1. Changes in the Health Care Environment: Health Care Delivery & Reimbursement
   1. The Patient Protection & Affordable Care Act offers 3 major programs that directly affect PT's:
      1. Accountable Care Organizations
      2. Medicare Innovation Models
      3. Centers for Medicare & Medicaid Services' Medical Home or Patient-Centered Medical Home Models
   2. Accountable Care Organizations (ACO)
      1. – Are a direct response to congresses continued efforts to reduce spending in healthcare by authorizing the development of ACOs under both Medicaid & Medicare programs – ACOs would authorize specific groupings of health professions to provide care while saving on unnecessary expenditures – at this time, PT's are not expressly included as eligible participants in ACOs, but advocacy groups such as the APTA are supporting inclusion among eligible practitioners because interventions have been shown to decrease overall patient care costs
   3. Medicare Innovation Models
      1. – They are to research, develop, test & expand innovative payment & delivery arrangements to improve the quality & reduce the cost of care provided to patients, especially in situations such as outpatient settings, that do not require referral by or plan of care established by a physician
   4. Medical Home or Pt-Centered Medical HOme Models
      1. – Designed to provide comprehensive primary care partnerships between individualm patients or families & their health providers – purpose is to develop & test service delivery models to decrease healthcare costs
2. Role of Lifestyle in Morbidity & Mortality
   1. Lifestyle Risk Factors:
      1. – Inactivity – poor diet – obesity – tobacco use
3. Fundamental Relationship Btwn Pt. & Practitioner in the Therapeutic Process
   1. – PTs should integrate adherence & lifestyle counseling into the practice for variety of reasons – Nonadherence can take the form of the patient doing less or more of the prescribed intervention, never starting, quitting prematurely – Degree of it here and should be assessed at each visit to help determine risk versus benefits to overall recovery – PTs are more likely to achieve patient cooperation/adherence when they try to understand the patient's perspective about the condition & its effects – PTs are more likely to facilitate change in the patient's health behaviors by understanding the patient's belief system, which is usually rational & based on culture, past experience & support systems
   2. Factors Related to Adherence Include:
      1. – Patient's personal characteristics – Variables associated directly with the disease/injury – Intervention variables – Those having to do with the relationship between the patient & practitioner
   3. Following a Tx plan reqs that the patient:
      1. – Chooses to do so – Knows when to enact the plan – Has the psychomotor skills to perform the plan – Remains motivated to follow through on to the problem results
   4. Explanatory Models in Clinical Practice
      1. def: Explanatory Models:
         1. Notions patients, families & practitioners have about a specific illness episode
      2. – Kleinman initiated the concept of explanatory models to analyze problems that may arise between patient & therapist during clinical encounter – every therapist has 1 or more explanatory models in mind when working with patients – PT uses this explanatory framework are modeled to guide patient evaluation & decision-making about patient management – the PT's primary role in facilitating patient movement & enhancing function has to do with changeable the individual & societal levels – achieving these goals requires of the PT explore the patient's treatment goals & explanatory model to determine potential intervention barriers
      3. Using Kleinman's Questions can help clarify the patient's beliefs & goals:
         1. 1. What you think caused the problem? 2. Why do you think it happened when it did? 3. What you think your sickness does to you? How does it work? 4. How severe is your sickness? Will it have a short course? 5. What kind of treatment do you think you should receive? 6. What are the most important results you hope to receive from this treatment? 7. What are the chief problems your sickness has caused you? 8. What do you fear most about your sickness?
4. Behavioral Theories to Inform Practice, Promote Adherence, & Facilitate Health Behavior Change
   1. 3 models of behavior theory the presumed that the beliefs of patients are major determinant of their behavior that draw on the Social Learning Theory include:
      1. the Health Belief Model
      2. the Five A's Behavioral Intervention Protocol
      3. the Transtheoretical Model of Change
   2. Social Learning Theory
      1. – Proposes that people learn is through direct observation of the beliefs & actions of others & outcomes of those actions – through these observations, people form their own ideas of how to behave & what to believe
      2. Self-Efficacy
         1. Def: Refers to a person's belief that he or she can accomplish a behavior
         2. 4 Strategies to use to enhance a pt's self-efficacy:
            1. Skills mastery
            2. – Involves ensuring the patient is able to perform the task – breaking a more complex task into smaller pieces that can be more easily learned and was an accomplished successfully – patient will need feedback to increase likelihood of mastery of skill – goal setting & contracting are other methods of providing feedback
            3. Modeling
            4. – In patient care settings, PT = model – in group education courses, someone much like the patient = model – group educational intervention can be successful because patients are modeling to each other, thereby enhancing their own self-efficacy – in order for modeling to be effective, PT must make sure patient is attentive to model, motivated to & able to perform the required activity, & able to retain the new information
            5. Reinterpretation of physiologic signs & sx
            6. – Reinterpretation of physical S&S: 1st, the PT must find out what patients believe about their conditions or how they interpret their present symptoms – i.e. patient believes pain with exercise is a sign of more damage then they are less likely to exercise so patient must be taught to reinterpret the beliefs about exercise & symptoms – PT may need to teach patient to distinguish between different types of pain
