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					 Chronic Disease
Self-Management
        Support
A P r Ac t i c A l A P P r oAc h
t o Wo r k i n g W i t h P e o P l e
W ith chronic DiseAse


                                       Toolkit

      shifting the way we think
                              Contents




                        www.practiceeducation.net


                    

November 12, 2008
                                                                                                                                                                                                         Contents
       ....................................................5
Toolkit.
  Introduction  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .5
  The Important Concept of “CHANGE TALK”  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .6

                ...........................................7
Stages.of.Change.

The.“5.A’s”.Approach.......................................11
  Self-Management Goal Setting  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 12

Behavioural.Change.Counseling..............................15
  Inspiring Change  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15
  Four General Principles  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15

                                       ....................18
Understanding.“Ready,.Willing.and.Able”.

Healthy.Changes.Action.Plan................................0
  Articulating the Plan for Change  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20
  Collaborative Goal Setting  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24

           ...............................................8
.Questions.

                                   .
5.Questions.to.Stimulate.Discussion. .......................9

Decisional.Balance.Grid....................................

Problem.Solving............................................4

                                            ...............5
Initiating.Self-management.Support.Framework.

          ................................................7
Care.Model.

Toolkit.Resources..........................................8




    
                                               Toolkit




                                                                                            Toolkit
Intro d uctIo n
This Toolkit provides several strategies and tools that a clinician can use to facilitate
and/or support clients in chronic disease self-management . Those in the health care
profession can use these tools to understand and assist clients in changing their
behaviour to better manage their chronic conditions . Some of these tools such as
the Healthy Changes Action plan or the Decisional Balance Grid can also be taught
directly to the client . Please note that the original work of this Toolkit comes from
“Chronic Disease Services” by Catherine Ryan, RN, MN, Quality Improvement
Consultant for the Vancouver Island Health Authority (VIHA) . We thank Ms . Ryan
for her permission to modify this work and adapt it for this Toolkit .




     5
t h e i m P o r tA n t c o n c e P t o f “ c h A n g e tA l k ”
Change talk is self-motivating speech .

The patient articulates the reasons for and advantages of change by talking about the
following items:

    1. Disadvantages of the status quo by highlighting the “not so good” things about
            their present situation .
    2. Advantages of change by highlighting all the “good” things to be gained by
            changing .
    3. Optimism for change that includes “can do” statements that declare that
            change is not only good but also very possible .
    4. Intention to change by making a commitment to change that becomes evident
            in comments that range from direct statements to a vision about how things
            will be .

Change talk that reflects an intention to change may take on a variety of forms that
include:

    •       Cognitive – “I think it’s time for me to make a plan .”
    •       Emotional – “This isn’t how I want my life to continue .”
    •       Behavioural – “I’m not sure what I will do, but I will figure it out .”




        
                                         Stages of




                                                                                        Toolkit
                                          Change
G uIdIn G t h e Pro cess
The process of change is complex . Understanding the complexities of the change
process takes the pressure off both the health care provider and patient because they
understand that the goal is not to achieve instant transformations .

The stages of change approach (based on the Prochaska & DiClemente model) can be
used with any patient who might benefit from a healthier lifestyle, regardless of the
degree of motivation to adopt change .

Three key elements of this approach are:

   1. Supporting the patient as they journey through the stages of change,
         rather than “convincing” them to change
   2. Using goals and questions that match each stage of change
         to help facilitate the change
   3. Recognizing that movement through the stages of change
         is not a linear process . As a result the notion of a relapse
         should not be regarded as a failure, but rather as a learning
         opportunity .




     7
Precontemplation stage
Goal: The core goal of this stage is to get the patient thinking about change .

strategies for this stage include:

    •       Using relationship-building skills
    •       Personalizing risk factors
    •       Providing information about patient’s status vs . the norm
    •       Using teachable moments; the symptom as a message
    •       Expressing your concern vs . relying on scare tactics
    •       Educating in small pieces, repeatedly and over time

Questions for this stage:

                           “How do you know that there is a problem?”

                           “What warning signs would let you know that there is a
                            problem?”

                           “Have you tried to change in the past? Can you tell me how
                            this went for you?”

                           “If you did decide to change, what do you imagine might be
                            some advantages?”


contemplation stage
Goal: Patient to examine benefits and barriers to change .

strategies:

    •       Elicit from the patient reasons to change and consequences of not changing
    •       Explore ambivalence; acknowledge the patient for considering the difficulties
            of change
    •       Restate both sides of ambivalence
    •       Discuss possible solutions, one barrier at a time
    •       Pose advice gently to avoid resistance
    •       Use Decisional Balance Grid



        8
Questions for this stage:




                                                                                          Toolkit
                           “Why do you want to make the behaviour change at this time?”

                           “What were the reasons for not changing earlier?”

