A white paper brief action planning
Obesity Damara Gutnick, MD, Kathy Reims, MD, Connie Davis, MN, ARNP, Heather Gainforth, PhD, Melanie Jay, MD, MS, and Steven Cole, MD From the New York University School of Medicine, New York, NY Drs. Gutnick and JayUniversity of Colorado Health Sciences Center, Denver, CO Dr. ReimsUniversity of British Columbia, BC, Canada Dr. DavisUniversity College London, London, UK Dr. Gainforthand Stonybrook University School of Medicine, Stonybrook, NY Dr.
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To describe Brief Action Planning BAPa structured, stepped-care self-management support technique for chronic illness care and disease prevention. A review of the theory and research supporting BAP and the questions and skills that comprise the technique with provision of a clinical example. BAP facilitates goal setting and action planning to build self-efficacy for behavior change. It is grounded in the principles and practice of Motivational Interviewing and evidence-based constructs from the behavior change literature. Comprised of a series of 3 questions and 5 skills, BAP can be implemented by medical teams to help meet the self-management support objectives of the Patient-Centered Medical Home.
BAP is a useful self-management support technique for busy medical practices to promote health behavior change and build patient self-efficacy for improved long-term clinical outcomes in chronic illness care and disease prevention.
Chronic disease is prevalent and time consuming, challenging, and expensive to manage . Given the health and financial impact of chronic disease, and recognizing that patients make daily decisions that affect disease control, efforts are needed to assist and empower patients to actively self-manage health behaviors that influence chronic illness outcomes. Patients who are supported to actively self-manage their own chronic illnesses have fewer symptoms, improved quality of life, and lower use of health care resources . Many times, patients want to make changes that will improve their health but need support—commonly known as self-management support—to be successful.
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Involving patients in decision making, emphasizing problem solving, setting goals, creating action plans ie, when, where and how to enact a goal-directed behaviorand following up on goals are key features of successful self-management support methods [3,6—8]. However, the practicalities of these approaches in clinical settings have been questioned. Finally, while chronic disease self-management programs have been shown to be effective when used by peers in the community , similar results in primary care are not well established.
Given the challenges of providers practicing, learning, and using each of these approaches, efforts to develop an approach that supports patients to make behavioral changes that can be implemented in typical practice settings are needed. In acknowledgement of these evolving practice realities, the National Committee for Quality Assurance NCQA included development and documentation of patient self-management plans and goals as a critical factor for achieving NCQA Patient-Centered Medical Home PCMH recognition .
Successful PCMH transformation therefore entails clinical practices developing effective and time efficient ways to incorporate self-management support strategies, a new service for many, into their care delivery systems often without additional staffing. In this paper, we describe an evidence-informed, efficient self-management support technique called Brief Action Planning BAP [21—24]. BAP evolved into its current form through ongoing collaborative efforts of 4 of the authors SC, DG, CD, KR and is based on a foundation of original work by Steven Cole with contributions from Mary Cole in .
This technique addresses many of the barriers providers have cited to providing self-management support, as it can be used routinely by both individual providers and health care teams to facilitate patient-centered goal setting and action planning. BAP integrates principles and practice of MI with goal setting and action planning concepts from the self-management support, self-efficacy, and behavior change literature. In addition to reviewing the principles and theory that inform BAP, we introduce the steps of BAP and discuss practical considerations for incorporating BAP into clinical practice.
In particular, we include suggestions about how BAP can be used in team-based just click for source practice settings within the PCMH. Finally, we present a common clinical scenario to demonstrate BAP and provide resource links to online videos of BAP encounters. BAP is a highly structured, stepped-care, self-management support technique. Composed of a series of 3 questions and 5 skills reviewed in detail belowBAP can be used to facilitate goal setting and action planning to build self-efficacy in chronic illness management and disease prevention [21—24].
The overall goal of BAP is to assist an individual to create an action plan for a self-management behavior that they feel confident that they can achieve. BAP is currently being used in diverse care settings including primary care, home health care, rehabilitation, mental health and public health to assist and empower patients to self-manage chronic illnesses and disabilities including diabetes, depression, spinal cord injury, arthritis, and hypertension.
BAP is also being used to assist patients to develop action plans for disease prevention. For example, the Bellevue Hospital Personalized Prevention clinic, a pilot clinic that uses a mathematical model  to help patients and providers collaboratively prioritize prevention focus and strategies, systematically utilizes BAP as its self-management support technique for patient-centered action planning. In addition, a set of guidelines designed to ensure fidelity in BAP research has been developed .
Underlying Principles of BAP BAP is grounded in the principles and practice of MI and the psychology of behavior change. Within behavior change, we draw primarily on self-efficacy and action planning theory and research. We discuss the key concepts in detail below. The Spirit of MI MI Spirit Compassion, Acceptance, Partnership and Evocation is an important overarching tenet for BAP.
Compassionately supporting self-management with MI spirit involves a partnership with the patient rather than a prescription for change and the assurance that the clinician has the patients best interest always in mind Compassion . Demonstrating MI spirit throughout the change conversation is an essential foundational principle of BAP. Action Planning and Self-Efficacy In addition to the spirit of MI, BAP integrates 2 evidence-based constructs from the behavior change literature: Action planning requires that individuals specify when, where and how to enact a goal-directed behavior eg, self-management behaviors.
