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1A Parallel | grueninger | swiss health coaching program |

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1A Parallel | grueninger | swiss health coaching program |

  1. 1. Swiss College of Primary Care Medicine ICMI International Conference on Motivational Interviewing 2014 The Swiss Health Coaching Program: Motivational Interviewing in health behavior counselling for primary care consultations Ulrich GRUENINGER, MD1, Stefan NEUNER, MD MPH1,2, Margareta SCHMID, MD2,3 1 Swiss College of Primary Care Medicine, Bern, Switzerland 2 Institute of Family Medicine, University of Zürich, Zürich, Switzerland 3 Institute of Social and Preventive Medicine, University of Zürich, Zürich, Switzerland
  2. 2. Swiss College of Primary Care Medicine ICMI International Conference on Motivational Interviewing 2014 The Swiss Health Coaching Program: Motivational Interviewing in health behavior counselling for primary care consultations Preview: Health Coaching in Primary Care 1. Why, and what for? 2. The role and potential of MI 3. How does Health Coaching work? 4. Does it really work? (our study) 5. Our dissemination program
  3. 3. Behavioural counselling in primary care practice Physicians treat patients, not problems. Patients‘ focus is on wellbeing and life skills, not on problem behavior. Experience from practice calls for three fundamental changes – first and foremost in ourselves: 1. a change of perspective (behavioral dimension) 2. a change of paradigm (roles of patient and counselor) 3. a change in our professional practice and culture
  4. 4. 1) Change of perspective Behavior has a pivotal role in disease and health a) Health behavior and the burden of disease  determinants of health: “10 – 20 – 70%”: genetics < health care << behavior  everywhere in medical care: health promotion, prevention, therapy, rehabilitation b) Interventions for health behavior should address the whole picture  Unfavorable behaviors come often combined ...  ... but most behavioral interventions focus on a single behavior / disease  These mono-thematic interventions do not fit… …. patients’ reality ( individual constellation of behavior, exper., resources, prefs) …. physicians’ professional reality (practice, staffing, training time) c) Our intervention styles ... (traditionally directive, corrective, prescriptive, proscriptive) .... neglect the central role of the patient .... neglect the potential of modern concepts of intervention (e.g. health literacy, empowerment, Shared Decision Making, Motivational Interviewing, Self- Management-Support)
  5. 5. 2) Change of paradigm: roles Physician and patient are both experts Clinician’s expertise Patient’s expertise Diagnosis Experience of illness Disease aetiology Social circumstances Prognosis Attitude to risk Treatment options Values and resources  The patient is the expert for his/her own life.  Patient and physician are partners. Coulter A., Collins A. (2011) Making Shared Decision-Making A Reality Coulter A. (2011). Engaging Patients in Healthcare O‘Connor J (2007) Coaching
  6. 6. 3) Change in professional practice and culture Behavioral interventions need both ... 1) an attitude that ... ... is patient-centered:  the patient is in the focus, not a problem  the patient is partner of the physician ... is health-oriented:  helps the patient keep himself healthy  respects patient‘s autonomy, and fosters self-responsibility ... re-defines the roles:  the patient takes the main role  the physician becomes the patient‘s coach 2) a methodology that ... ... combines proven models of health promotion and counselling  Health literacy and empowerment  Shared Decision Making  Self-management support  Motivational Interviewing ... uses a generic approach to counselling - useful for all health relevant behaviors - useful for all medical encounters ... operationalizes these models for use in everyday practice: - Steps, modules, practice support materials
  7. 7. Therapeutic Relationship Planning (SMART) Drucker 1954 Doran 1981 8 Motivational Interviewing Miller&Rollnick 1991/2002 Rollnick&Miller 2008 Elwyn 2014 Shared Decision- Making Scheibler&Pfaff 2003 Coulter 2011, Elwyn 2014 The role and potential of MI The cycle of behaviour change and the respective coaching-tasks (Prochaska 1986, Grüninger 1995) Cycle Change/MI/SDM Self-Management Support Assal 1995 Glasgow 2002 Packer 2012 www.gesundheitscoaching-khm.ch Trial Precontemplation Contemplation Action Maintenance Termination Relapse