                           “What could keep you from changing at this time?”

                           “What are the barriers today that keep you from changing
                            your behaviour?”

                           “What might help you to overcome the barriers?”

                           “What has helped you with change in the past (people,
                            programs, behaviours)?”

                           “What would help you at this time?”

                           “What challenges do you have to overcome?”


Preparation stage
Goal: The goal of this stage is to allow the patient to discover the elements necessary
for decisive action .

strategies for this stage include:

    •       Encouraging the patient’s efforts
    •       Assisting in documenting plans (may use Healthy Changes Plan focusing on
            the importance and confidence rating)
    •       Decisional Balance Grid

Questions for this stage:

                           “What will you do if you encounter problems?”

                           “When will you begin and what is your target date for
                            completing the change?”




        9
Action stage
Goal: The core goal of this stage is to help the patient take decisive action .

strategies for this stage include:

    •    Reinforcing the decision
    •    Delighting in even small successes
    •    Viewing problems as helpful information

Questions for this stage:

                        “How is your change plan progressing?”

                        “Have you encountered any difficulties?”

                        “How do you feel about your change in activity/lifestyle?”


Maintenance stage
Goal: The core goals of this stage are to help the patient incorporate change into daily
life .

strategies for this stage include:

    •    Continuing reinforcement
    •    Warning about potential relapse and helping the patient understand that
         relapse is not uncommon

Questions for this stage:

                        “What have you found to be most helpful in maintaining the
                         change?”

                        “What have you done to deal with difficulties?”




    10
relapse stage




                                                                                        Toolkit
Goal: The core goal of this stage is to help the patient learn from the temporary
success and become reengaged in the process .

strategies for this stage include:

    •    Reframing “failure” as “evidence of ability to succeed” and “lessons for the
         future”
    •    Reminding the patient that change is a process and that most people recycle

Questions for this stage:

                        “What would you like to do first to get back to success?”

                        “What have you learned that will help you achieve success
                         again?”




    11
                            The “5 A’s”
                            Approach
S el f- M a n a g e M e n t
G oAl settIn G
The 5 A’s approach presented below is collaborative . The Health Care Professional
(HCP) Assesses the client, then provides Advice that is relevant to the client’s specific
condition . Based on the assessment and advice, the HCP would then gain Agreement
from the client that they may need to change or that their lack of management is
harmful to their health . There are several stages of agreement such as agreement that
there is a problem, agreement that they need to make a change or agreement on a goal
or action plan .
Once agreement is reached the HCP works with the client or Assists them in
developing their goals . From there the HCP Arranges follow-up consultation .


Assess…
In order to best assess the patient the following should be considered/understood:

    •    Knowledge about the chronic condition
    •    Beliefs about who/what is responsible for health/illness and the significance of
         good self-management
    •    Stage of change
    •    Behaviour that is already established around activities such as following




    1
         a healthy diet, exercising, taking medication, monitoring own condition,




                                                                                           Toolkit
         keeping appointments
    •    Ability to process new information and carry out independent activities
         (consider barriers such as altered cognition and physical limitations)
    •    Past experiences in achieving personal goals (may impact future efforts to
         incorporate healthy lifestyle changes)
    •    Life circumstances; consider determinants of health such as income,
         education and social supports (may influence patient’s ability to improve own
         health status)

         »   Stages of Change and Decisional Balance Grid are tools that the HCP uses
             to provide advice to the client .


Advise…
The clinician uses advice to:

    •    Provide information about disease process and health
         risks
    •    Discuss the benefits both of changing and not
         changing
    •    Create discrepancy
    •    Assure that support is available to help the patient achieve change

         »   Stages of Change and Decisional Balance Grid are tools that the HCP uses
             to provide advice to the client .


Agree…
Agree with the client with respect to their priorities and then agree on a goal that the
client wants to work towards .

    •    Establish priorities for change, based on patient’s status and preferences
    •    Collaboratively set realistic goals that correlate well with patient’s level of
         conviction
    •    Develop some detail around goals by creating a mental image of what success
         would look like




    1
   •     Establish partnership and relationships to develop a rapport with the patient

         »   Decisional Balance Grid and Healthy Changes Action Plan are tools that
             the HCP uses to provide advice to the client .


Assist…
The HCP works with the client to assist him/her in developing strategies that move
the client towards their goal .

   •     Explore specific strategies
   •     Examine personal and emotional barriers
   •     Discuss problem-solving techniques
   •     Identify social and environmental supports
   •     Encourage the patient to restate their plans to ensure mutual understanding
   •     Use a planning tool, such as Healthy Changes Action Plan – Tool #4

         »   Decisional Balance Grid and Healthy Changes Action Plan are tools that
             the HCP uses to provide advice to the client .


