Members’ willingness to change focus of program

Nurses ask about members’ values, concerns

Humana’s Personal Nurse training program includes one component that many disease management programs leave out — recognizing that people are willing to work on changes according to their own values and not according to the values of an external agent, such as a case manager, Vaughn Keller, MFT, EdD, asserts.

"We teach the nurses to talk to members about their values and what health care behavior they want to change and to focus on that," adds Keller, director of clinical behavior changes at the Louisville, KY-based health benefits company.

For instance, even though a nurse knows, based on claims data, that a member is a smoker and needs to quit, the nurses never start out talking about smoking. Instead, they find out what the members’ health concerns and health challenges are and focus on the areas that the individual members are ready to change.

The majority of the Personal Nurse training process, developed by Keller, is based on four concepts of behavior change developed by a number of experts: motivational interviewing, stages of change, self-determination theory, and conviction and confidence. He has developed a similar training program for Humana’s case managers.

The nurses learn to use a unique computer application, especially designed to work with behavioral changes. Based on answers the nurses enter into the program, the application can identify a member’s confidence and conviction to make changes.

The application also includes access to an extensive medical library, giving the nurses instant links to hundreds of health care-related web sites and resources.

During the training process, nurses are blindfolded part of the time to increase their ability to pick up on verbal cues during a telephone conversation.

"The telephone eliminates 70% of all the information you get during a face-to-face interview. All of the visual cues are eliminated," Keller reports.

For instance, if you’re talking to someone in person, you can see if they’re paying attention. On the telephone, you have to find other ways to find out what you need to know.

"We have to get the nurses to start relying upon their sense of hearing and to develop an acuity of hearing that is greater than nurses who are dealing with other populations," Keller says.

When a Personal Nurse calls a member for the first time, he or she asks the member three questions:

1. What are you doing now that you feel contributes to your health?

"As they report the things they are doing, the nurses reinforce them. They ask how the member decided to work on that particular issue and if they’re having any problems with it. It’s a way of getting people to immediately understand that they are doing something to take control," Keller explains.

2. Most of us at one time or another do things we know aren’t in our best interest, like forgetting to wear our seatbelt. Are you doing anything in that category?

The nurses always mention some items that are close to whatever risky behavior they suspect the member is engaging in.

3. Most of us, at one time or another, have gotten advice from a doctor or someone else about something we should do, like flossing after meals, but we may be having a hard time following. Does this apply to you?

As he or she probes for adherence, the nurse mentions several types of advice the member may have gotten.

After the nurse identifies two or three issues the member has mentioned, he or she asks the member if any are of any particular concern and if the member is willing to talk about the issue.

The nurse then asks the member: "On a scale of 1 to 10, how convinced are you that it is in your best interest to change this behavior? On a scale of 1 to 10, how confident are you that you can change it?"

The computer program takes the member’s scores and comes up with different strategies the nurse can use to address the issue. The nurse selects the strategy he or she thinks is most appropriate and starts to work with the member.

The nurses work carefully to build up a relationship and might say something like: "You’re more interested right now in losing weight than stopping smoking, and that’s what we’ll focus on right now. If at some point you want to talk about smoking, we can."

"Without a relationship, you can’t bring about change. All you do is build up resistance, especially over the telephone. All the nurse has to work with is her relationship. She is the intervention," Keller says.

During the training program, the nurses listen to audiotapes of other nurses working with members and participate in role-playing and simulated telephone interviews.

The nurses progress into working with the application as if they’re having a conversation with someone on-line, locating the information the caller needs and making suggestions.

During the basic orientation program, a group of Humana executives talks to the nurses about where the program fits into Humana’s corporate strategy.

After the training is complete, the nurses attend annual corporatewide conferences and regional workshops to reinforce their training.