How to manage chronic diseases by changing human behavior.

In our country, patients are the most under-utilized resource, and they have the most at stake. They want to be involved and they can be involved. Their participation will lead to better medical outcomes at lower costs with dramatically higher patient/customer satisfaction.

Charles Safran, M.D., Former President, American Medical Informatics Association, speaking to Congress in 2004

Behavioral change theories:

Behavioral psychology provides a number of models for understanding how to affect behavioral change.

Wikipedia outlines various theories and models on human behavior [ LINK HERE ]

Self-Efficacy

“Can I do it?” – the individual answer can predict how much effort they will put towards changing their behavior. If they don’t believe they can do it, they won’t try.

Learning Theories/Behaviour Analytic Theories of Change

Baby stepping to bigger changes. Behavior is a gradual process that starts with observation, imitation, and through a system of rewards leads to bigger changes.

Social Learning/Social Cognitive Theory

3 things govern change, and by reinforcing change through alignment:

1. Personal elements:  Do you believe it can be done? Do I recognize the problem?
2. Behavioral elements: Does my behavior align with the change? Must I change it?
3. Environmental elements: Does my environment enforce or detract from the change?

Theory of Reasoned Action

A person reasons whether their behavior is positive or negative subject to their own belief system and societal belief systems. Personal attitude and social pressure can change behavior.

Theory of Planned Behavior

Behavioral change is predicted and affected by:

1. How much control a person has over behavior.
2. How much a person wants to change.

Transtheoretical/Stages of Change Model

Behavioral change is a 5 step process:

1. Precontemplation: Become aware there is a problem, but do not intend to change.
2. Contemplation: Must desire to change in near term (6 months).
3. Preparation: Plan to change (usually in the next month).
4. Action: Have made changes to their behavior.
5. Maintenance: Trying to prevent relapse.
6. Termination: 100% self-sufficient – no temptation for relapse.

Behavioral health focused on Health:

Patients can affect their health through behavior. This widely held belief has led governments around the world to focus on behavioral change. Here are various models:

Health Belief/Health Action Model

According to [http://www.jbpub.com/samples/0763743836/Chapter%204.pdf]

Health behavior is determined by personal beliefs or perceptions about a disease and strategies available to decrease the occurrence.

Perception of the disease:

1. Perceived Seriousness: How serious is it? How will it affect me?
2. Perceived Susceptibility: How likely are these outcomes? How much am I at risk?
   • Notes: Seriousness + Risk = behavior change. (usually)
   • But: If risk is perceived to be low, unhealthy / risky behavior can result.
   • But: College students do not change behavior even when risk is high.
3. Perceived Benefit: How will I benefit from changed behavior?
4. Perceived Barriers:
   • The most significant factor determining change.
   • Barriers: difficulty starting new behavior, fear of not being able to achieve the outcome,
5. Self Efficacy: The perception that one can change.

• Various other modifying variables change perception: Skill, education, past experience…
• Cues to Action summon change: events, people, or other trigger events

Resources: [Chapter http://www.jbpub.com/samples/0763743836/Chapter%204.pdf]

There are a number of articles that indicate that behavior can be affected for better outcomes. I won’t go into them here, but there is a greater question. Why is so little being done to manage chronic diseases?

Why isn’t more done?

Misaligned incentives:

Organizations with pay for service revenue models are disincentisized  to better the health of chronic disease patients.

Consider, 75% of healthcare spend is on chronic diseases. Why would an industry reduce the revenue generation of their most profitable segment?

Managing chronic diseases is hard enough, but when pay per service revenue models stand in the way of better health outcomes, the solution is untenable.

Tyranny of the Urgent

Our system provides acute, episodic care. Preventative care takes a back seat. A favorite analogy puts:

A farmer was seen running around herding his cattle. He drove them back to his farm, but given he didn’t have a fence, the cattle just roamed freely. The poor farmer constantly had to herd them back to his farm.

Then a man came up and asked the farmer, “why don’t you build a fence for your cows?”

The farmer said: “Ain’t got time. I’m too busy herding them.”

If we only deal with acute problems, we’ll never get around to prevention.

Consistent change requires 3 linked things:

1. Community Resources: Gyms, community centers, etc..
2. Healthcare System with aligned payment structures
3. Provider organizations to provide the care

We need better payment models:

1. Align payment with health outcomes.
2. Move away from pay for service revenue models.

Physicians need help:

1. Decision Support.
2. Efficient workflow.
3. Information : reliable, easily accessible, more consistent, more timely.

Patients must be engaged. They must:

1. Recognize there is a problem.
2. Motivated to change.
3. Believe they can change.
4. Be given ways to change.
5. Prompted to act.
6. Supported by society (friends, family, providers) to maintain their efforts.

The work is hard. The Challenge great, but the prize is worth the fight. We can succeed.

About hitmanalan

Alan has worked in Healthcare IT for the past 9 years at the following companies: http://www.medco.com/, http://www.merck.com/, http://www.ammeddirect.com/.