Arrange…
The HCP works with the client to arrange follow-up, which might include:

   •     Next visit
   •     Phone call
   •     E-mail
   •     Mailed reminder
   •     Contract (written or verbal)
   •     Next appointment record
   •     Personal health plan




    14
                 Behavioural




                                                                                           Toolkit
                    Change
                 Counseling
InsPIrIn G ch A n Ge
This approach steers away from a confrontational or authoritative style and focuses on
the patient’s goals and readiness to change . The major objective is to help the patient
resolve ambivalence about a change in behaviour and in so doing get “unstuck .” To
achieve this, the reason for the change is emphasized over the actual problem that
is being addressed . This approach is similar to “Motivational Interviewing,” another
term that is often used to help counsel clients to change behaviour .




                   Four.General.Principles
1.    express empathy
Acceptance facilitates change and reflective listening helps to clarify dilemmas by
mirroring the patient’s experience .




     15
                                                              C A Se . ex A M Ple
A 45-year-old male patient with hypertension presents because of his wife’s insistence
that he talk to a doctor about his lack of energy .

          Patient: “She thinks it’s because I need to lose weight, but I work long hours
          so naturally I am tired at the end of the day . Really, I don’t need to be here at
          all .”

          Dr: “You don’t see the connection between your lack of energy and present
          weight, although your wife apparently does . Please tell me more about how
          your low energy is affecting your life .”

(A reflection of the patient’s comment is followed by a non-confrontational statement
that invites exploration of the presenting issues .)


2.    develop discrepancy
The individual must present an argument for
change .

A discrepancy between present behaviour and
broader goals and values can be a strong motivating
factor . The process of developing discrepancy
often begins with ambivalence . As ambivalence is
amplified, discrepancy increases and this may tip
the balance in the direction of positive change .

          Patient: “Like I said, I’m tired at the end of the day, so I don’t do very much
          after work . Of course, then all the chores around the house build up, and
          I barely have the energy to even think about what needs doing . It’s really
          frustrating . I used to find time to keep up with the chores and go out for a
          walk with my wife every night . That was a few years ago though, and I was
          quite a bit lighter then .”

          Dr: “I get the impression that you were more satisfied with your life when
          you were able to complete the household chores and enjoy an evening walk .
          However, your low energy is getting in the way and this could be related to
          your present weight .”

(A discrepancy between the patient’s desired situation and present circumstances is
being established . The patient states the discrepancy and the physician reframes it .)




     1
3.       roll with resistance




                                                                                                Toolkit
Resistance is a signal to respond differently .

Argumentation is counterproductive because it invokes a defensive stance that
increases resistance to change .

          Patient: “OK . So I have put on some weight . Sure I’d like to lose it, but I’ve
          tried a few times; it’s very hard . Don’t tell me to go on a diet and join a gym or
          something because I know all about that!”

          Dr: “It sounds like you’ve looked into diet and exercise and you’ve made
          several attempts to lose weight .”

A simple, yet reflective statement diffuses resistance .


4.       support self-efficacy
Belief in “self” is a strong personal motivator .

Without confidence in one’s ability to succeed, change is unlikely to take place .
The key to supporting patients’ self-efficacy is to help them believe that they can
be successful . This may be achieved by highlighting past accomplishments and by
conveying the message that you have faith in their ability to change .

          Dr: “My sense is that you would like to lose some weight . I remember that
          several years ago you were determined to lose weight before your daughter got
          married, and you did it . I know how worried you were when the company you
          worked for shut down, but you went back to school and got a new and more
          fulfilling job . When you are ready to lose some weight, I know you will be
          successful .”

This exchange demonstrates three critical elements:

     •    Accurate empathy
     •    Non-possessive warmth
     •    Genuineness

Don’t underestimate the power of your words .



     For more information on Behavioural Change Counseling, please see Resources .



     17
Understanding
       “Ready,
  Willing and
         Able”
This common phrase fits well with anyone entering a change process . Willingness
(importance attributed to change), ability (confidence in being able to achieve change),
and readiness (high priority placed on change) are the three critical components
of motivation . Ask the patient to rate the following components on a scale of 1–10
(1 being not confident and 10 being very confident):

    •    Willingness – How important is this change to you?
    •    Ability – How confident are you that you can achieve this change?
    •    Readiness – What is the priority of this change for you right now?

Questions to explore their rating may include “Why did you select ___ rather than
zero?” Or “What would it take to move up from ____?”

The value of assessing a patient’s belief in their own abilities and the importance and
priority of a desired change is twofold:




    18
  •    Predicts likelihood of success




                                                                                        Toolkit
  •    Provides a focus for discussions (i .e ., Should I help the patient see the
       importance of change, should I support the patient’s ability to achieve change
       or should I help the patient examine priorities?)


understanding the patient’s willingness to change




  19
                      Healthy
                     Changes
                   Action Plan
A r t Ic u l At I n G t h e
Pl A n for ch A n Ge
This is a highly practical tool that patients and health care providers can work on
together . It provides a mechanism for clearly articulating the “nuts and bolts” of a plan
for change and includes strategies to promote success and anticipate challenges .


