Based on the recommendations of the United States Preventive Services Task Force (USPSTF), Medicare has begun to reimburse primary care providers for select preventive care services. Within that framework of preventive services, we are seeing more and more services designed to promote behavioral change. Both the Intensive Behavioral Therapy for Obesity and the Intensive Behavioral Therapy for Cardiovascular disease (HCPCS codes G0447 and G0446) are good examples of this.
First and foremost, it is important to understand that prevention doesn’t work unless patients are ready, willing and able to make the necessary changes for behavioral change to happen. The primary care provider plays an integral part in this service, but results only occur if the patient actually changes their behavior over the long term. The big question is how to trigger long term behavioral change in a short 15 minute office visit.
The 5 A’s
The USPSTF recommends the 5 A’s to support primary care providers use of behavioral intervention among patients. The 5 A’s provide guidance to providers helping them manage behavioral change in the short time period they have to spend with patients. Medicare has built the 5 A’s into the requirements for reimbursement of both IBTO and IBTCV.
The 5 A’s are described below:
- Assess – Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
- Advise – Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
- Agree- Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
- Assist – Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
- Arrange – Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.
Unfortunately, despite the success the 5 A’s have had in research studies, they fail to address patients who are not ready for change. This is where the 5 R’s come into play.
The 5 R’s (Readiness)
The 5 R’s consist of five elements providers can use to promote readiness among patients who are not yet ready or willing to work toward behavioral changes in their lives.
The 5 R’s are described below:
- Relevance – Encourage the patient to indicate why changing their unhealthy behavior is personally relevant.
- Risks – Ask the patient to identify potential negative consequences of the unhealthy behavior.
- Rewards – Ask the patient to identify potential benefits of stopping the unhealthy behavior.
- Roadblocks – Ask the patient to identify barriers or impediments to quitting.
- Repetition – The motivational intervention should be repeated every time an unmotivated patient has an interaction with a clinician. Patients who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.
Understanding Behavioral Change
If providers are going to be promote behavioral change, they must have an understanding of what is behind the behavior. This may require providers to delve into the world of sociology and psychology to have a basic understanding of what causes addictive behavior and what it will take to help patients modify those behaviors.
I began my career in education, a field of study that is long steeped in behavioral modification. I believe providers can learn from the educational field to help them increase patient motivation and support behavior management. The study of education has spent over a century developing theoretical philosophies that dictate how to encourage individuals to implement change that they wouldn’t naturally do. Examples include getting children to learn to read or getting a MD/DO student to study enough to pass their board exams. This area may best be understood by imagining the patient asking, “What’s in it for me?”
Many MIPS/MACRA quality measures are based on both provider actions and the behavioral changes of patients. The following paragraphs may help providers adopt theoretical practices from psychology, sociology and education.
Any good therapist, counselor or coach will tell you that their job is to help patients take responsibility for their own health. It is important that providers understand that unlike E&M services where they are prescribing medication for illnesses or give a diagnosis that is treated by a medical provider, behavioral change requires the provider to encourage and/or support change. In all behavioral change scenarios, the patient is the only person who can be responsible for long term success.
Boundaries through Goals and Objectives:
To effectively separate the provider’s place in behavioral management from the patient’s responsibilities, it is helpful for the provider to have clearly defined goals and objectives for each behavioral change they are pursuing with the patient. We will briefly explore how goals and objectives are defined and how they can be used in the practice’s behavioral modification support program.
Defining Goals and Objectives:
Developing effective goals and objectives requires an understanding of the way these two terms differ.
- A goal is long term, such as “The patient’s BMI will be be less than 30 in 12 months.”
- Objectives are short term and are always measurable. For example, Objective 1 may be: “The patient will walk 30 minutes every day for the next 30 days.” Objective 2 may be: “The patient will reduce their daily caloric intake to not exceed 2000 calories per day for the next two weeks.”
The objectives need to have an expiration date. Timelines help give patients real metrics to meet. Having these set goals and objectives are the first step in developing a behavioral modification program. If a provider needs more information on how to develop goals and objectives, we recommend they visit the Tips for Writing Goals and Objectives website.
When developing a behavioral modification program, or any preventive service program, it is imperative to support a self-directed approach with patients. Again, this is something of a paradigm shift for many providers who have discouraged patients from becoming self-directed.