  8. 8. Some of the MI tools used - Leading – Guiding – Following - Resisting the fix-it reflex - Scales (VAS): re importance, confidence, readiness - Change talk, working with ambivalence and resistance - Decisional balance …. and others, e.g.: E – P – E: elicit – provide – elicit Past experiences and achievements: building on successes and resources Hypothetical questions: imagine the future Explore extremes: what worst /best case 9 ICMI 2010 - Health Coaching - © SCPCM-KHM
  9. 9. During family physician visit In patient's daily life Fill out personal health behavior questionnaire ASK for interest in personal health behavior ASSESS personal health behavior pattern and beliefs Choose target behavior and starting point AGREE on target and steps for a personal health project WS 1 WS 2b WS 2a WS 3 ACCOMPANY throughout project implementation Work on personal health project: a) on one's own WS 4 b) with third party support brief interventions by family physician counselling by other health professional community offers (groups, commercial etc.) WS 4 1 2 3 4 Step 1: raise awareness Step 2 develop motivation Step 3: planning Step 4: accompany © SCPCM/KHM 2006-10 WS 1 WS 2a WS 2b WS 3 WS 4 work-sheets patient-doctor How does ‚Health Coaching‘ work in practice? © Project Health Coaching SCPCM 1. Ask 2. Assess 3. Agree 4. Accompany Flow-chart: ‚Health Coaching‘ – a cooperative venture of patient and physician
  10. 10. During family physician visit In patient's daily life Fill out personal health behavior questionnaire ASK for interest in personal health behavior ASSESS personal health behavior pattern and beliefs Choose target behavior and starting point AGREE on target and steps for a personal health project WS 1 WS 2b WS 2a WS 3 ACCOMPANY throughout project implementation Work on personal health project: a) on one's own WS 4 b) with third party support brief interventions by family physician counselling by other health professional community offers (groups, commercial etc.) WS 4 1 2 3 4 Step 1: raise awareness Step 2 develop motivation Step 3: planning Step 4: accompany © SCPCM/KHM 2006-10 WS 1 WS 2a WS 2b WS 3 WS 4 work-sheets patient-doctor How does ‚Health Coaching‘ work in practice? © Project Health Coaching SCPCM 1. Ask 2. Assess 3. Agree 4. Accompany Flow-chart: ‚Health Coaching‘ – a cooperative venture of patient and physician
  11. 11. Der Rote Faden - wie das Gesundheitscoaching abläuft In der Hausarztkonsultation Im Alltag des Patienten Fragebogen Gesundheitsverhalten ausfüllen 1) Gesundheitsverhalten ansprechen RF 1 2) Gesundheitsverhalten analysieren ein Zielverhalten und Ansatzpunkte auswählen 3) ein Gesundheits-projekt ausarbeiten RF 2b RF 2a RF 3 4) Projekt schrittweise umsetzen und Erfahrungen nützen Gesundheitsprojekt umsetzen: a) selber RF 4 b) mit zusätzlicher Unterstützung Kurz-intervention des Hausarztes Beratung durch Fach-person Regionale Angebote (Kurse und Gruppen) RF 4 1 2 3 4 © KHM 2006-09 RF 1 RF 2a RF 2b RF 3 RF 4 Arbeitsblätter Patient-Arzt Step 1: Ask FlowChart_09Sept_fhx_v1 letzte Fassung 27.09.09 19:27 a. Introduction and informed consent b. Self assessment of health behaviour pattern c. Motivation – importance – confidence – Readiness for change d. Interest in continuing
  12. 12. Self-assessment of behavior Self-assessment of motivation & Stage of Change ‚change talk‘ Introduce Role Change Der Rote Faden - wie das Gesundheitscoaching abläuft Regionale Angebote (Kurse und Gruppen) © KHM 2006-09 Step 1: Ask FlowChart_09Sept_fhx_v1 letzte Fassung 27.09.09 19:27 In der Hausarztkonsultation Im Alltag des Patienten Fragebogen Gesundheitsverhalten ausfüllen 1) Gesundheitsverhalten ansprechen RF 1 2) Gesundheitsverhalten analysieren ein Zielverhalten und Ansatzpunkte auswählen 3) ein Gesundheits-projekt ausarbeiten RF 2b RF 2a RF 3 4) Projekt schrittweise umsetzen und Erfahrungen nützen Gesundheitsprojekt umsetzen: a) selber RF 4 b) mit zusätzlicher Unterstützung Kurz-intervention des Hausarztes Beratung durch Fach-person RF 4 1 2 3 4 RF 1 RF 2a RF 2b RF 3 RF 4 Arbeitsblätter Patient-Arzt a. Introduction and informed consent b. Self assessment of health behaviour pattern c. Motivation – importance – confidence – Readiness for change d. Interest in continuing Interested? matter/worr y