1.    Goal statement
The healthy change I want to make is… (be specific and lay out some details about
when you will begin, where the change will take place, and how frequently your new
activity will occur) .

Setting SMART Goals .

                                                                      ex A M Ple
                       “My goal is to exercise regularly. I will begin on Friday
                        by walking for a mile at my neighbourhood park twice a
                        week. In addition, I will go to my local community centre
                        tomorrow and get information about fitness classes.   ”


     0
2.       steps toward change




                                                                                           Toolkit
The steps to making my healthy change are… (describe the separate actions you will
undertake that will move you closer to your goal) .

                                                                       ex A M Ple
                        “I will continue my walking program by adding one block to
                         the distance each time until I reach two miles, twice a week.
                         I will sign up for a fitness class (possibly yoga) once a week
                         and after one session of classes will review my choice and
                         consider a continuation or an alternative class.    ”


3. Barriers
The following things might make it difficult for me to make my healthy change…
(include barriers such as scheduling conflicts, family responsibilities, work demands,
past difficulties in making a change, transportation issues, to establish priorities for
change, weather restrictions) .

                                                                       ex A M Ple
                        “I may have to work late sometimes which could conflict
                         with my fitness class. Also, I’m not sure how frequently
                         the bus runs past the community centre and I don’t
                         know if I will stay interested in my walking program
                         when the weather gets colder.  ”


4.       overcoming Barriers
My plan to overcome the things that might make it difficult for me to make
my healthy change is… (list some ideas to deal with each of the difficulties
identified) .

                                                                     ex A M PleS
difficulty #1 - Missing fitness class because of work

solutions

     •    Attend class on alternate day




     1
     •    Get a fitness video to use at home
     •    Accept that it is OK to miss the occasional class

difficulty #2 - Uncertainty about bus schedule

solutions
     •    Check schedule; if inconvenient, choose a class that starts at a different time
     •    Try to get a ride to class

difficulty #3 - I may not want to continue walking once the weather gets bad

solutions

     •    Get good rain/bad weather gear
     •    See if partner/friend will accompany


5.       support
The support I will need to make my healthy change
includes… (consider domestic support, financial, and encouragement from friends and
family) .

                                                                        ex A M Ple
                          “I will talk to my family about my plan to begin exercising
                           regularly. I will let them know that although I am looking
                           forward to this change, it will not be easy for me and I
                           would appreciate their support. Then I will suggest specific
                           ways they could help, such as getting dinner started or
                           looking after the baby.  ”


6.       confidence rating
My confidence that I can make my healthy change is… (rate on a scale of 1–10 where
1 = not confident and 10 = very confident) .


                             1   2     3   4   5   6 7   8   9   10




     
                                                                                      ex A M Ple




                                                                                                                                    Toolkit
                            “On a scale of 1–10, I rate my confidence that I will make
                             my healthy change as a ‘9.”’

IMPortAnt: If I n Cratingeis low,fdoB e hproceed! R C h a another goal ore L I n g this
        4 P R the I P L S o            not a V I o u Choose n g e C o u n S modify                                         P R o B L e M S o LV I n
one so that it is more realistic . Success breeds success . Literature indicates that a rate
                                                                                                                •     Identify the problem. Be specific!
of 7 and above is a high indicator of success .                                                                 •     List all possible solutions. Brainsto
      Inspiring Change                                                                                                ideas, from the ridiculous to the
                                                                                                                      sublime.
          1. Express empathy
7.    Importance rating
        2. Develop discrepancy
                                                                                                                •     Pick one idea. Sometimes a combin
                                                                                                                      of a couple of ideas works.
          3. Roll with resistance                                                                               •     Try it out for 2 weeks. Give it a goo
                                1    2    3         “ready, 7 8 9 10
                                               4 Be 5 6 willing, and able”                                            test!
          4. Support self-efficacy                 Ready = high priority on change now                          •     If it doesn’t work, try another.
                                                                                                                •     If that still doesn’t work, find a
                                                      Willing = change is important
8.    review                                            Able = confident of success
                                                                                                                      resource for ideas. Maybe a friend o
                                                                                                                      professional can help.
                                                                                                                •     If that doesn’t work, accept that the
I will review my healthy change plan with (choose appropriate individual) on the                                      problem may not be solvable at this
following date: _________                                                                                             time. Set it aside for now and work
                                                     shifting the way we think                                        something else.