There are four very important aspects of self direction:
- Self-Activation – motivation
- Self-Efficacy – belief in one’s ability
- Self-Management – ability to take responsibility
- Self-Advocacy – ability to stand up for one’s self
We will explore these in more depth below. As we explore these, look for ways the 5 R’s lend themselves to promoting change among your patients.
Patient Self-Activation or Motivational Conflict
I once had a university professor tell our class: “Conflict is the catalyst of change. If there is no conflict there will be no change.” In other words, there must be something that is causing the patient enough conflict (difficulty) that they are willing (motivated) to take the steps necessary for change. Examples of this may be a patient diagnosed with diabetes. The fear of that causes them to start exercising and maintaining their weight. Conflict to change can be varied based upon the patient. If patients have chronic illnesses or are prone to a chronic illness often the conflict can be loss of life, loss of independence or loss of the ability to do the things they do now. Pain can often plays a significant role in motivational conflict. Helping patients identify their motivational conflict will enable them to self-activate around healthy behavioral change. It is important to be honest with patients and not gloss over the reasons for their situation.
Whatever the cause for change, the provider needs to identify this and be able to discuss this with the patient. This is especially true when that patient has fallen off the wagon. Again, it is useful to remember the 5 R’s can be used to promote this conflicted change in patients.
It is inevitable that even your most dedicated behavioral change patients will fall off the wagon. Except for patients who must have absolute abstinence, this doesn’t have to be a bad thing. For the most part, when patients fall off the wagon, you can simply remind the patient about their motivational conflict that initially motivated them. The provider can check to see if the motivation is still in place and whether or not the conflict is still present. If not, the patient may no longer be willing or ready for change. More often than not however, helping the patient recommit to their mission for change will be enough to get them back on track. If not, the process may need to go back to square one by helping the patient identify the motivational conflict that would be adequate to promote life changes. The repetition aspect of the 5 R’s are a useful component to this level of support.
Self-efficacy is essential in patient success. The patient must believe he/she can be successful. When that belief is tested, the provider will be responsible for helping reinstill that belief within their patients.
If a patient is going to be successful in the changes you have placed in front of them, they must have the belief that they can change but they also must have the skills necessary to manage the change.
This sounds simple and with the plethora of information available about changes such as tobacco cessation and weight loss one would think that no new information is necessary. Nothing could be farther from the truth. Providers can not assume patients know how to change their behavior. They must also be respectful of the patient’s existing knowledge. Much can be gleaned by asking patients questions about their understanding. An example may be, “Do you know how to reduce your caloric intake to between 1500 to 2000? Do you know the foods you can eat to do that? Having handouts are essential but also having resources the patient can use. Programs such as Weight Watchers may be a good resource for referring your patients to. Especially if they haven’t had much experience or success with behavioral change in the past.
Providers will never have enough time to spoon feed patients the information needed to meet behavioral changes, support self efficacy, self management or self activation. For success to occur the patient MUST know when to ask for help. What is probably even more important is that the patient feels comfortable getting help.
Due to the lack of time Providers have to spend with patients, this area of support is especially concerning for patient long term success. If a provider isn’t available when a patient needs support from the practice, then the providers need to have other supports set in place. Often this can be done with your wellness team or community health workers. Whatever the case may be, it is essential that each patient have a way to reach and access their provider (or the provider’s team) when they need support.
Self-advocacy also includes encouraging patients to reach out to the practice before chronic conditions get too extreme. Training patients not to wait when symptoms begin is essential to keeping more serious illness from occurring.
In summary, by instituting the following four self-directed components into their practice, providers will be more effective assisting patients to navigate the often onerous aspects of behavioral change.
- Self-activation – where the provider helps the patient set goals and objectives that support their changes.
- Self-efficacy – where the provider supports the patient’s beliefs that they are capable of change.
- Self-management – where the provider assists the patient with acquiring the tools, supports and resources necessary for the patient to manage their behavioral changes.
- Self-advocacy – where the provider has set up a system that encourages the patients to access the provider when they need help/support as well as systems to manage patient needs immediately when they arise.
Through the success of effective behavioral change, providers will see significantly improved health outcomes with their patients.