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Brief Action Planning

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Title: Brief Action Planning


1
  • Brief Action Planning
  • Learning Session 2
  • Adapted from the work of Dr. Rahul Gupta, Margie
    Wiebe (RN) CCMI
  • Presenters name here
  • Location here
  • Date here

2
Faculty/Presenter Disclosure
  • Speakers Name Speakers Name
  • Relationships with commercial interests
  • Grants/Research Support PharmaCorp ABC
  • Speakers Bureau/Honoraria XYZ Biopharmaceuticals
    Ltd
  • Consulting Fees MedX Group Inc.
  • Other Employee of XYZ Hospital Group

3
Disclosure of Commercial Support
This program has received financial support from
organization name in the form of describe
support here e.g. educational grant.
This program has received in-kind support from
organization name in the form of describe the
support here e.g. logistical support.
  • Potential for conflict(s) of interest
  • Speaker/Faculty name has received
    payment/funding, etc. from
  • organization supporting this program AND/OR
    organization whose product(s) are
  • being discussed in this program.
  • Supporting organization name developed/licenses
    /distributes/benefits from
  • the sale of, etc. a product that will be
    discussed in this program enter generic
  • and brand name here.

4
Mitigating Potential Bias
Explain how potential sources of bias identified
in slides 1 and 2 have been mitigated. Refer to
Quick Tips document
5
Certification
  • Up to 21 Mainpro Certified credits for GPs
    awarded upon completion of
  • All 3 Learning Sessions (NOTE Credits and
    payment will be based on the exact number of
    hours in session)
  • At least 1 Action Period
  • The Post-Activity Reflective Questionnaire (2
    months after LS3)
  • Up to 10.5 Section 1 credits for Specialists
  • All 3 Learning Sessions (NOTE Credits and
    payment will be based on the exact number of
    hours in session)
  • The Post-Activity Reflective Questionnaire (2
    months after LS3)

6
Learning Session Action Period Workflow
7
Payment Stream 1 (ideal)
Current Rates Current Rates Current Rates Current Rates
GPs Specialists MOAs
Hourly Rate 125.73 148.31 20.00
Action Period 1 880.10 1,038.16 N/A
Action Period 2 660.07 778.62 N/A
Payment made after attending LS2 Payment made after attending LS2
GPs GPs
PMV 125.73
LS1 440.05 (125.73 x 3.5hrs max.)
AP1 880.10
TOTAL 1,445.88
Specialists Specialists
LS1 519.08 (148.31 x 3.5hrs max.)
AP1 1,038.16
TOTAL 1,557.24
MOAs MOAs
PMV 20.00
LS1 80.00 (20.00 x 4hrs max.)
TOTAL 100.00
Payment made after attending LS3 Payment made after attending LS3
GPs GPs
LS2 440.05 (125.73 x 3.5hrs max.)
AP2 660.08
LS3 440.05 (125.73 x 3.5hrs max.)
TOTAL 1,540.18
Specialists Specialists
LS2 519.08 (148.31 x 3.5hrs max.)
AP2 778.62
LS3 519.08 (148.31 x 3.5hrs max.)
TOTAL 1,816.78
MOAs MOAs
LS2 80.00 (20.00 x 4hrs max.)
LS3 80.00 (20.00 x 4hrs max.)
TOTAL 160.00
8
Agenda
  • Peer Sharing/Learning (30 mins)
  • Advanced Pain Tool Use (45 mins)
  • Comprehensive BAP
  • Patient Self-Manangement
  • Mindfulness/Relaxation Techniques
  • Practicing using techniques
  • Return to Function (30 mins)
  • Break (15 mins)
  • Pharmacotherapy (45 mins)
  • Non-opioid pharmacotherapy
  • Opioid Management
  • Comorbidity between addiction and pain
  • Case Study Application (30 mins)
  • Assessing Pain and creating a management strategy
  • Wrap up (15 mins)
  • Action period planning

9
Learning Objectives LS 2
  • Use appropriate tools to assess pain and plan a a
    management strategy for 6 patients with chronic
    pain
  • Reflect on his/her delivery of pain tools and
    develop a process improvement plan

10
Learning Objectives - BAP
  • Define Brief Action Planning (B.A.P.) and
    describe the process
  • Explore a case study illustrating how B.A.P.
    supports patient self-management
  • Practice B.A.P. to develop comfort and skill

11
  • Everyone has a doctor in him or her, we just
    have to help that doctor in its work. The natural
    healing force within each of us is the greatest
    force in getting well.
  • -Hippocrates (460-377 B.C.)