                                              h e a Lt h y C h a n g e S a C t I o n P L a n                          DeCISIo n aL BaLa nC
                                                                                                                                G R I D (D B G
                                                                                                           Change Goal:
      1.  The change I want to make is: (Something       4.  Plans to overcome barriers: What could
      I WANT to do this week.) My goal is:               you do to handle these barriers? ______________    BENEFITS                           CONCER
      ________________________________________           ___________________________________________        S (1)                       (3)
                                                                                                            T
                                                                                                            A
                                                                                                            T
      2.  Describe the steps I will take: (So that       5.  Importance ____ and confidence ____            U
                                                                                                            S
      someone else could understand and see.)            ratings. How important is the plan to you on a
                                                         scale of 1–10? How confident are you that you      Q
          *   WHERE                                                                                         U
                                                         can do the whole plan?                             O
          *   WHAT
                                                                                                                (2)                     (4)
          *   WHEN
                                                         6. Follow-up: Who are you going to talk to         C
          *   HOW MUCH                                                                                      H
                                                         about the plan and when? __________________        A
          *   HOW OFTEN                                  _________________________________________          N
                                                                                                            G
      3.  Barriers: What might get in the way of your                                                       E
      plan? ____________________________________




     
c o ll A B o r At I v e
G oAl settIn G
1.       explore problems
     •    Clear definitions of what the client sees as problems are required . Health care
          providers and clients often have different priorities about the most important
          issues related to care . Clients are most likely address change related to
          problems that are personally meaningful and relevant to them .


2.       Assess
     •    Impact of illness
     •    What part of living with (insert disease) is the most difficult or unsatisfying
          for you?
     •    What is it about (insert disease) that bothers you most?
     •    What is your main problem?
     •    What concerns you?
     •    What is hardest for you?
     •    What are your issues?
     •    What do you struggle with?
     •    Could you tell me more about that?
     •    Can you give me some specific examples?
     •    Can you paint a picture of the situation for me?
     •    Symptoms of illness




     4
3. With the client, identify the physical and




                                                                                             Toolkit
psychological symptoms of the existing illness
such as pain, limitations in range of motion (roM)
and strength, depression
     •    Use objective measures for assessment if possible, such as pain scales, ROM
          assessments, depression scales .
     •    Lifestyle factors
          -   Consider factors that may be related to and affect the presentation and
              subsequent course of the illness such as diet or nutrition, weight, smoking,
              stress and exercise .
          -   Use specific guidelines relating to these lifestyle factors .


4.       Identify feelings
     •    Clients seldom make and sustain changes in situations unless they care deeply
          about solving the problem or improving the situation . It is common for people
          to repress uncomfortable emotions . Repressed emotions reduce the energy
          and clarity necessary for effective problem-solving .
     •    Discussing the feelings associated with their situation can energize clients .
          When they experience the depth of their anger, sadness or dissatisfaction by
          talking about their feelings, they are much more likely to take action on their
          own behalf .


5.       establish goals
     •    Help the client identify concretely how the situation would appear if it were
          improved . The means imagining the particulars of the situation if it were to
          be changed and imagining how they would feel if the situation improved .
          It is also useful to help clients imagine how they would feel if things did
          not improve . These questions help clients focus on tangible elements in the
          situation that must change in order for them to feel better . Document the
          changes they have identified .

                                                                                ASk
                         “What do you want?”

                         “What needs to happen?”




     5
                         “How would this situation have to change in order for you to
                          feel better about it?”

                         “Where would you like to be regarding this situation in a
                          month? In three months?”

                         “How will you feel if you do/do not meet your goals?”

                         “What will happen if you do not do anything to change the
                          situation?”

                         “How will you feel if things do not change?”


6.       determine motivation
     •    Clients need to develop clarity about whether or not they are fully committed
          to changing their situation . They should feel free to make or not make a
          commitment to change . It is important that clients do not feel pressure to
          change to please the health care provider . Changes made in response to
          someone else rarely last .


7.       Assess level of motivation
     •    Are you willing to take action to improve the situation for yourself?
     •    How important is it to you for this situation to change?


8. determine client’s readiness for change and
select appropriate approaches
     •    Refer to stages of change discussion/handout


9.       What are frequent problems with goal setting?
     •    Different priorities, which can include:
          -   Too many goals . No more than two or three goals at a time for a client to
              work on . The best case is one goal at a time .
          -   Send message to the client, without overwhelming . You and he/she will
              work together and tackle this a bit at a time . You will not abandon them
              through this process .




     
•    Relevance to personal life




                                                                                      Toolkit
     -   The overall goal of CDSM is creating self-reliance around personal
         goal-setting and action planning .
     -   How will self-management impact the normal rhythm of their day?
•    Readiness and motivation
     -   Supporting clients to examine risks and consequences . Some may need to
         do this by self-experimentation, by trying and succeeding or by trying and
         failing .
     -   Assisting clients to choose “outcomes” that they define as meaningful .
         What do we do if we don’t agree with their goals?