            7. Persuasion
            8. – Verbal persuasion: involves urging patient to do more by giving verbal support & encouragement – as last resort may emphasize negative consequences of not participating in program; this should be use with care only after trying other methods – initial focus on positive consequences = important aspect of patient-practitioner collaboration
   3. Health Belief Model
      1. – The patient must believe that he/she is susceptible to disease or condition, that the disease has consequences, that changing a behavior can reduce the threat, that the benefits of changing the behavior outweigh the cost of barriers, & that he or she is capable of making the change (perceives self-efficacy) – asked the patient how the possible adverse consequences of poor appearance to a treatment program were continuing an undesired behavior – ascertain whether patient believes intervention will help – discussion of cost & barriers versus benefits – is the belief in the ability to make the desired change = final construct of model – PT can assist with increasing patient's confidence and successfully making the change by setting small, attainable goals
      2. Key concepts of the Health Belief Model ox 13-2 p. 222
         1. Perceived threat (susceptibility):
            1. belief that it is possible to get the disease or condition
         2. Perceived severity:
            1. belief that it is possible to get the disease or condition
         3. Perceived benefits:
            1. belief that the recommendations or behavior change will be helpful
         4. Perceived barriers:
            1. beliefs about the cost (monetary, time, psychological) of initiating the recommended action or behavior change
         5. Perceived a self-efficacy:
            1. belief in one's ability to change a behavior
   4. Five A's Behavioral Intervention Protocol
      1. – Is a sequence, systematic process that is applied during the initial visit & at subsequent visits to promote adherence – each step has a purpose and, if performed well, is likely to achieve its intended effect
      2. Steps of the 5 A's Process p. 223
         1. 1. Addressed the issue 2. Assess the patient 3. Advise the patient 4. Assist the patient 5. Arrange follow-up
      3. Step 1: Address the Issue
         1. – Patients are willing to discuss the problems that brought them to therapy but may not have come thinking about behavior change
         2. Facilitative questions:
            1. These questions open the door to discussions of healthy behavior changes 1. What do you think is the problem? 2. What kinds of things you feel will help you get better?
      4. Step 2: Assess the Pt.
         1. – At least 3 main areas should be assessed:
            1. Recent attempts to follow a HEP or change in unhealthy behavior
            2. Patient's readiness to change
            3. Patient's motivation to perform the program or make the desired behavior modification
         2. Facilitative questions:
            1. These questions can help focus the intervention, ID motivational factors, & direct the intervention in a way that will encourage success 1. Can you think of any problems with carrying out this program? 2. What kinds of things are you unable to do now that you would like to be able to do?
      5. Step 3: Advise the Pt.
         1. – Advise the patient of the importance of adhering to the therapy program for initiating a lifestyle change – social pressure, especially of exerted by persons viewed as important in the patient's life can be an important influence
         2. Facilitative Statements:
            1. Completing your HEP regularly & correctly is important to getting you back to the activities you enjoy. We need to agree on what you feel you can do on a daily basis to accomplish that
      6. Step 4: Assist the Pt.
         1. Consists of 3 Major Activities:
            1. Negotiating a plan
            2. Educating the patient about the program or correcting any mistaken beliefs or assumptions
            3. Identifying & problem-solving any barriers to following a plan
         2. – Once a program has been agreed on, educate the patient on how to do it, when to do it, what side effects to expect & what to do if they occur, the timeframe in which an improvement should be noticed, & what changes will be evidence of improvement – Developing an initial program based on what the patient tells you rather than simply informing him/her of the program, increases likelihood that the patient will be at hearing & successful thus the patient help decide on what to do himself/herself
      7. Step 5: Arrange for Follow-up
         1. – This step allows the PT to address the patient's adherence to the negotiated plan which helps convey that the patient is accountable
         2. Facilitative Statements:
            1. When you come back and 2 weeks, we will talk about how you are doing & what problems you have had in following your HEP
   5. Transtheoretical Model of Change
      1. – Is an effective model for initiating behavior change - suggests that making a behavior change such as following a HEP follows a nonlinear progression of 5 stages also known as the Stages of Change Model – Application of the stage process implies that the PT first assesses a patient's stage & then uses education & persuasion to move the patient closer to the action stage
      2. Stages of Change Model:
         1. 1. Preocontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance
      3. Precontemplation Stage
         1. Patient has no intention to make a behavior change within the near future usually within the next 6 months – lack of knowledge about consequences of continuing with unhealthy behavior – may have been unsuccessful in changing behavior in the past or proceeds change as being too difficult
         2. How to Facilitate:
            1. – PT can provide information about the potential risks of continuing the behavior & benefits of change – patient may need time to assimilate the information & the emotions associated with it – PT should be empathetic & encouraging & promote self-efficacy
      4. Contemplation Stage