  13. 13. - 14 1) sensibilisieren Worksheet (p.1-4) Ein Programm des Schweizer Kollegiums für Hausarztmedizin Arbeitsblatt 2: Mein Gesundheitsprojekt Name ...................................... Auf was kann ich aufbauen? Was will ich und wohin gehe ich? Patient questionnaire Brochure Nächste Besprechung und was ich bis dann mache Meine früheren Erfahrungen Hindernisse Meine Stärken und Unterstützungsquellen Mein Ziel Meine Schritte zum Ziel (Massnahmen) Meine Erfahrungen mit meinem Projekt Info-Bedarf & Notizen Mein Thema .................. 2) build motivation 3) plan a project 1) raise awareness 4) accompany implementation Tools for patient-physician cooperation in Health Coaching consultations
  14. 14. 3) Change in professional practice and culture What Health Coaching contributes 1) an attitude that ... ... is patient oriented:  the patient is in the focus, à not Health a problem Coaching is ‚learning by doing‘:  the patient is partner of the physician there are no failures, no losers à Health Coaching facilitates success in small ... is health oriented:  what keeps the patient in good health steps for patient and physician  how the patient keeps himself healthy à Health Coaching builds upon success and time ... lives newly defined roles:  the patient takes the main role  the physician becomes the patient‘s coach 2) a methodology that ... ... combines proven models of health promotion and counselling  Health literacy and empowerment  Shared Decision Making  Self-management support  Motivational Interviewing ... uses a generic approach to counselling - for all health relevant behaviours - for all medical encounters ... operationalizes the models for use in everyday practice: - Steps, modules, practice support materials
  15. 15. Health Coaching: Timeline for education, training, support Site visit PLANNING HC program coaches ... Intervision/Supervision ... the physician coaches ... ... the patient Self- Assessment Self-study 2x 1d training workshops/SPs Refresher course (half day) Practice visits, phone support KNOWLEDGE SKILLS LEARNING OBJECTIVES E-learning for brush-up and support LEARNING PHASE (4 mths) PRACTICE PHASE (12 mths)
  16. 16.  12 months, 20 primary care offices, 1045 patients  acceptance, feasibility, effects (patients, physicians, health care system) ++ 954 (91%) of the invited patients took part ++ 37% completed their personal health project ++ Ratings of motivation, concept, acceptance and feasibility ++ Health behavior change   18 Does Health Coaching work? An extended pilot test 1:1 (all 4 steps of the counselling process) of the “Health Coaching” program were consistently high in physicians and patients Neuner-Jehle S, Schmid M, Grüninger U.: BMC Family Practice 2013;14(100) www.gesundheitscoaching-khm.ch
  17. 17. Seite 19 Before#counselling## All#areas#of#choice#n=403# 9%# 45%# 46%# health#behaviour#favourable# health#behaviour#could#s7ll#be#improved# health#behaviour#unfavourable# A* er$$counselling$ All#areas#of#choice#n=403$ 39%$ 21%$ 40%$ health#behaviour#favourable# health#behaviour#could#s7ll#be#improved# health#behaviour#unfavourable# www.gesundheitscoaching-khm.ch Health Coaching works ... pilot test: 12 months, 20 primary care offices Neuner-Jehle S et al: BMC Family Practice 2013;14(100)
  18. 18. Vorher Gewicht Bewegung Ernährung Nachher Stress Rauchen 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Health Coaching works pilot test: 12 months, 20 primary care offices Stufenveränderung Selbsteinschätzung Verhalten Kreis 1 vs. Kreis 4 nach Zielen TN nach Abschluss Gewicht n=104 Bewegung n=75 des Programms (T4) Ernährung n=41 Stress n=38 Rauchen n=35 Mittelwert Verbesserung 1 - 2 Stufen keine Stufen-Veränderung Stufen-Verschlechterung weight physical.act. nutrition stress smoking mean a) 50% of participants improve health behaviour* *) equals NNcounsel 6-7 (one out of 6 enrolled) b) remainder are sensitized Before After weight phys.ac t nutrition stress smokin g Neuner-Jehle S et al: BMC Family Practice 2013;14(100)
  19. 19. What patients say
  20. 20. Health Coaching in everyday office practice What patients say Statements (Pat. D.S.): „It‘s not about my blood pressure or my cholesterol, but about me as a person“. „My health is my own responsibility – I cannot delegate it to my doctor.“ „My doctor has become a precious coach for me.“ „I enjoy looking forward to the next consultation“.
