Building a better behavior change model for chronic conditions

In our last blog, we focused on practical steps to improve your personal health in a world where unhealthy food and lifestyle options have become the cultural norm. In this blog, we focus on how to help patients who are living with a chronic disease and are struggling to change deep-seated lifestyle habits and thinking.

Let’s focus on diabetes as an example. Statistics show that 34.2 million Americans are living with diabetes and another 88 million are at high risk of developing diabetes. Given that diabetes is preventable or reversible – or at least controllable – in most cases with adherence to an effective lifestyle and treatment plan, why are millions of people not successfully following the recommendations of their clinical team in order to avoid disease progression and minimize the risk of unpleasant hospital visits, medical costs, and medical procedures?  

Both patients and clinicians can become stuck. Research shows, for example, only 19% of patients with diabetes have all three of the key clinical indices in a healthy range: blood glucose, blood pressure, and blood lipids. Clinicians look at these every day in their work and know that patients in poor control in these 3 areas face a difficult journey ahead. Clinicians are frustrated when patients don’t follow their advice to “lose weight, exercise, eat healthier, and take prescribed medications,” especially as these actions can improve troubling clinical results. Real damage starts to happen to the human body when out-of-range clinical indices persist over time and inevitably lead to avoidable medical complications and treatments that no one wants.

From the patient’s perspective, it may seem like their doctors do not have the time to teach them how to better follow the agreed treatment plan or to motivate them to make necessary lifestyle changes to be safe. Patients may also unrealistically expect to be “fixed” or “saved”.

We explore here why patients (and their clinical team) can become “stuck in sickness” and why it is essential that behavior medicine strategies are used to provide a fresh perspective.

Supporting patients to make informed decisions about health and lifestyle choices

There are many health behavior change models available that can help clinicians empower and motivate patients with chronic conditions to do what is in their best interests while optimizing their health. But these models are often locked away in wordy research papers full of jargon. Although these models and programs are based on them, clinicians may feel that they are inaccessible, uninteresting, or irrelevant, even if freely available on the web. Clinicians do not typically pore through research papers looking for practice gems; they are busy seeing patients. Although research is important, psychologists must build a bridge between these research models and the practical realities and needs of frontline clinical care teams. Adapting these models to be relevant and accessible to those in real-world clinic settings was a central goal when we developed Silver Fern’s Practical Behavior Change Model.

Lifestyle-related chronic diseases require high levels of daily patient engagement and sustained personal effort. Given this, several models help us understand why many patients with diabetes and other chronic conditions get stuck as a result of these demands. These models include Social Cognitive Theory; the IMB model; Self Determination Theory; the Health Beliefs Model; the Transtheoretical Model, COM-B; as well as Motivational Interviewing and the “5 As” techniques.

After years of working with these models in clinical programs (particularly Motivational Interviewing and IMB) and wanting to adapt them to apply to more scalable commercial programs, it became clear that a new model was needed. Silver Fern’s Practical Behavior Change Model draws on the overlapping themes of these research-based models but presents the main concepts in a more actionable way for people working on the front lines of clinical care. We further infused the approach with additional insights available from the growing medical specialty of Lifestyle Medicine. The goal in developing a new model was to provide an accessible, prevention-based approach for clinicians working with patients who have or at risk of developing chronic disease, particularly those who struggle with unhealthy food and lifestyle choices and demanding treatment plans.

Our behavior change model strips the challenge down to the most basic drivers of success. In order to help patients to avoid becoming “stuck in sickness” and to  make informed and practical decisions about their personal lifestyle habits and the treatment plan that best fits them, each patient needs Information, Motivation, and Behavior Skills that are unique to their individual situation and that evolve over time to meet their changing circumstances and needs.

Silver Fern Healthcare, LLC’s Practical Behavior Change Model © 2020

Let’s dive into these three key drivers:

Information. Patient outcomes improve when they have access to information in several fundamental areas, yet that information is rarely provided in routine medical care or national practice guidelines for clinicians. Patients must understand that modern culture and our daily lifestyle habits – particularly what we eat and drink – is driving obesity and the recent emergence of epidemic chronic conditions. (See more about this topic in this previous post.) Patients must be able to discuss their treatment options with clinicians and interpret key clinical terms and laboratory results. They must understand how, for each of us, our idiosyncratic attitudes and feelings around health and wellness heavily affect our ability to make lifestyle changes. And they need help navigating insurance coverage. Exploring these topics creates building blocks for an individualized approach to improving and maintaining health over the long haul. Permanent, healthy-lifestyle change and treatment engagement are the goals. 

Motivation. Patients need ongoing motivation from the clinical team to help them evaluate the pros and cons of any proposed behavior changes and answer the question: “Why should I do this?” Additionally, patients need help exploring and overcoming practical barriers to personal change, answering a question that is often in the back of patients’ minds but rarely explored by clinicians, “How can I do this?” Answering this question involves identifying and solving for practical barriers, drawing on the help of people close to the patient, connecting the patient virtually with inspiring people who have successfully made similar changes, and managing the negative people in their lives who undermine the patient’s efforts to make changes.

Behavior Skills. In addition to information and motivation, patients need to develop a range of behavior skills and master many practical, daily tasks associated with chronic condition management. The clinical team can teach and support these tasks. These include, for example, creating heathy meals that the patient loves to eat; getting regular exercise; smoking cessation; managing chronic stress and mental health issues; and monitoring vital signs and symptoms that go into the treatment plan. Patients must see this work as a wise investment of time and money and as a positive, lifelong journey of personal improvement that is worth their effort in order to achieve a lifelong pattern of health and vitality.

Through Information, Motivation, and Behavior Skills, Silver Fern’s Practical Behavior Change Model provides an “engine of behavior change”. This engine drives change in targeted self-management behaviors that in-turn lead to positive outcomes important to patients and their families: quality of life, independent living, and freedom from unnecessary medical costs.

In future posts, I’ll talk in more depth about how the Silver Fern Behavior Change Model can be applied to patients living with diabetes and also how telehealth and an emerging new blend of in-person and virtual visits for chronic care teams will be the reality of a post COVID-19 world.

Garry Welch, PhD is an expert in the area of behavior medicine for chronic disease care. He has extensive experience leading clinical research on behavior change strategies for people with diabetes and other chronic diseases. Dr. Welch’s 30+ years of clinical research led to co-founding Silver Fern Healthcare. He leads research and development at Silver Fern.

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