Given the demonstrated potential of action planning for ensuring individuals achieve their health goals, the BAP framework aspires to assist patients to create an action plan. Several reviews of the literature have suggested a strong relationship between self-efficacy and adoption of healthy behaviors such as smoking cessation, weight control, contraception, alcohol abuse and physical activity [39—42].
Furthermore, Lorig et al demonstrated that the process of action planning itself contributes to enhanced self-efficacy . Description of the BAP Steps The flowchart in Figure 1 presents an overview of the key elements of BAP. An example dialogue illustrating the steps of BAP can be found in Figure 2. Three questions and 3 of the BAP skills ie, SMART plan, eliciting a commitment statement, and follow-up are applied during every BAP interaction, while 2 skills ie, behavioral menu and problem solving for low confidence are used as needed.
The distinct functions and the evidence supporting the 3 questions and 5 BAP skills are described below. Eliciting a Behavioral Focus or Goal Once engagement has been established and the clinician determines the patient is ready for self-management planning to occur, the first question of BAP can be asked: The powerful link between consistency of word and action facilitates development and commitment to change the behavior of focus . Responses to Question 1 generally take 3 forms Figure 1: A group of patients immediately present an idea that they are continue reading to do or are ready to consider doing.
For these patients, clinicians can proceed directly to Skill 2—SMART Behavioral Planning; that is, asking patients directly if they are ready to turn their idea into a concrete plan. Another group of patients may want or need suggestions before committing to something specific they want to work on. For these patients, clinicians should use the opportunity to offer a Behavioral Menu Skill 1. A third group of patients may not be interested or ready to make a change at this time or at all. Some in this group may be healthy or already self-managing effectively and have no need to make a plan, in which case the clinician acknowledges their active self-management and moves to the next part of the visit.
Others in this group may have considerable ambivalence about change or face complex situations where other priorities take precedence. Would it be OK if I see more you about this again at our next visit? Other patients may benefit from additional motivational approaches to further explore change and ambivalence.
If the clinician does not have these skills, patients may be seamlessly transitioned to another resource within or external to the care team. Offering a Behavioral Menu If in response to Question 1 an individual is unable to come up with an idea of their own or needs more information, then offering a Behavioral Menu may be helpful [44,45]. A behavioral menu is comprised of 2 or 3 suggestions or ideas that will ideally trigger individuals to discover an idea of their own. There are click here distinct evidence-based steps to follow when presenting a Behavioral Menu.
Asking permission to share ideas respects patient autonomy and prevents the provider from inadvertently assuming an expert role. It helps to mention things that other patients have decided to do with some success. Using this approach avoids the clinician assuming too much about the patient or allowing the patient to reject the ideas.
It is important to remember that the list is to prompt ideas, not to find a perfect solution . Evocation from the Spirit of MI is built in with this prompt . Diagrams with equally weighted spaces assist clinicians to resist prioritizing as might happen in a list. Empty circles alongside circles containing varied options evoke patient ideas, consistent with the Spirit of MI Figure 3, Visual Behavioral Menu Example .
SMART Planning Once an individual decides on an area of focus, the clinician partners with the patient to clarify the details and create an action plan to achieve their goal. Commitment predicts subsequent behavior change, and the strength of the commitment language is the strongest predictor of success on an action plan [43,52,53].
Scaling for Confidence After a commitment statement has been elicited, the second question of BAP is asked. Not at all sure, somewhat sure, or very sure? Problem Solving for Low Confidence When confidence is relatively low ie, below 7we suggest collaborative problem solving as the next step [8,51]. Low confidence or self-efficacy for plan completion is a concern since low self-efficacy predicts non-completion . Successfully implementing the action plan, no matter how small, increases confidence and self-efficacy for engaging in the behavior . There are several steps that a clinician follows when collaboratively problem-solving with a patient with low confidence Figure 1.
A Behavioral Menu can be offered if needed. For example, a clinician might say something like: A 5 is a lot higher than a 1. People are more likely to have success with their action a white paper brief action planning when confidence levels are 7 or more. Do you have any ideas of how you might be able to increase your level confidence to a 7 or more? Perhaps one of these ideas seems like a good one for you or maybe you have another idea?
Arranging Accountability Once the details of the plan have been determined and confidence level for success is high, the next step is to ask Question 3: Research supports that people are more likely to follow through with a plan if they choose to report back their progress  and suggests that checking-in frequently earlier in the process is helpful . Ideally the clinician and patient should agree on a time to check in on the plan within a week or two Figure 2, entry The patient may also choose to be accountable to themselves by using a calendar or a goal setting application on their smart phone device or computer.
Follow-up Follow-up has been noted as one of the features of successful multifactorial self-management interventions and builds trust . Follow-up with the care team includes a discussion of how the plan went, reassurance, and next steps Figure 4. Checking-in encourages reflection on challenges and barriers as well as successes. Patients should be given guidance to think through what worked for them and what did not. If follow-up is not done with the care team in the near term, checking-in can be accomplished at the next scheduled visit. Patient portals provide another opportunity for patients to dialogue with the care team about their plan.