  21. 21. What I‘ve learnt from health coaching My communication skills have improved – Motivational Interviewing – Practical tools – Change Talk I have more pleasure at work – Burnout prevention My professional and personal attitude has changed – During medical training: socialized as ‚maker and shaker‘ – Now in my practice: an empathic coach 23 18.06.2012 Health Coaching in the test of everyday office practice What doctors say „If only I had learned this in my medical training... !“ „Health coaching works, is efficient and I enjoy it every day.“
  22. 22. Where do we go from here? The next step: Swiss Health Coaching Program 1. Country-wide dissemination in three national languages (deutsch – français – italiano) 2. Four target groups – primary care physicians (continuing education, postgraduate training, pregraduate education) – Practice assistants and practice nurses (office teams) 3. Modular package for training and support Short seminar (2-3 hrs) Training w/SPs (1 day) Refresher (2-3 hrs) Skills-training  Brief Manual Web-based library, toolbox E-learning modules Self-study  Consultation worksheet Patient health questionnaire Info brochure, WR screen Practice support 
  23. 23. Swiss College of Primary Care Medicine ICMI International Conference on Motivational Interviewing 2014 The Swiss Health Coaching Program: Motivational Interviewing in health behavior counselling for primary care consultations Ulrich Grueninger 2 bonus slides  Swiss College of Primary Care Medicine ueli.grueninger@hin.ch www.gesundheitscoaching-khm.ch www.kollegium.ch 1. Neuner-Jehle S, Schmid M, Grüninger U. BMC Family Practice 2013;14(100): www.biomedcentral.com/1471-2296/14/100. 2. Neuner-Jehle S, Schmid M, Grüninger U. PRAXIS 2014;103(5):271-77. 3. Neuner-Jehle S, Grüninger U, Schmid M. Rev Med Suisse 2014;10:1057-63.
  24. 24. ...and there is more to come A vision: SunflowAelcromhoold el (Bsp. Nat. Programm Alkohol / Projekte aus Dialogfeld Ärzteschaft) Smoking (Bsp. NP Tabak; Frei von Tabak) Physical activity (Bsp. PAPRICA, NP B&E, etc.) Overweight/ Nutrition (Bsp. NP B&E) Stress/ Mental Health (Bsp. GC, Suizid-prävention, Bündnis D.) ... other ... (eviprev etc.) COUNSELING Core knowledge, Skills and attitudes (e.g. Health Coaching) A longterm vision: Health Coaching – model for cooperation between single-factor and multidimensional interventions („Sunflower model“) A core module „Knowledge, skills and attitudes for counseling and coaching“ can be combined with one or more modules on single-factor (mono-thematic) interventions
  25. 25. Summary: Health Coaching is 1 – 2 – 3 – 4 ONE program: 1. A framework for a unified approach to counselling for sustainable health behavior change in primary care consultations* TWO roles are re-assigned: 1. Patient as main actor 2. Physician as coach THREE challenges: 1. Activate individuals with their individual motivations (patients, physicians) 2. Assess and address individually variable behaviors (do.) 3. Find ways to integrate all into daily routines (do.) FOUR steps for Health Coaching: Ask – Assess – Agree & Arrange – Accompany with use of MI elements (dt.: Sensibilisieren, Motivieren, Planen, Begleiten) *) in all areas of medical care (health promotion, prevention, therapy, rehabilitation) 27
  26. 26. Swiss College of Primary Care Medicine ICMI International Conference on Motivational Interviewing 2014 The Swiss Health Coaching Program: Motivational Interviewing in health behavior counselling for primary care consultations Ulrich Grueninger Swiss College of Primary Care Medicine ueli.grueninger@hin.ch www.gesundheitscoaching-khm.ch www.kollegium.ch 1. Neuner-Jehle S, Schmid M, Grüninger U. BMC Family Practice 2013;14(100): www.biomedcentral.com/1471-2296/14/100. 2. Neuner-Jehle S, Schmid M, Grüninger U. PRAXIS 2014;103(5):271-77. 3. Neuner-Jehle S, Grüninger U, Schmid M. Rev Med Suisse 2014;10:1057-63.

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