Featured Guest Blogger: Janice M. Prochaska, Ph.D
The passage of the Affordable Care Act and emergence of Patient Centered Medical Homes and Accountable Care Organizations has highlighted the need for expanding the patient role in treatment decisions, health care, and chronic care disease management through informed choice and shared decision-making. But this is a movement that has been steadily building for several years.
Remember back to the Balanced Budget Act of 1997? Along with providing new health plan options, Congress mandated that the Centers for Medicaid and Medicare Services (CMS) educate beneficiaries about their new options and demonstrate improvement over time in beneficiaries’ level of awareness and understanding about those options. The Act specified both the information to be provided and the channels to be used to disseminate the information. But those provisions could not ensure that beneficiaries would use the information and seriously consider the range of options available to them. That’s where we came in.
In 1999, Pro-Change began a systematic program of research for CMS to examine whether the Transtheoretical Model of Behavior Change (TTM, also known as the stage model) could explain and facilitate movement from one level of readiness to make informed choices to another; provide reliable methods of identifying groups of beneficiaries who may be more or less receptive to messages about informed choice; and provide guidance in targeting and tailoring messages to different groups.
Briefly, the TTM understands change as progress over time, through a series of stages: Precontemplation, Contemplation, Preparation, Action, and Maintenance. Nearly 35 years of research on a variety of health behaviors have identified principles (confidence and the pros and cons of making a change) and 10 processes of change that work best in each stage to facilitate change.
We've used the lessons learned through the CMS research, as well as the TTM’s data driven and empirically validated theoretical framework, to develop tailored, engaging, and accessible strategies to promote informed choice and shared decision making with health care providers.
Let’s look at those lessons and how they can shape intervention delivery:
- Employ a user-centered design in all phases of development. This means extensive interviews with health care professionals and key informants, and multiple focus groups with patients to hear their ideas, their struggles, and their strategies.
- Develop an operational definition of what it means to be in the action stage for informed choice and shared decision making to assess a patient’s stage of change in order to tailor interventions.
- Use plain language and avoid health care jargon. When a potentially unfamiliar term must be used, it should be defined. Off-the-shelf software can help identify problematic language, but nothing replaces putting materials in front of real people. Conduct cognitive testing to ensure the materials are understood as intended.
- Give the right messages at the right time. While information plays a key part in shared decision-making, it’s essential to present the information gradually, in a stage-appropriate fashion. For example, people in pre-Action stages (Precontemplation and Contemplation), aren’t ready for a decision tool that helps them make a choice. Rather, they need to realize why it’s important to share in decision-making, and how doing so or not doing so will affect other people in their lives as well as their own self-image.
- Help patients overcome the barriers to engaging in shared decision making by encouraging them to get support from family and friends, as well as professional assistance. Recommend strategies to help them persist in the face of difficulties.
- Use engaging strategies and activities to activate the processes of change. For example: use metaphors, storytelling, testimonials; and simple, interactive tools and worksheets.
Deborah A. Levesque, Carol O. Cummins, Janice M. Prochaska, and James O. Prochaska. Stage of Change for Making an Informed Decision about Medicare Health Plans Health Services Research 41. Article first published online: 21 APR 2006 | DOI: 10.1111/j.1475-6773.2006.00547.x
About the Author:
Janice M. Prochaska, Ph.D. is President and CEO of Pro-Change Behavior Systems. She leads a team of experts in organizational behavior, statistical analysis, measurement development and health behavior change. Her research on organizational change using the Transtheoretical Model led to a contract with Electronic Data Systems and the beginning of the company in 1997. Before Pro-Change, she worked as a program developer, grant writer, lecturer, and administrator in social services for 28 years. She is recognized as one of the most published authors in social work. She graduated Phi Beta Kappa from Wayne State University in 1966, received an MSW in social work from Wayne State University in 1968, and a Ph.D. in social work administration and policy from Boston College in 1998.