The 5 As An EvidenceBased Assessment Intervention Model

The 5 A’s: An Evidence-Based Assessment & Intervention Model for Just About Everything Presented August, 2011 by Katherine M. Dollar, Ph. D, and Laura Wray, Ph. D n Based on slides developed by Christopher Hunter, Ph. D, ABPP Do. D Program Manager for Behavioral Health in Primary Care and Margaret Dundon, Ph. D National Program Manager for Health Behavior n National Center for Health Promotion and Disease Prevention Text: Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention Hunter et al, 2009 1

Goals 1. Use 5 As as an Operational Framework Assess Advise Agree Assist Arrange 2. Walk Away with Tools You Can Immediately Use Whitlock, E. P. , Orleans, C. T. , Pender, N. , & Allan, J. (2002). Evaluating primary care behavioral counseling interventions: An evidence-based approach. American Journal of Preventive Medicine, 22, 267 -284. 2

The Wisdom of Pooh “ Here he is Edward Bear, coming downstairs now, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it…” A. A. Milne 3

5 A’s-Assess, Advise, Agree, Assist, Arrange Diagram adapted from: Glasgow, R. E & Nutting, P. A. (2004). Diabetes. In Handbook of Primary Care Psychology. Ed. , Hass, L. J. (pp. 299 -311) Assess Risk Factors, Behaviors, Symptoms, Attitudes, Preferences Arrange Advise Specify plans for follow-up (visits, phone calls, mail reminders) Specific, personalized, options for tx, how sx can be decreased, functioning, quality of life/health improved Personal Action Plan 1. List goals in behavioral terms 2. List strategies to change health behaviors 3. Specify follow-up plan 4. Share plan with practice team Assist Agree Provide information, teach skills, problem solve barriers to reach goals Collaboratively select goals based on patient interest and motivation to change 4

Phases of a 30 -Minute Appointment 1. Introduction of behavioral health consultation service (1 -2 minutes) 2. Identifying/Clarifying consultation problem (10 -60 seconds) 3. Conducting functional analysis of the problem (12 -15 minutes) 4. Summarizing your understanding of the problem (1 -2 minutes) 5. Listing out possible change plan options (selling it) (1 -2 minutes) Advise Agree 6. Starting a behavioral change plan (5 -10 minutes) Assess Assist Arrange

5 A’s- Assess, Advise, Agree, Assist, Arrange 1. Introduction (1 -2 minutes) “I’m one of the behavioral health providers for the clinic and I’m (a social worker/a health psychologist/a psychology intern…. ) I work with the primary care team in situations where good health care involves paying attention to physical health, habits, behaviors, emotional health and how those things interact with each other. Anytime (insert name of the referring provider) wants he/she can call me in as a consultant to help the two of you better manage the difficulties you’re currently having. To help the two of you do this I’m going to spend about 25 -minutes with you in a consultation appointment. I want to get a good idea of what’s working well, what’s not working so well…. Take the information you give me and together, we’ll come-up with a plan to help you best manage your current problems or concerns. 6

5 A’s- Assess, Advise, Agree, Assist, Arrange 1. Introduction (1 -2 minutes cont. ) “As we go through the appointment today, I’ll be writing a note that will go into your electronic medical record and I’ll be giving (Dr. , PA. , or Nurse Practitioner) ____some feedback on whatever plan we come up with. Is it okay with you if I take some notes while we talk? Do you have any questions about who I am or my role in the clinic? ” n n If yes, spend time needed to make sure patient understands the purposes of this service. If no, continue with clarification of the consultation problem. 7

Demonstration: Introduction of Services (Assess 1) 8

Practice: Introduction of Services (Assess 1) 9

5 A’s- Assess, Advise, Agree, Assist, Arrange 2. Identifying/Clarifying consultation problem (10 -60 seconds) “It looks like Dr. Smith wants me to help the two of you better manage your anxiety. Is that what you see as the main problem or is it something different? ” n After the individual says they see “anxiety” as the main problem, immediately say something like, “Well I’m going to ask you a bunch of questions about that. ” and launch into the functional analysis. 10

Demonstration : Identifying/Clarifying Problem (Assess 2) 11

Practice: Identifying/Clarifying Problem (Assess 2) 12

5 A’s-Assess, Advise, Agree, Assist, Arrange 3. Conducting functional analysis of the problem (12 -15 minutes) -Biopsychosocial Model -Physical -Behavioral -Cognitive -Emotional -Environmental factors

5 A’s-Assess, Advise, Agree, Assist, Arrange 3. Conducting functional analysis of the problem (12 -15 minutes) n n n Physical - (what is going on in the persons body): e. g. , sleep, pain, blood pressure, blood glucose, Emotional - (how do they feel): e. g. , sad, happy, angry, worried, anxious, depressed, frustrated, stressed Behavioral - (what do they do or not do): e. g. , too much or too little activity; saying or not saying things; Environmental/Social - (place, time of day, others around) e. g. , afternoon, when boss is there Cognitive - (thoughts)-what are they thinking in association with sx and/or poor functioning? 14