         1. – Patient is beginning to think about making a positive change in behavior within the next 6 months or so but is not wholly committed to carrying it out – may vacillate between feeling confident that the change is good & necessary & find that it may be too difficult to achieve & my not be necessary after all
         2. How to Facilitate:
            1. – PT can assist by clarifying the possible risks involved in resisting change & highlighting the benefits of making it – Expressing concern about continuation of a risky behaviors often a good strategy to move the patient along
      5. Preparation Stage
         1. – Making plans to change/moving towards making a change & plans to do so within the next 30 days – patient has now made a commitment to change
         2. How to Facilitate:
            1. – PT should assist in developing & supporting a plan of action which include realistic implementation strategies & attainable goals – PT can ask the patient to articulate reasons for changing which can get the ball rolling – may weigh the perceived benefits against the perceived barriers
      6. Action Stage
         1. – Implementation of plan occurs; patient begins actively participating in their treatment programs
         2. How to Facilitate:
            1. --PT can support patient first by promoting patient's self-confidence and his/her ability to achieve desired goals & second by outlining the steps to reach their goals – part of the support PT can offer is to a patient in developing skills needed to overcome unanticipated barriers to progress. Without these problem-solving skills patient is vulnerable to relapse into old, more comfortable behavior patterns
      7. Maintenance Stage
         1. – This is where the behavior change has persisted for more than about 6 months – main goal = prevention of relapse
         2. How to Facilitate:
            1. Discussion to help maintain the new behavior can include such things as: – Problem-solving potential new barriers – Identifying new rewards or adherence or behavior change – Reminding the patient of the risks of nonadherence
   6. Comparing the Three Models Figure 13-4 p. 225
5. The Pt-Practitioner Collaborative Model
   1. – This model will help PTs focus their interventions on the patient's needs & improve adherence to treatment – disease = what went wrong with the body as a machine – illness = represents a person's experience of the disease & its effects on his/her life – Understanding disease & illness is a critical aspect of successful therapeutic intervention
   2. 4 phases of the Model to assist patients in preventing the disease or relapse and promote health that can easily be integrated into the PT eval process:
      1. 1. Establishing the therapeutic relationship 2. Diagnosing through mutual inquiry 3. Finding common ground through negotiation 4. Intervening and following up
   3. Establishing the Therapeutic Relationship
      1. Entails:
         1. Communicate respect & care via: – positive verbal & nonverbal interactions – active listening – responsive touch
      2. Behaviors that Facilitate or Impede Ability to connect w/Pts.:
   4. Diagnostic Process: Mutual Inquiry
      1. Entails:
         1. Physical & movement diagnosis Begin behavioral diagnosis process: – identify disease beliefs – identify treatment beliefs – identify valued activities – identify potential barriers to treatment
   5. Finding Common Ground Through Negotiation
      1. Enails:
         1. Continue with behavioral diagnosis Identify best treatment patient is likely to follow: – Link to valued activity – identify specific barriers to treatment – assess self-efficacy make a mutual agreement for long & short term goals
      2. Questions to ask:
         1. 1. What problems do you anticipate? 2. What are your beliefs or feelings about exercise? 3. What are the best & worst things about exercise? 4. What can I do to help you succeed
      3. Good questions for assessing the pt's motivation include:
         1. 1. What is the most important activity that you wish to return to? 2. What symptoms do you want to minimize first? 3. How confident are you and your ability to perform the program? 4. Do you think these exercises will help you recover?
   6. Teaching & Problem Solving During Intervention & Follow-up
      1. Entails
         1. – Teach performance skills, providing knowledge of how to implement & monitors of treatment, design reminder strategies – evaluate for treatment effect – evaluate for adherence – problem solved to eliminate barriers to adherence – modify success indicators as patient progresses
      2. – Inclusion of reminder strategies can also increase adherence: – use of daily exercise log – setting a specific time of day to exercise – engaging a family member or friend to be an "exercise buddy"
      3. Follow-up Questions:
         1. 1. Can you show me the exercise? 2. What changes have you noticed since starting the program? 3. Have there been any negative consequences of doing the exercises? 4. Have you had problems remembering to do them?
   7. Removing Barriers To Intervention
6. Motivational Interviewing
   1. Def: motivational interviewing = directives, client centered counseling style for eliciting behavior change by helping clients explore & resolve ambivalence
   2. – Purpose = allow the patient to arrive at the conclusion that a behavior change is necessary or desirable – PT should ask open-ended questions to encourage the patient to identify the problem behaviors, alternatives & choices. In this way, the process is patient centered, not therapist driven
   3. Requires:
      1. – Careful listening, encouraging the desire to change from the patient by eliciting cognitive dissonance, & instilling confidence in the patient's ability to make the change, thus reducing or resolving the cognitive dissonance – showing empathy & encouragement throughout the process to support the patient self-efficacy
   4. Sequence of Steps in the Motivational Interveiwing:
      1. 1. Awareness building (helping the patient to recognize the pros & cons of continuing the behavior) 2. Creating alternatives to the current behavior 3. Problem-solving 4. Making choices between alternative behaviors 5. Goal setting 6. Avoidance of confrontation