Health Behavior Change: Consumer Engagement (Part 1 in a Series)
Joan Kenerson King, Integrated Health Senior Consultant, National Council
Health behavior changes, like changing eating or exercise habits, can profoundly affect the overall health of individuals with mental illnesses and addictions. Given the high rates of preventable chronic health problems among this population, these changes can be life changing and, in some cases, life giving. Some of the people that could most benefit from having care that supports them to make health behavior changes receive health and wellness support in behavioral health settings. Despite great efforts, health and wellness goals can be hard to achieve. One solution lies in applying behavioral health providers’ well-tuned engagement skills to this new arena of physical health behavior change.
The Ingredients of Success
As a behavioral health provider trying to understand how to best engage consumers in the change process, it’s helpful to first step back and think about changes you’ve made. Have you ever quit smoking, began an exercise regime, or made another positive change in your life? What were the ingredients of your success?
For many people, they find change easier when they have:
- A support system comprised of people who believed in you and your capacity for change even before you did.
- The necessary knowledge and education to approach change.
- A person to help you make small – tiny – steps toward change.
- A way to monitor change and someone to hold you accountable.
- Celebration of small achievements in the change process.
You can take your understanding of what goes into successful change and bring it to the table with those you serve.
A Strong Relationship
A strong relationship can serve as a strong motivator for change. Engaging people in hopeful, respectful, and supportive relationships creates a context where change is possible. When supporting a person’s health behavior change, your hope and belief that they can change can help the person capture that vision for him or herself. A respectful relationship focuses on the many ways in which the person has already changed, even in ways they may be unaware, and honors the hard work that change entails. In this kind of relationship, you can look for moments in the person’s life when he or she was successful and help the person see those moments as ones that can build more change possibility. Support in the context of health behavior change may take many forms. It may mean connecting the person contemplating change to a peer who has been successful with a similar change; it may mean exploring together concrete strategies and resources for change; or it may involve assuming a cheerleading or coaching role and “being with” the person throughout the change process.
It is critical to fully explore the person’s worldview, their experience with change, and what change is most important to him or her. Each person has valid reasons not to change behaviors, and providers must come to understand the root of a person’s behavior. The reasons are usually complicated, but if the person knows you care enough to try to understand and that you believe that they have the capacity for change, you will have made it that much easier to engage them in change.
Less is More
People don’t always understand that change is a possibility for them. Part of that is because they do not understand that even very small changes make a difference. A woman 130 pounds overweight may think she has to lose all the weight in one fell swoop like she sees on the hit show Biggest Loser. She may think that requires exercising 4 hours a day and drastically cutting her daily calorie intake. Those are big changes — and daunting ones. However, a 5% reduction in body weight can improve health substantially.
Small changes matter. We can help people see that change is possible when approached in small, incremental steps. We can achieve this by educating them on the change process. For example, instead of focusing on a goal of losing 130 pounds, discuss what would happen if this woman drank five sugary drinks a day instead of six, or gave up the remote and changed the TV manually. Those are small, meaningful changes that one can build upon over time.
You cannot run a marathon without first being able to walk around the block. There are steps to follow, and, for some people, change can start with just walking across the room five times a day.
Goal Setting and Support
Many care plans revolve around 3-month increments. For example, a provider may write that an individual will lose 12 pounds in 3 months. Then, if that’s the last discussion about it, at the 3-month check-up, it’s likely the goal wasn’t met. In this situation, the provider offered little to no regular support. People will meet greater success if they have specific weekly goals that providers support by regularly checking in to see how it’s going, celebrate successes, or discuss alternatives if the individual is having difficulty. If you had a client with addictions issues, would you only ask them about cravings once every 3 months in a care plan? Some of the same techniques and strategies we use to help our clients stay on task with their recovery goals work great to help with health behavior change goals.
To help those you serve improve their health, look at how you approach client engagement in the health behavioral change process. Can you help individuals work toward positive health improvements by supporting them as they work toward small, achievable goals? Can you help them measure their achievements and celebrate their successes? Everyone has the capacity for change, and you can help them achieve it!
For more on health behavior change and consumer engagement and other integration topics, visit www.integration.samhsa.gov.
Look for the second article in this Health Behavior Change series in the next issue of eSolutions, when CIHS focuses on self-management.
At Greater Cincinnati Behavioral Health Services (GCB), 75% of services are provided in the community, placing great emphasis on consumer engagement. Faced with reaching a segment of the population that is traditionally difficult to engage in care, the organization’s 300 staff members use active strategies to connect the 4,000 individuals with serious behavioral health problems it serves with a comprehensive array of services and supports.
GCB’s robust case/care management department spends a great deal of time in clients’ homes, in work settings, on the streets, with family members — anywhere they can reach and engage consumers. GCB provides behavioral healthcare and primary care, as well as wellness, vocational, and housing support services. Regardless of the engagement strategy, client need, or type of professional (e.g., nurse care managers, wellness liaisons, peers, primary care staff), one element is universal: engagement centers on one-on-one interaction. Staff work with clients to identify goals, which the entire treatment team supports through daily meetings to keep atop of progress, address barriers, and problem solve. They find the participation of PBHCI staff and nurses, as well as a consulting primary care provider, extremely helpful to overcome any issues a client faces.
In the past year, the agency has also begun to train staff to better help clients identify and meet meaningful goals, and to support them as they work toward their goals. As they continue to train staff, they avoid goals such as “I want to get my SSI,” focusing instead on goals like “I want to be a healthier person. I want to live a longer, healthier life. I want to better manage my health and mental health conditions.” This represents a huge leap for GCB, one that also entails reviewing existing treatment plans to ensure that staff actively engage clients on important physical health issues such as diabetes, instead of focusing exclusively on the traditional behavioral health services and supports. In short, they have shifted focus to improving the quality of their treatment planning.
