Members should be in the action phase
Nurses in HealthPartners' outpatient case management program go through extensive training to help them assess a patient's readiness to change.
"It is important for the case managers to find out the patients' stage of readiness in order to create interactions, conversations, and means of motivating them to change," says Karen Kraemer, RN, CMC, senior director of Bloomington, MN-based HealthPartners' case management program.
The case managers have to be astute in assessing whether a patient is ready to make a major lifestyle change or is just contemplating it.
"If they are only contemplating change, it will make it worse if you treat them as if they are further along," Kraemer adds.
The case managers use their motivational interviewing skills and ask open-ended questions to help determine a patient's willingness to change, says Diane Reuss, RN, CMC, outpatient case manager.
"Sometimes I start hearing little hints, like ‘my family is making me do this.' That's when I know that they aren't in the action phase yet, because they're being pushed to change," she says.
The case managers don't press the members to make changes, but they do keep reminding them of the changes they need to make.
For instance, if a member is a smoker and has trouble breathing, the case manager will say something like, "I know you're not ready to quit smoking, but you need to remember that it's contributing to your health problems."
"We use our nursing expertise to help them choose their priorities and what actions will affect them most," Reuss adds.
For instance, if a diabetic with fluctuating blood sugar levels says he or she wants to lose weight, stop smoking, and exercise, the case managers suggest that they focus first on the diet because that will help them more in the short term.
Health actions, or steps the patient takes to improve their health and care, are the centerpiece of HealthPartners' case management initiatives.
The patients agree to take action on something that is meaningful to them that actually will make a positive impact on their health. The members make an agreement to achieve their goal by a certain time.
"The case manager coaches the patient along in making their choices regarding the action they, themselves, will take. This is patient-driven, not case manager-driven," Kraemer says.
Health actions focus in the following areas:
- coordination of medical care;
- daily activity and fitness;
- interdependence with family and friends;
- mental challenges;
- community involvement and purpose.
The readiness to change assessment is based on the findings of James Prochaska, PhD, professor of clinical and health psychology at the University of Rhode Island.
Following the model of a book club, the case managers at HealthPartners have read and discussed Prochaska's book, Changing for Good.1
They read a chapter each month, then get together, and talk about how to apply it. Then they use the skills they learned in the book with their patients.
1. Prochaska J, Norcross J, Diclemete C. Changing for Good. New York City: William Morrow & Co.; 1994.