Transcript Types of Communication - New York Hospital Queens

Psychosocial Assessment and Behavioral
Interventions in the Patient Interaction
A Patient-Centered Approach
Michael Bednarski, PhD
Data on Behavioral Interventions
• Risky behavior – leading cause of morbidity/mortality
(50%)
• 47% of Patients do not adhere to treatment – risky
behavior
• Behavioral interventions
– Under-utilized
– only 2% to 15% improve
• What can we do about this?
What The Psychosocial Provides
Examines the role of non-physical factors in illness and Tx
– Emotions, behavior, values, and environmental conditions lifestyle
choices
Determines sources of stress (and support) in the patient’s life
and environment
– Identifies social supports, economic barriers
– Illuminates psychological deficits, personal barriers, and strengths
Frames illness & Tx within the life-context of the patient
– Applies treatments that fit within the patient’s world
PA & BI go hand-in-hand
– Use the PA to identify and reinforce behavioral interventions
What the Behavioral Intervention Provides
– Examines patient behavior – Provides physician, nurse,
PA response to patient behavior and/or modifiable
environmental stressors that are causes or cocontributors to illness, or obstacles to effective
treatment.
– Provides strategies/referrals to help patient recognize
and modify behavior.
Why a Patient-Centered Approach
(Individualized Communication Skills)
Facts:
• Culturally, socioeconomically, psychologically diverse population
• ACGME – Communications/Interpersonal Competency
• Strong Evidence Base for Patient-Centered Methodology
Challenges:
• Treatment Adherence (47%)
• Forget 50% w/in 5 minutes
• Health Literacy –Institute of Medicine
• High M&M due to risky behavior
• Busier Schedules - Drain on resources
Benefits:
• Better Outcomes
• Efficiency of Care – fewer Dx tests - fewer referrals
• Patient Satisfaction
• Perceived Competence
• Increased Compliance
• Reduced Litigation
What is a “Patient-Centered” Approach?
1.
A biopsychosocial model that integrates Cultural Sensitivity,
Psychosocial Awareness, Socioeconomics, and Behavioral Factors
into the doctor-patient interaction.
2.
Embraces the “real life” circumstances of each patient – as
described by each patient.
3.
Care that requires an understanding of own personal,
cultural/ethnic, and methodological “blind spots”
4.
Utilizes proven constructs from psychological research –
treatment-effect size and outcomes
We can no longer ask: “What illness does this person have?”
We must also ask: “Who is the person who has this illness?”
Does it take longer?
Psychosocial Factors That Impact Health Behavior
•
Cultural/Ethnic Diversity
– Differences in social structure, values, and beliefs influence health practices
and help-seeking behavior. Creates language barriers. Activates our own
cultural blind-spots” – Increases “symptom-focused” Dx & Tx
•
Social Determinants of Health (SDOH)
– Socioeconomic disparities that lead to chronic stress, morbidity, mortality,
and inhibit access to health education and care.
– Influence attitudes towards the health care system, access to care and
barriers to Tx
•
Psychological Factors
– Nonphysical factors such as, emotions, behavior, values, and social stressors
play in the etiology, diagnosis and treatment of physical illness (86% - 43%)
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MD & the Treatment Alliance
– Use of active listening skills, rapport, individual differences, perspectivetaking
– Increases Pt involvement – info sharing, responsibility for treatment
Conducting the Psychosocial Assessment
• Assess the chart for potential psychosocial issues that may
relate to illness and personal resources…before greeting the
patient. What might some of these be?
• Notice the patient’s presentation of self , history, anxiety,
intelligence, insight, etc, and potential relationship to
health issues.
• Identify patient feelings
• Thoughtfully relate your observations to the patient during
the interview.
• Integrate psychosocial data into themes that may form the
basis of your behavioral intervention
Behavioral Assessment/Intervention
• Conduct a “person-focused” interview
– Creates a foundation of trust if you must confront the patient’s
behavior, lifestyle choices, or other problem at some point later in
the interview.
• Asses psychosocial factors and obstacles to compliance
– Note insight, intelligence, or psychological/behavioral barriers
– Identify lifestyle factors such as income, education, and living
conditions that may contribute to presenting problem.
• Discuss problematic behaviors/environmental challenges
– Thoughtfully share your observations with the patient. Gently let
the patient know the concern you have for the impact such forces or
behaviors may have on his or her health and well-being.
• Make effective treatment referrals and recommendations
– know referral sources available, treatments available. Call to
determine if your patient kept the appointment.
Structuring the Behavioral Intervention
• Review chart for relevant personal data - Before entering room
• Introduce the interview process - Encourages patient
participation . Conduct you own mini psychosocial assessment
• Conduct interview - Apply active listening skills – use
paraphrasing, “connection” points, while interviewing
• Identify the behavior – explore root causes and assess patient
awareness of problem and actions taken
• Assess required skills to change the behavior – include
involve social supports
• Reinforce the positive benefits of change – and/or leverage
the consequences of failure to change. Set the “Psychological
Contract”
Patient-Centered Communication Skills
The 90 Second “Tell”
Doctor-Patient Role Play
Foundation of Patient-Centered
Communications
Individual Differences - Doctor-Patient Communication Styles
– Learning Styles
Active Listening Skills - Listening with the “Third Ear”
Non-Verbal Behavior - Cuing & Synchronicity
Information-Giving and Retention Skills - Paraphrasing,
Interpreting, Teaching-Back
The “Psychological Contract” - The quest for compliance
Patient-Centered Interventions
Core Concepts
• Joining
– Entering into the patients’ perception of the situation – trying to
see it the way they see it. And explain it that way.