12
What is Brief Action Planning?
  • a highly structured
  • patient-centered
  • stepped-care
  • evidence-informed
  • self-management support technique based on the
    principles and practice of Motivational
    Interviewing.

Gutnick et al, 2014, Jrnl Clin Outcomes
Mgmt Reims et al, Brief Action Planning White
Paper, 2014 both available at www.centreCMI.ca
13
Spirit of Motivational Interviewing
  • Compassion
  • Acceptance
  • Partnership
  • Evocation

Miller W, Rollnick S. Motivational Interviewing
Helping People Change, 3ed, 2013
14
Is there anything you would like to do for your
health in the next week or two?
Behavioral Menu
Elicit a Commitment Statement
SMART Behavioral Plan
How confident or sure do you feel about carrying
out your plan (on a scale from 0 to 10)?
If Confidence lt7, Problem Solve Barriers
Would it be helpful to set up a check on how
things are going with your plan?
Check on progress
15
Three Questions of B.A.P.
Is there anything you would like to do for your
health in the next week or two?
How confident or sure do you feel about carrying
out your plan (on a scale from 0 to 10)?
Would it be helpful to set up a check on how
things are going with your plan?
16
Five Skills of B.A.P.
Behavioral Menu
SMART Behavioral Plan
Elicit a Commitment Statement
If Confidence lt7, Problem Solve Barriers
Check on progress
17
Is there anything you would like to do for your
health in the next week or two?
Behavioral Menu
Elicit a Commitment Statement
SMART Behavioral Plan
How confident or sure do you feel about carrying
out your plan (on a scale from 0 to 10)?
If Confidence lt7, Problem Solve Barriers
Would it be helpful to set up a check on how
things are going with your plan?
Check on progress
18
Example Case
19
Example Case
  • 62 year old female cashier with long history of
    severe migraines, still debilitating 1x weekly
    (in bed 2 days). On long-acting opioid,
    sumatriptan and codeine for BTP.
  • Continues to miss many afternoons at work due to
    migraines
  • Low self-esteem, timid, anxious, perfectionist
  • Frustrated, feels at the mercy of migraines,
    lots of incompletions
  • Is there anything you would like to do for your
    health in the next week or two?

20
Example Case
  • I want to make my mornings less stressful

21
Stating Action Plans in the Positive
  • We are trained to focus on whats wrong with
    ourselves
  • Preoccupation with whats wrong means less
    focus on what allows us to flourish
  • The brain cannot visualize negatives
  • The brain is continually responding to pictures
  • Research suggests shifting focus to positive
    visuals enhances cognitive abilities and inspires
    action
  • Example I want to stop being in so much pain.
  • Physician What would you prefer to experience?
  • I want to feel more comfort in my body.
  • I want to feel energetic.
  • Frederickson Branigan. Cognition and Emotion,
    200519, 313-332.

22
Example Case
  • I want to make my mornings less stressful.
  • What would you prefer?
  • To feel more at ease in the mornings.
  • How will you start?
  • Dont know.

23
Skill 1
Behavioral Menu
  • Offer a behavioral menu when needed or requested.

24
Behavioral Menu
  1. Is it okay if I share some ideas from other
    people who are working on something similar?
  2. If yes, share two or three varied ideas briefly
    all together in a list. Then say
  3. Maybe one of these would be of interest to you
    or maybe you have thought of something else while
    we have been talking?

Physical Activity
Healthier eating
Better Sleep
Adapted from Stott et al, Family Practice 1995
Rollnick et al, 1999, 2010
25
Example Case- Behavioural Menu
  • Is it ok to share some ideas?
  • You might consider working on becoming more
    assertive, or getting better at completing
    things.
  • Does one of these ideas interest you, or maybe
    you have thought of something else?
  • I want to make my mornings less stressful

26
Skill 2
SMART Behavioral Plan
  • Action Planning is SMART Specific, Measurable,
    Achievable, Relevant and Timed.
  • With permission
  • What?
  • When?
  • Where?
  • How often/long/much?
  • Start date?

Based on the work of Locke (1968) and Locke
Latham (1990, 2002) Bodenheimer, 2009
27
Example Case SMART goal-setting
  • I want to make my mornings less stressful.
  • Would it be okay to get more specific?
  • Sure
  • What would you like to do?
  • To feel more at ease in the mornings.
  • How will you start?
  • Dont know.