7
                                             3 Questions
                                 1. What worries you the most about your condition?
                                 2. What would you most like to change?
                                 3. How do you think you might do that?




               P R o B L e M S o LV I n g                 T H E T H REE- Q U ESTIO N
                                                                       In teRV Ie W
      •   Identify the problem. Be specific!
      •   List all possible solutions. Brainstorm        1. What worries you the most about your
          ideas, from the ridiculous to the                 condition?
          sublime.
                                                         2. What would you most like to change?
      •   Pick one idea. Sometimes a combination
          of a couple of ideas works.                    3. How do you think you might do that?
      •   Try it out for 2 weeks. Give it a good
          test!
      •   If it doesn’t work, try another.
      •   If that still doesn’t work, find a
          resource for ideas. Maybe a friend or a                 Assessing
          professional can help.                             Readiness
      •   If that doesn’t work, accept that the
          problem may not be solvable at this
          time. Set it aside for now and work on
nk        something else.


          DeCISIo n aL BaLa nCe                                 5 QUESTIO NS TO
                    G R I D (D B G)                   St I M u L ate DI S C u S SIo n
 Change Goal:
                                                         1. How has your life changed since you
  BENEFITS                        CONCERNS                  developed… ?
  S (1)                    (3)
  T                                                      2. Can you tell me what having … is like
                                 8
  A                                                         for you?
  T
  U                                                      3. What do you find challenging about
  S
                                                            living with… ?
  Q
                 5 Questions




                                                                                            Toolkit
                 to Stimulate
                  Discussion
The objectives of these questions are to:

     1. Explore the client’s personal experience of living with a chronic condition
     2. Set the stage for goal-setting
     3. Identify a focus for self-management


1.     how has your life changed since you developed…?
Typically health care providers are expected to concentrate on what is wrong with
a client . Since most life-altering events have positive and negative elements, it is
reasonable to consider both possibilities in the context of chronic disease . For
example, clients with chronic conditions may be fearful of uncertain health problems
in the future, but they may also develop a deeper appreciation of the things in life that
they deem to be most important . This question provides an opportunity to explore
how a client’s life has changed for better and for worse . Positive changes suggest a
growth in self-awareness and self-esteem, which are helpful attributes for developing
self-management skills . Perceived negative change presents an opportunity for efforts
toward supporting improved self-management .




     9
2.    can you tell me what having…is like for you?
Although clients with chronic conditions encounter many similar experiences, each
walks a slightly different path that cannot be entirely predicted . Health care providers
are most knowledgeable about the usual trajectory of a chronic disease, and to some
extent less typical courses of events . Only the client can fully appreciate the combined
physical, psychological, social and spiritual impact of having
a chronic condition . This question encourages clients to
share their experiences, reveal areas in which support may be
needed and help the health care provider to gain insight .


3. What do you find most challenging
about living with…?
It is reasonable to assume that having a chronic condition
presents certain challenges . Health care providers may have
a pre-conceived notion of the nature of these challenges .
For example, in diabetes one might expect a client to have
difficulties with diet, exercise, weight control and lifestyle . By asking clients to talk
about their own unique challenges around living with a chronic condition, other less
obvious issues may emerge, such as the impact on family relationships or the ability to
achieve personal aspirations .


4.    how do you feel you are managing your…?
This strongly conveys the message that clients do in fact self-manage . Practically
speaking, one cannot not self-manage because opting out is a simply an ineffective
style of self-management . It is most helpful if clients are quite specific in their
responses to this question . For example, what behaviours are they actually engaging in
that justify the reply?




     0
R o B L e M S o LV I n g                      T H E T H REE- Q U ESTIO N
                                                           In teRV Ie W
the problem. Be specific!
                                   1. What worries how most about your
                 5. Is there anything about you theyou are managing




                                                                                                               Toolkit
 ossible solutions. Brainstorm
                 your…
om the ridiculous to the that you would like to change?
                                      condition?
                                               2. What would you most like to change?
                  Although this is
  idea. Sometimes a combinationa closed-ended question, it provides a good opener for a discussion
                                               3. How do you think you might do be a
                  about specific areas for change . If the answer is “yes,” this wouldthat? good
ple of ideas works.
                  opportunity
 t for 2 weeks. Give it a good to initiate the Healthy Changes Action Plan . If the answer is “no,” several
                  possibilities exist: the client may already be an expert self-manager, may lack sufficient
                  knowledge or may be in the “pre-contemplation” stage of change (see Tool #1) .
 n’t work, try another.
 ill doesn’t work,Reflecting and/or rephrasing the client’s response will help to move the conversation
                   find a
                  forward .
  for ideas. Maybe a friend or a                         Assessing
 nal can help.                                   Readiness
oesn’t work, accept that the
 may not be solvable at this
 it aside for now and work on
ng else.