5 A’s-Assess, Advise, Agree, Assist, Arrange 3. Conducting functional analysis of the problem (12 -15 minutes-cont) How does the problem functionally impair the patient? n Any changes in work performance n Any changes in work relationships n Any changes in significant familial relationships (spouse, children, etc. ) n Any changes in social activities (going out with friends, church) n Any changes in engaging in fun/recreational/relaxing activities n Any change in exercise n Any Changes in Sleep, Energy, Concentration, Appetite? n Do they consume caffeinated drinks? If so, how many a day and how many ounces each time? n Do they consume ETOH? If so, how many per sitting, how many ounces? n Any over the counter medications or supplements? n Ask them to describe their mood over last 2 weeks. 15

5 A’s-Assess, Advise, Agree, Assist, Arrange n Measurement -based care n Brief Assessments within PC-MHI PHQ-9 n PCL-M n AUDIT-C n BOMC n Others? n 16

Video: Functional Assessment (Assess 3) 17

Practice: Functional Assessment (Assess 3) 18

Summarize 4. Summarizing your understanding of the problem (1 -2 minutes) n “I’d like to summarize my understanding of what you’ve told me to make sure I have it right. If I’ve missed something or have it wrong it’s important that you correct me to make sure I have it right. Give Summary………. n “Do I have it right, or did I miss it? ” 19

Demonstration: Summarize Understanding (Assess 4) 20

Practice: Summarize Understanding (Assess 4) 21

5 A’s-Assess, Advise, Agree, Assist, Arrange 5. Listing out possible change plan options (selling it) (1 -2 minutes) -Review treatment and change options -Give clear, specific, & personalized change advice -What changes will be involved and how they might be beneficial

5 A’s-Assess, Advise, Agree, Assist, Arrange 5. Listing out possible change plan options (selling it) (1 -2 minutes) n Collaboratively select goals based on patient’s interest in & willingness to change behavior • • • Patients decide on their course of action based on the options discussed. Pt. may not like any of the options. May suggest other options of their own. Might take time to think about it or discuss with significant other 23

5 A’s-Assess, Advise, Agree, Assist, Arrange - Find common ground & define behavior change goals & methods - Shared decision making = - Greater sense of personal control - Choices based on realistic expectations - Change matches patient values 24

Show Video Segment: Advise/agree (Change Plan Options) (Advise) 25

Practice: Advise/Agree (Change Plan Options) (Advise) 26

5 A’s-Assess, Advise, Agree, Assist, Arrange 6. Starting a behavioral change plan (5 -10 minutes) n Develop a specific tailored action plan (i. e. , the intervention) n BHP’s job is to help the patient…. n 1. Learn new information n 2. Develop new skills (self-management, relaxation) n 3. Help identify, address, and overcome barriers n 4. Solve problems n 5. Develop confidence to successfully change 27

5 A’s-Assess, Advise, Agree, Assist, Arrange 6. Starting a behavioral change plan (5 -10 minutes) n Blending- Develop plan to blend your services with other services within PC-MHI to best meet the Veteran’s needs, as appropriate and available. n n n Care Management Co-located behavioral health prescriber Facility Health Behavior Coordinator 28

5 A’s-Assess, Advise, Agree, Assist, Arrange 6. Starting a behavioral change plan (5 -10 minutes) n - Specify follow-up plans BHP- Make specific plans for subsequent contacts n PCP n Specialty providers n If following up with PCP- discuss what information or skill will be the focus of next appointment n Make it happen n 29

Video: Assist/Arrange 30

Practice: Assist/Arrange 31

5 A’s-Assess, Advise, Agree, Assist, Arrange Diagram adapted from: Glasgow, R. E & Nutting, P. A. (2004). Diabetes. In Handbook of Primary Care Psychology. Ed. , Hass, L. J. (pp. 299 -311) Assess Risk Factors, Behaviors, Symptoms, Attitudes, Preferences Arrange Specify plans for follow-up (visits, phone calls, mail reminders) Advise Personal Action Plan 1. List goals in behavioral terms 2. List strategies to change health behaviors 3. Specify follow-up plan 4. Share plan with clinic team Specific, personalized, options for tx, how sx can be decreased, functioning, quality of life/health improved Assist Agree Provide information, teach skills, problem solve barriers to reach goals Collaboratively select goals based on patient interest and motivation to change 32

Questions and Comments 33

Helpful IPC Resources http: //vaww. visn 2. med. va. gov/bh/cih/index. html (CIH sharepoint site) n http: //vaww 4. va. gov/pcmhi n http: //www. cfha. net n http: //www. integratedprimarycare. com E-mail addresses: margaret. dundon@va. gov katherine. dollar@va. gov Questions? n 34