28
Example Case SMART goal-setting
  • I want to feel more at ease in the mornings.
  • Can I share some ideas that have worked for
    others?
  • You might pace yourself differently, or reduce
    your expectations. Does that trigger any
    thoughts?
  • I will not answer my phone til noon, I will say
    NO to unreasonable requests for my time, I will
    break tasks into 30 minute chunks.
  • Whats enough for the first 2 weeks?
  • 5 mornings of ease per week.

29
Skill 2
SMART Behavioral Plan
  • Is her plan SMART?
  • Specific, stated in positive
  • Measurable
  • Achievable
  • Relevant
  • Timed
  • Locke Latham. Building a Practically Useful
    Theory of Goal Setting Task Motivation.
    American Psych, 200257, 705-717Frederickson
    Branigan. Cognition and Emotion, 200519,
    313-332.
  • Bodenheimer. Goal-Setting for Behavior Change in
    Primary Care. Pt Educ Couns 200976(2)174-80

30
Skill 3
Elicit a Commitment Statement
  • After the plan has been formulated, the clinician
    elicits a final commitment statement.
  • The strength of the commitment statement
  • predicts success on action plan.

Aharonovich, E. Cognition, commitment language,
and behavioral changePsychology of Addictive
Behaviors, 200822556-562Amhrein PC. Client
commitment language during motivational
interviewing predicts drug use outcomes. Journal
of Consulting and Clinical Psychology,
200371862-878
31
Example Case Eliciting a Commitment Statement
  • Just to make sure we both understand the details
    of your plan, would you mind putting it together
    and saying it out loud?
  • Over the next 2 weeks, I will make my mornings
    feel more at ease. I will not answer the phone
    til noon, I will say NO to unreasonable requests,
    and I will break tasks into 30 minute segments. I
    will do this 5x per week.

32
Three Questions of B.A.P.
How confident or sure do you feel about carrying
out your plan (on a scale from 0 to 10)?
33
Skill 4
Problem Solving
  • Problem-solving is used for confidence levels
    less than 7.
  • Note If the patient indicates his/her level is
    lt7, the likelihood of a successful behavioural
    change is low.

Bandura, 1983 Lorig et al, Med Care 2001
Bodenheimer review, CHCF 2005 Bodenheimer, Pt Ed
Couns 2009.
34
Self-efficacy
  • Peoples beliefs about their capabilities to
    perform specific behaviors and their ability to
    exercise influence over events that affect their
    lives. Self-efficacy beliefs determine how people
    feel, think, motivate themselves and behave.
  • - Albert Bandura

Mt Frosty, BC by C. Davis
35
Problem solving
Confidence lt7 A __ is higher than a zero, thats
good! We know people are more likely to complete
a plan if its higher than 7.
Any ideas about what might raise your
confidence?
Yes
No
Behavioral Menu
Assure improved confidence. Restate plan and
rating as needed.
36
Example Case Problem SolvingI want to feel
more at ease in the mornings.
  • Considering a scale of 0-10, how sure are you
    about completing your plan?
  • 4/10.
  • OK, 4 is better than 3! When confidence is
    greater than 7, people are more likely to
    succeed. Do you have any ideas about how you
    might raise your confidence to a 7 or greater?
  • If I expect myself to do it even 2x per week,
    that feels more possible.
  • How sure are you now?
  • 8/10.

37
Would it be helpful to set up a check on how
things are going with your plan?
38
Skill 5
Check on progress
  • Checking on the plan builds confidence.

Check often with new action plans and decrease
frequency as behavior is more secure. When
working with a clinician Regular contact over
time is better than 1x intervention. Follow-up
builds a trusting relationship.
Resnicow, 2002 Artinian et al, Circulation, 2010
39
Checking On Plan with Clinician
How did it go with your plan?
Completion
Partial completion
Did not carry out plan
Recognize success
Recognize partial completion
Reassure that this is common occurrence
What would you like to do next?
40
Is there anything you would like to do for your
health in the next week or two?
Have an idea?
Not sure? Behavioral Menu
Not at this time
Permission to check next time
SMART Behavioral Plan
With permission What? When? Where? How
often/long/much? Start date?
1) Ask permission to share ideas. 2) Share 2-3
ideas. 3) Ask if any of these ideas or one of
their own ideas might work.
Elicit a Commitment Statement
How confident or sure do you feel about carrying
out your plan (on a scale from 0 to 10)?
Confidence 7
Confidence lt7, Problem Solving
Would it be helpful to set up a check on how
things are going with your plan?
How? When?
Check on Progress
Would you like to set a specific time to check
back in with me so we can review how things have
been going with the plan?
Would you like to set a specific time to check
back in with me so we can review how things have
been going with the plan?
Would you like to set a specific time to check
back in with me so we can review how things have
been going with the plan?
Would you like to set a specific time to check
back in with me so we can review how things have
been going with the plan?
41
The client does the most talking in Brief Action
Planning
42
EXERCISE Practicing B.A.P.
  • Use Worksheet as your guide
  • Divide into groups of 2 (patient provider)
  • Spend 5 minutes in each role, then switch
  • PATIENT Choose something real you want to do in
    the next week or two
  • PROVIDER Use 5 minutes to practice approach