 Io n aL BaLanCe                                    5 QUESTIO NS TO
      G R I D (D B G)                     St I M u L ate DI S C u S SIo n
                                             1. How has your life changed since you
                  CONCERNS                      developed… ?
           (3)
                                             2. Can you tell me what having … is like
                                                for you?
                                             3. What do you find challenging about
                                                living with… ?
                                             4. How do you feel you are managing
                                                your… ?
           (4)
                                             5. Is there anything about how you are
                                                managing your … that you would like
                                                to change?



                                             www.practiceeducation.net




                      1
              Decisional
            Balance Grid
For each section of the Decisional Balance Grid, discuss the effects within each of
the following areas: family system; school/employment; peers/significant others;
legal system; leisure/recreational activities; finances; mental and physical health;
perceptions of self .


tips for using the dBG
This is really a guide for conversation and you can be as formal or informal as you
wish depending on your clients’ needs .

Prior to using this tool:

    •    Client identifies one issue to talk about
         changing
    •    Health care professional assesses potential
         for change? Identify stage of change you
         think client may be at

Use this tool as a basis for discussion before moving on to the Healthy Changes Plan .

Plan does not need to be completed in one visit . If not completed in one visit be sure
to validate areas covered last time to ensure nothing has changed .

Examples of when this tool might be helpful:

    •    Staying in own home vs . moving to assisted living or facility
    •    Time for placement of dementing spouse



    
                                                ideas, from the ridiculous to the            condition?
                                                sublime.
                                                                                          2. What would you most like to c
                                           • Pick one idea. Sometimes a combination
                                                of a couple of ideas works.               3. How do you think you might d
                                           • Try it out for 2 weeks. Give it a good
  able”
                                                test!
                Helpful phrases to get you started:




                                                                                                           Toolkit
 ity on change now                         • If it doesn’t work, try another.
                   • What is troubling you right now? doesn’t work, find a
                                           • If that still
 e is important
                   • What do you find most resource for about living with…? or a
                                                 challenging ideas. Maybe a friend                Assessing
ent of success                                  professional can help.
                   • How has your life changed since you developed…?                          Readiness
                                           • If that doesn’t work, accept that the
                                                problem like not be solvable at this
                   • Can you tell me what having… ismay for you?
                                                time. Set it aside for now and work on
the way we think                                something else.


geS aCtIo n PLa n                                 DeCISIo n aL BaLa nCe                            5 QUESTIO NS
                                                            G R I D (D B G)              St I M u L ate DI S C u S SI
                                      Change Goal:
 overcome barriers: What could                                                            1. How has your life changed sinc
ndle these barriers? ______________    BENEFITS                       CONCERNS               developed… ?
________________________________       S (1)                   (3)
                                       T                                                  2. Can you tell me what having …
                                       A                                                     for you?
                                       T
nce ____ and confidence ____           U                                                  3. What do you find challenging a
                                       S
important is the plan to you on a                                                            living with… ?
 How confident are you that you         Q
                                        U                                                 4. How do you feel you are manag
hole plan?                              O                                                    your… ?
                                            (2)                (4)
                                                                                          5. Is there anything about how yo
up: Who are you going to talk to       C
                                       H                                                     managing your … that you wou
an and when? __________________        A                                                     to change?
______________________________         N
                                       G
                                       E

                                                                                          www.practiceeducation.n




                    
   Beh aVIo uR Ch a n ge Co u nSeLIn g
                                                                         •
                                                                         •


                                                                         •
                                                                                    P R o B L e M S o LV I n g
                                                                               Identify the problem. Be specific!
                                                                               List all possible solutions. Brainstorm
                                                                               ideas, from the ridiculous to the
                                                                               sublime.
                                                                               Pick one idea. Sometimes a combination
                                                                                                                                  Problem
                                                                                                                            T H E T H REE- Q U ESTIO N


                                                                                                                          1. What worries you the most about your
                                                                                                                             condition?
                                                                                                                                         In teRV Ie W



                                                                                                                          2. What would you most like to change?




                                                                                                                                   Solving
                                                                               of a couple of ideas works.                3. How do you think you might do that?
                                                                         •     Try it out for 2 weeks. Give it a good
        Be “ready, willing, and able”
                                                                               test!
            Ready = high priority on change now                          •     If it doesn’t work, try another.
                                                                         •     If that still doesn’t work, find a
             Willing = change is important
                                                                               resource for ideas. Maybe a friend or a            Assessing
               Able = confident of success                                     professional can help.                         Readiness
                                                                         •     If that doesn’t work, accept that the
                                                                               problem may not be solvable at this
                                                                               time. Set it aside for now and work on
            shifting the way we think                                          something else.