Another caveat to consider is that the process of planning is more important that the actual plan itself. It is imperative to allow the patient, not the clinician, to determine the plan. For example, a patient with multiple poorly controlled chronic illnesses including depression may decide to focus his action plan around cleaning out his car rather than disease control such as dietary modification, medication adherence or exercise.
The clinician may initially fail to view this as a good use of clinician time or healthcare resources since it seems unrelated to health. However, successful completion of an action plan is not the only objective of action planning. Building self-efficacy, which may lead to additional action planning around health, is more important [4,46]. When to Use BAP Opportunities for patient engagement in action planning occur when addressing chronic illness concerns as well as during discussions about health maintenance and preventive care.
BAP can be considered as part of any routine clinical agenda unless patient preferences or clinical acuity preclude it. As with see more clinical encounters, the flow is often negotiated at the beginning of the visit. BAP more info be accomplished at any time that works best for the flow and substance of the visit, but a few patterns have emerged based on our experience.
BAP fits naturally into the part of the visit when the care plan is being discussed. Care plans can include additional recommendations for testing or screening, therapeutic adjustments and or referrals for additional expertise. Another variation of when to use BAP is the situation when the patient has had a prior action plan and is being seen for a recheck visit. Discussing the action plan early in the visit agenda focuses attention on the work patients have put into following their plan.
Descriptions of success lead readily to action plans for the future. Time spent discussing failures or partial success is valuable to problem solve as well as to affirm continued efforts to self-manage. BAP can also be used between scheduled visits. The check-in portion of BAP is particularly amenable to follow-up by phone or by another supporter. A pre-arranged follow-up 1 to 2 weeks after creation of a new action plan  provides encouragement to patients working on their plan and also helps identify those who need more support.
Finally, BAP can be completed over multiple visits. For patients who are thinking about change but are not yet committed to planning, a brief suggestion about the value of action planning with a behavioral menu may encourage additional self-reflection. Many times patients return to the next visit with clear ideas about changes that would be important for them to make. Fitting BAP into a Minute Visit Using BAP is a time-efficient way to provide self-management support within the context of a minute visit with engaged patients who are ready to set goals for health.
With practice, clinicians can often conduct all the steps within 3 to 5 minutes. However, patients and clinicians often have competing demands and agendas and may not feel that they have time to conduct all the steps. Thus, utilizing other members of the health care team to deliver some or all of BAP can facilitate implementation. Teams have been creative in their approach to BAP implementation but 2 common models involve a multidisciplinary approach to BAP.
In one model, the clinician assesses the patient readiness to make a specific action plan by asking Question 1, usually after the current status of key problems have been addressed and discussions begin about the interim plan of care. In another commonly deployed model, the front desk clerk or medical assistant helps to get the patient thinking by asking Question 1 and perhaps by providing a behavioral menu.
When the clinician sees the patient, he follows up on the behavior change the patient has chosen and affirms the choice. Clinicians often flex seamlessly with other team members to complete the action plan depending on the schedule and current patient flow. Regardless of how the workflows are designed, BAP implementation requires staff that can provide BAP with fidelity, effective communication among team members involved in the process and a standardized approach to documentation of the specific action plan, plan for check-in and notes about follow-up.
Care teams commonly test different variations of personnel and workflows to find what works best for their particular practice. Implementing BAP to Support PCMH Transformation To support PCMH transformation substantial changes are needed to make care more proactive, more patient-centered and more accountable. One of the common elements for PCMH recognition regardless of sponsor is to enhance self-management support [20,57,58]. Practices pursuing PCMH designation are searching for effective evidence-based approaches to provide self-management support and guide action planning for patients.
The authors suggest a white paper brief action planning of BAP as a potential strategy to enhance self-management support. In addition to facilitating meeting the actual PCMH criteria, BAP is aligned with the transitions in care delivery that are an important part of the transformation including reliance on team-based care and meaningful engagement of patients in their care [59,60].
In our experience, BAP is introduced incrementally into a practice initially focusing on one or two patient segments and then including more as resources allow. Successful BAP implementation begins with an organizational commitment to self-management support, decisions about which populations would benefit most from self-management support and BAP, training of key staff and clearly defined workflows that ensure reliable BAP provision.
Documentation of the actual goal and follow-up is an important component to fully leverage BAP. Goals captured in a template generate actionable lists for action plan follow-up. Since EHRs vary considerably in their capacity to capture goals, teams adding BAP to their workflow will benefit from discussion of standardized documentation practices and forms. Summary Brief Action Source is a self-management support technique that can be used in busy clinical settings to support patient self-management through patient-centered goal setting.
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Care teams commonly test different variations of personnel and workflows to find what works best for their particular practice. A third group of patients may not be interested or ready to make a change at this time or at all. Three Core Questions Brief Action Planning is organized around three core questions: To describe Brief Action Planning BAPa structured, stepped-care self-management support technique for chronic illness care and disease prevention. How to deliver high-quality obesity counseling in primary care using the 5As framework.
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