The organization invests in training staff in motivational interviewing and therapeutic alliances, preparing them to better engage clients in health behaviors changes that will improve physical and mental health and increase their engagement competencies. In addition, the organization now retains more peers (i.e., peer wellness coaches), which has proved to be a huge advantage in getting clients interested in wellness activities.
The organization did have a bit of a head start. Nearly 10 years ago, GCB began co-locating an advanced practice nurse to support clients’ physical health. This small step led to their partnership with the local FQHC and then to the work they do under SAMHSA’s PBHCI program. They also look forward to Ohio’s implementation of a CMS funded health home demonstration project, which the agency sees as a means to sustain their strides in integrating primary and behavioral healthcare.
For more on the Greater Cincinnati Behavioral Health Services, visit www.gcbhs.com. To learn more about the PBHCI program, visit www.integration.samhsa.gov/about-us/pbhci.
You can also access CIHS’ motivational interviewing webinar series for in-depth information on this approach to consumer engagement.
Behavioral healthcare providers who work with clients toward behavior health changes often share common issues related to communications overload and resistance to change. A few tips to overcome these complications include:
- Collaborate with your client rather than directing and offering choices, whenever possible. Relying only on your expertise and not engaging the individual’s expertise about his or her own experience may lead to passiveness and half-hearted commitments.
- Share small amounts of information. Then, stop and check understanding before offering further information. Providing too much information at one time can lead the person to feel overwhelmed.
- Create opportunities for your client to voice his or her need for change and to express optimism about his or her ability to change. Attempting to force behavior change can lead to resistance and creates a power struggle that nobody wins.
Missed Past CIHS Webinars?
Access recordings and presentations at www.integration.samhsa.gov/about-us/webinars.
CIHS Launches Learning Networks on Medication Assisted Treatment for Substance Use
CIHS launched its Health Networks Learning Collaborative on Expanding the Use of Medications to Treat Individuals with Substance Use Disorders in Safety Net Settings. CIHS chose 19 organizations in three states — California, Maryland, and Ohio — to participate in the Health Networks Learning Collaborative. The program centers on medications as an essential, evidence-based component of treatment that can facilitate recovery. The Learning Networks will encourage individuals to sustain recovery and improve health across safety net settings by working with Single State Agencies and community safety net providers to increase the adoption of medications to treat individuals with substance use disorders in primary care, substance use treatment, and community mental health programs.
CIHS Concludes Integration Learning Community
CIHS concluded its first Integrated Health Provider Learning Collaborative program in May 2012. The program engaged 15 mental health, primary care, and substance use primary organizations to answer the question, “how can community mental health and addictions treatment organizations shift their practices to support bidirectional integration”? The project helped address the shortage of available behavioral health professionals that results from practice and process flow systems that do not use existing capacity because of no-shows and cancellations. During this 9-month program, participating sites learned how to nurture three primary values required for community behavioral health organizations to serve as partners in new service delivery models — be accessible, be efficient, and produce measurable outcomes.
HRSA to Fund 15 Rural Health Networks
HRSA will fund 15 awards for rural, non-profit, or public entities that represent a consortium/network of three or more healthcare provider organizations (e.g., social service agencies, faith-based organizations, mental health agencies, charitable organizations, educational institutions, employers, local government agencies, or other entities) to promote the development of integrated healthcare networks to achieve efficiencies, improve the quality of essential health care services, and strengthen the rural healthcare system. These rural health networks will involve an organizational arrangement of at least three separately owned healthcare providers that come together to develop strategies for improving health services delivery systems in a community. Applications are due by October 15, 2012.
New Research Shows Collaborative Chronic Care Models Work
A recent study in the American Journal of Psychiatry shows that collaborative care models can improve mental and physical outcomes for individuals with mental illnesses across a wide variety of care settings.
Online Medicaid Expansion Planning Toolkit
The Center for Health Care Strategies gathered a compendium of resources to help states design programs to address the needs of the Medicaid expansion population. This online toolkit includes these reports, briefs, case studies, presentations, and links to state and plan materials.
For Primary Care Providers: Special Behavioral Health Training
The American Psychiatric Association is offering training sessions for primary care providers at the 2012 Institute on Psychiatric Services in New York City. The training sessions include a special primary care oriented track on Saturday, October 6 that will include over 20 sessions focused on primary and behavioral healthcare integration. Many sessions are particularly relevant for primary care providers (e.g., a course on psychopharmacology), and are led by nationally recognized leaders. The track will also feature a daylong Buprenorphine certification course on Friday, October 5.
CMS Awarded Innovation Grants, Many for Integration Projects
The Center for Medicare and Medicaid Health Care Innovation Awards fund up to $1 billion in grants to applicants who will implement the most compelling new ideas to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid, and Children's Health Insurance Program (CHIP), particularly those with the highest health care needs. Many of the awardees received funding to support integration efforts.
New Report on States’ Implementation of Medicaid Expansion
The Government Accountability Office has released a new report on states’ actions to implement the Medicaid expansion. The report addresses several key topics, including states’ responsibility for implementing the expansion provisions under the Affordable Care Act, actions states have taken thus far to prepare, and states’ views on the fiscal implications of the expansion on state budget planning.
New Report on Maximizing Enrollment for Medicaid, CHIP and Exchanges
The Affordable Care Act envisions a technology-enabled enrollment environment where consumers can seamlessly connect to coverage in Medicaid, CHIP, or exchanges, requiring states to rethink how they deliver assistance to support enrollment. This new Maximizing Enrollment brief draws on experience in states that have pioneered tools like secure online accounts and online chat to consider how current consumer assistance, as well as state staffing and organizational structure may change as technology transforms the enrollment process.