   h e a Lt h y C h a n g e S a C t I o n P L a n                              DeCISIo n aL BaLa nCe                               5 QUESTIO NS TO
                                                                                         G R I D (D B G)                 St I M u L ate DI S C u S SIo n
                                                                    Change Goal:
: (Something      4.  Plans to overcome barriers: What could                                                              1. How has your life changed since you
                  you do to handle these barriers? ______________    BENEFITS                          CONCERNS              developed… ?
_________         ___________________________________________        S (1)                      (3)
                                                                     T                                                    2. Can you tell me what having … is like
                                                                    1. Identify the problem . Be specific!
                                                                     A
                                                                     T
                                                                                                   for you?
 (So that         5.  Importance ____ and confidence ____            U                                                    3. What do you find challenging about
                                                                     S
d see.)           ratings. How important is the plan to you on a
                  scale of 1–10? How confident are you that you     2. List all possible solutions .4. livingdo you feel you are managing
                                                                    Q                                Brainstorm ideas, from the ridiculous to the
                                                                                                       How
                                                                                                              with… ?
                                                                     U
                  can do the whole plan?                             O
                                                                         (2)
                                                                                sublime . (4)                                your… ?
                                                                                                                          5. Is there anything about how you are
                  6. Follow-up: Who are you going to talk to         C
                  about the plan and when? __________________       3. Pick one idea . Sometimes a combination of a couple of ideas works .
                                                                     H
                                                                     A
                                                                                                                             managing your … that you would like
                                                                                                                             to change?
                  _________________________________________          N
                                                                     G
 way of your
__________
                                                                    4. Try it out for 2 weeks . Give it a good test!
                                                                     E

                                                                                                                          www.practiceeducation.net
                                                                    5. If it doesn’t work, try another .
                                                                    6. If that doesn’t work, find a resource for ideas . Maybe a friend or a professional
                                                                                can help .
                                                                    7. If that doesn’t work, accept that the problem may not be solvable now . Set it
                                                                                aside for now and work on something else .




                                                                     4
          Initiating Self-




                                                                           Toolkit
           management
                 Support
             Framework
           Precontemplation
                                                      Contemplation
                            5 Questions
                             5 Questions
                                                     Decisional
                                                    Balance Grid
              3 Questions          5 A’s
                                 Assess                               Preparation
Relapse                                   Advise
                                  Agree    Assist    Healthy
                                     Arrange         Changes
                        Bubble                      Action Plan
                        Diagram

                                                         Action
               Maintenance



      5
Supporting clients with their chronic disease management requires different tools
and strategies . The “Initiating Self-Management Support Framework” was developed
by Vancouver Community’s Steering Committee for Chronic Disease Management .
It is a useful framework to assist the Facilitator and Learners to understand and put
into context the strategies that can be used to support clients in chronic disease self-
management .

The 5 A’s is at the centre of supporting clients, but keep in mind it is not a linear
process . Health care providers can move in a linear format from the first A to the last
(Assess then to Agree, Advise, Assist and Arrange) . Or, they may move from one A to
another outside of “standard” order .

Different tools, such as the 3 questions, 5 questions, Decisional Balance Grid, Bubble
Diagram or the Healthy Changes Action Plan can be utilized to support one or more
of the 5 A’s . Identifying the client’s stage of change can guide the health care provider
in deciding which tool to use . There is no “cookie cutter” solution, as each health care
provider and client situation differs . Therefore it is useful to have a menu of options .




    
      Care




             Toolkit
     Model




7
                                Toolkit
                              Resources
For use or reprint of these articles, please contact the individual authors directly .

    1. Barr, Victoria; Robinson, Sylvia; Marin-Link, Brenda; Underhill, Lisa; Dotts,
         Annie; Ravensdale, Darlene; Salivaris, Sandy . “The Expanded Chronic Care
         Model: An Integration of Concepts and Strategies from Population Health
         Promotion and the Chronic Care Model”
         http://www .longwoods .com/view .php?aid=16763&cat=328
         Accessed 29 October 2008 .
    2. Funnell, Martha . “Helping Patients Take Charge of their Chronic Illnesses”
         http://www .aafp .org/fpm/20000300/47help .html
         Accessed 29 October 2008 .
    3. Huffman, Melinda . “Health Coaching: A New and Exciting Technique to
         Enhance Patient Self-Management and Improve Outcomes”
         http://www .nursingcenter .com/prodev/ce_article .asp?tid=711946
         Accessed 29 October 2008 .
    4. Tanner, Elizabeth . “Chronic Illness Demands for Self-Management in Older
         Adults .” You may click the following link to find out how to access full-text
         versions of the article:
         http://linkinghub .elsevier .com/retrieve/pii/S0197457204002721




    8

				
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