– Using the personal data from the psychosocial to leverage behavior
change
– Using strengths to reinforce desirable behaviors – Then using
leverage to discourage undesirable behavior and motivate behavior
change.
•The Psychological Contract
• agreement about the reciprocal obligations between doctor and
patient based upon the trust and beliefs that have been established
in the interaction
Individual Differences
“Active Listening” and the Behavioral
Intervention
What is Active Listening?
• Asking questions that demonstrate you have been listening to the
patient.
• Questions that sum up, explore, and paraphrase information and
observations made during the interaction.
• Shows interest in the patient, not just the presenting problem –
“Joining”
Benefits?
• Helps patients verbalize issues that are a focus of their concern
• Gets them more involved in treatment.
• Improves “working alliance”
• Improves diagnostic accuracy
Active Listening Tips
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Establish eye contact – Shows your attention is undivided - Helps to
recognize non-verbal
Acknowledge what the patient is saying – Says you are interested in what
the patient is telling you. Nod with understanding and say… “Mm
Hmm….I see”
Use silence - Communicates "What you are saying matters to me. Lets
patient collect thoughts.
Ask open-ended questions – Cannot be answered by a simple "Yes" or
"No". Helps patient provide more relevant information and to feel that
his or her opinion matters.
Paraphrasing - Restate in your own words what you think the patient has
said. This conveys that you are trying to understand. Gives patient the
opportunity to correct.
Reflect feelings - Without interrupting, give a name to the feelings you hear
in what the patient is saying.
“Teach-Back” technique –Ask patient to describe his or her understanding
of what you discussed.
Non-Verbal Behavior
• “Body Language” – Gestures, facial expression,
posture, physical distance, tone
• Big part of Doctor-Patient interaction and what
the patient notices most
“The Silent Treatment”
Tips to Improve Your Nonverbal “Listening”
• Gently introduce yourself – shake hands, notice their space
• Establish/maintain good eye contact
– Stay at eye-level with patient
– Nod with understanding
• Remove barriers to communication
– Remove distractions - Turn TV off, asks strangers to leave,, etc
• Notice your own communications – physical states
• Use silence
• Recognize patient behavior – anxiety, pressured speech,
passivity, etc
Culturally Sensitive
Communications
What do we mean by “culture”?
• An integrated pattern of behaviors, learned beliefs, and assumptions
about the world. Passed on from one generation to another.
• Related to the solutions each culture has had to create in accordance to
the demands of the environments in which they live.
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American diversity statistics
11 ½ % of Population is Foreign Born and Rising
By 2050 white non-Hispanics will decrease from 75% (1996) to 50%
of the population.
African American, Hispanic, and Asian American – double digit
growth in last 10 yrs.
32 million speak language other than English at home.
Tips For Working With all Cultural Groups
• Treat Each Person Uniquely - Each individual is different and may not fit
the common pattern for his/her ethnic group. Do not assume each
individual is bound to communicate in a certain way
• Determine Level of Acculturation – notice dress, language skills, and
mannerisms
• Listen to the Patient – focus on explanation of cause of illness w/o
rushing, concluding, or judging.
• Ask Yourself - “Am I aware of assumptions & cultural biases. that impact
my understanding?” “Do I prompt and appreciate the belief systems, or
health attitudes of this patient?”
• Notice and Use Non-Verbals - smiling, silence, gestures, nodding, eye
contact, body language, touch, etc. Follow their lead.
Structuring the Clinical Interview
• Phase 1
– Review chart for non-biologic factors – before entering
– Introduce self and the interview process – (1 minute)
– Connecting – Symptom-focused, background focused, “small talk”
- (3 to 5 minutes)
– Clinical Information gathering
• Phase 2
– Reviewing the information, paraphrasing, checking-back, feedback
– Reconnecting – “How are we doing so far?” - (2 minutes)
• Phase 3
– Discussing the treatment options/plan
– Identify/discuss non-biologic factors & behavioral interventions
– “Teaching -Back:”
– Obtain agreement - The “psychological contract”
Providing Information Patients Will Remember
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Weave it into the context of patient’s life situation
Demonstrate a Caring Approach
Notice How You Deliver Information
Assess, “Normalize”, Utilize Patient Anxiety
Give at an Appropriate Time – And Summarize
Be Direct and Supportive
Provide Information the Patient Can Act On
Check to See if The Patient Understand
Essential Questions to ask Yourself
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Has the purpose of the interview been explained to the patient so that he or
she is made to feel an important part of the interaction, free to express self,
and can interrupt or ask questions?
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Is there anything in the patient’s cultural make-up, social support, socioeconomic status or lifestyle practices that impact your diagnosis or lead to
concerns about treatment adherence?
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What is the quality of the patient’s interaction with you? Patient’s level of
self-awareness, attention, ability to express his/her concerns, anxieties
(normative). Is there a history of mental illness or psychosocial stressors for
this patient (pathological)?
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Is the patient able to repeat your recommendations or instructions back to
you? Are there any obstacles to follow-up treatment that you noticed in your
interaction with this patient? Personality? Social Support? Finances?
Transportation? Level of education (ability to understand and carry out your
instructions)?