43
EXERCISE Practicing B.A.P.
De-Brief
44
Tips For Using These Tools
  • Practice and get feedback.
  • Set SMART goals for yourself.
  • Choose easy patients to start with.
  • Work over multiple appointments.
  • Focus on the spirit of the interview.

45
Mindfulness Based Stress Reduction(MBSR)
  • Program started in 1979 at U Mass Medical School
    by Dr. Jon Kabat-Zinn
  • 8 week group program, usually 2.5 hour class with
    all-day retreat
  • Trainings include breath/body awareness,
    developing acceptance of present moment, and
    understanding stress physiology
  • Over 30 years of research, documenting its value
    in improving patient self-management and the
    capacity to more effectively deal with stress
    illness

46
MBSR Chronic Pain
  • Chronic Pain Vowles McCracken 2005, 2008
  • 108 171 patients respectively, intensive
    programs
  • demonstrated improvements pre- to post- treatment
    on measures of pain, depression, pain-related
    anxiety, disability, medical visits, work status
    and physical performance
  • Chronic Pain Simpson Mapel 2011
  • RCT with 32 people mix of FM, arthritis, IBS,
    migraines etc
  • Significant positive changes around rumination,
    magnification and helplessness (better able to
    manage pain)

47
MBSR-Chronic Back Pain
  • Low Back Pain Morone, Greco Weiner 2008
  • RCT with 37 people greater acceptance,
    engagement in activities and overall physical
    functioning
  • Failed Back Surgery Syndrome Esmer et al 2010
  • Single-center, prospective, randomized trial with
    25 people clinically significant increase in
    pain acceptance, sleep QoL measure, decrease in
    pain, functional limitation frequency of
    use/potency of analgesics

48
MBSR Fibromyalgia
  • Fibromyalgia Kaplan, Goldenberg Galvin-Nadeau
    1993
  • Pre-post assessments with 59 people improved
    sleep, pain, fatigue, well-being, coping and FM
    symptomatology (SCL-90-R)
  • 51 responders (moderate to marked improvement)
  • Fibromyalgia Weissbecker et al. 2002
  • RCT with 91 women improved sense of coherence,
    lower perceived stress and less depression
  • Sense of Coherence disposition to experience
    life as meaningful and manageable

49
How might you bring Mindfulness to the Clinical
Encounter?
  • Mindful Listening (to self and patient)
  • Use CBIS handouts on body scan and mindfulness
  • Give mindfulness options for behavioural menu
    options (do one thing at a time, slow down,
    nothing time, breath awareness)
  • Suggest books
  • Be aware of local mindfulness programs

50
Suggested Books
51
Mindfulness Resources
  • CBIS handouts (body scan, mindfulness meditation,
    relaxation)
  • Mindfulness-Based Chronic Pain Management
    www.neuronovacentre.ca
  • The Mindfulness Solution to Pain (Dr. Jackie
    Gardner-Nix)
  • MBSR courses being held around BC www.mbsrbc.ca
  • Pain BC www.painbc.ca
  • Center for Mindfulnesswww.umassmed.edu/cfm/stress/
    index.aspx

52
Introducing Mindfulness to Patients
  • It is common for those dealing with chronic pain
    to focus on past issues (good or bad) , future
    concerns or judgments about the present
  • Mindfulness is the capacity to BE WITH and IN the
    constant flow of present moment
  • It allows for a clearer understanding of how
    thoughts and emotions can impact health and
    quality of life
  • This capacity is inherent with each person, and
    can be cultivated through practice
  • Would you like to hear some options for exploring
    mindfulness, or do you have some ideas of your
    own?

53
Questions?
54
Resources
  • Center for Comprehensive Motivational
    Interventions www.centreCMI.ca
  • Patient Self-Management Module (VCH) of PSP
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