from a realization that: § We do not set the agenda or make the decisions - the 93% rule. § We do not solve the problem or “get” the patient to do anything. § We are not “commanders” – we can only be “facilitators”: helping patients with their decision-making about what they want to do and what they can do. The “Commander” Approach

The “Facilitator” Approach 8 Tips For Having A Different Conversation (addressing feelings/beliefs/expectations) 1. The importance of taking time (foreplay): § Take a breath, get ready to actively listen. § Slow the pace and rhythm of speech. § Observe the seating (desk, computer). § Be prepared to listen and allow quiet. § Not a focus on numbers, tests, treatments.

8 Tips For Having A Different Conversation 2. Bring feelings, worries and concerns into the conversation because they drive the very behavior that you want to help patients change. § Ask open-ended questions. § Actively express empathy and understanding – we are in this together. § Summarize and reflect genuinely & frequently. § Overtly label feelings, concerns, worries. § Normalize feelings, beliefs, expectations. § Do not solve problems – just listen & understand. 8 Tips For Having A Different Conversation 3. Summarize & label both sides of problem so that the patient can make a decision: “Sounds like on the one hand you would really like to lose some weight because you know that it would help you manage your diabetes better.” “But on the other hand the thought of dieting feels overwhelming, you have tried it before and felt like you failed and now you feel very discouraged and not hopeful about starting again.”

8 Tips For Having A Different Conversation 4. Decide, Pick & Plan: § Given all of this – “What do you want to do?” § Is this really worth the effort? § Is the timing is right (it may not be). § “Are you sure you really want to try this?” § Help them pick something small and do-able to start (e.g., walk 15 minutes twice a week). § Pick something very specific (e.g., walk from house to park and back). § Help decide when, how often, where. 8 Tips For Having A Different Conversation 5. Anticipate and address potential obstacles: § What might prevent you from walking on Tuesdays and Thursdays. § What can you do if that happens? 6. Provide a simple daily or weekly tracking form. § Provides ongoing feedback to patients. § Allows review with clinician to problem solve.

8 Tips For Having A Different Conversation 7. Record everything on a structured action plan form, including the feelings/beliefs/expectations regarding completing the behavior and the reasons not to. § Copy for patient to take home. § Copy for clinician in clinical note. My Action Plan What health issue will you work on? S pecific Be specific about what the 1 or 2 things you will do and how often you will do them. Strategy 1 What you will do? How often will you do it? Strategy 2 What you will do? How often will you do it? M easurable How will you track your progress? A ttainable How confident are you that you can do it? On a scale of 1-10: 0 R ealistic What will make it hard for you to reach your goal? Barriers: How you will overcome them: ! T ime Follow up date: When will you start? Please add anything else related to achieving your goal here: For additional resources and information visit connectiontohealth.com !

8 Tips For Having A Different Conversation 8. Schedule a follow-up: § Within two weeks (do not let failure persist or success go unacknowledged). § Office visit, by phone, email, etc.. § Review plan (monitoring form), feelings, beliefs, expectations, obstacles. § Expect that the plan will need to be tweaked (warn the patient beforehand!). 8 Tips For Having A Different Conversation (Including The Missing Link) 1. The importance of taking time. 2. Bring feelings, beliefs, & concerns into the conversation. 3. Summarize & label both sides of the problem. 4. Help patient decide, pick and plan – their decision (be very specific). 5. Identify & address potential obstacles. 6. Provide a monitoring/tracking form. 7. Write it all down on a structured action plan. 8. Schedule a follow-up contact within 2 weeks.