EXECUTIVE SUMMARY
Case managers can improve client motivation through strategies that include learning what is important to them and breaking up their overall goal into bite-sized steps.
- • Focus on what’s important to the client.
- • Encourage clients to measure their small steps in the right direction to both reinforce the positive behaviors and to provide an incentive through recognition of small successes.
- • “Trick” clients into improving motivation and positive behaviors through small actions that affect their attitude and self-awareness.
Motivating clients to make changes for health improvement is one of the challenges in case management. Increasingly, evidence suggests fear tactics — i.e., telling them of the dire consequences of non-action — do not work. So what does?
Motivation is one of the most important factors in patients’ ability to stay healthy, notes Robert Drapkin, MD, FACP, an internist and author in St. Petersburg, FL.
In the U.S., many people will maintain their automobiles more meticulously than they’ll maintain their bodies, so it takes a concerted effort to improve their motivation, he adds.
One strategy is to find out what is important to the patient.
“Before I get started with patients, I ask them what their goals are, what they would like to accomplish,” Drapkin says.
So if the person’s goal is to improve his or her appearance and lose weight, then the daily measurement activity would be to record weight daily.
“I tell them that in order to achieve their goals, they’ll need to measure their activities on a daily basis so they can see that they are getting closer to their goals,” Drapkin adds. “This helps people control their behavior better.”
“Focus on what’s important to them and help them address the challenges they face,” says Judith Hibbard, DrPH, professor emerita of health policy at the University of Oregon in Eugene, and lead author of the Patient Activation Measure Survey.
For example, a client might mention the desire to attend a grandchild’s graduation in six months. So the case manager would help them learn the steps they would need to take to be able to achieve that goal, Hibbard adds.
Hibbard’s research when developing a case management measurement tool led her to the observation that people who showed less than desirable progress often were discouraged and would speak about their actions in negative terms. “They would say things like, ‘It doesn’t matter what I do, I can’t have a positive impact on my health.’ They lacked confidence,” Hibbard explains. “They felt overwhelmed with the tasks, had limited problem-solving skills, and often didn’t understand what their roles were in the care process.”
The way to motivate people to change is to help them have small successes that will replace the negative internal messages. For instance, a case manager can suggest they take a very small step, and when they are successful with that step, another small step can be added, Hibbard says.
“When they start to experience success then they become more motivated,” she adds.
This method relates to behavioral activation theory, which is used in treating depression and operates under the assumption that changing one’s behavior — even in small ways — will lead to a change in motivation and confidence.
For instance, a diabetic patient who has difficulty walking for exercise could be asked to take the stairs at work three times a week. This is a small action that has a higher likelihood of success, and when the patient does this, the activity is reinforcing and can lead to another, bigger activity, such as taking a walk once a week in the evening, Hibbard says.
“What the care manager does is not prescribe the activity so much as bite-size the activity according to the person’s motivation,” she adds.
There are case management programs that can help with bite-sizing activities, or a case manager could develop an approach that is based on heading in that direction, Hibbard suggests.
“One way to change a person’s mindset is to think in terms of increases of activation, on a zero to 100 scale, as one of the outcomes,” she adds. “Think of zero to five as a success and look for intermediate outcomes.”
Ultimately, that’s how case management should work: providing reward based on patients’ activation scores, Hibbard says.
Starting with easy activities will work with any patient, Drapkin says.
“If walking is painful, then have the person try swimming or walking in a pool, where it’s less stress on the joints and muscles,” he suggests. “The person’s body will adapt, and the patient can increase the amount of time in the activity.”
Another strategy is to teach patients to trick themselves into improving their willpower. For instance, a patient who would like to lose weight can take a cell phone photo of his or her body once a month and also record waist measurements at that time, Drapkin suggests.
“These are objective measurements that help people stay on their diet and routine,” he says.
As their willpower improves and they lose weight, they’ll see improvements in their appearance via the photos, and also see smaller waist sizes in their measurements. At the same time, their behavior change will be reinforcing in how they feel as their energy levels and health also will begin to improve, Drapkin explains.
“I tell patients that it’s a race won by the turtle, not the hare,” he says. “It’s a lifelong process of having a healthy lifestyle, so I have them write down their goals, keep journals, and record their daily weight.”
Drapkin also asks patients to record the food they eat and note the proportions of protein and carbohydrates. If a patient shows no improvement, he might say, “What you’re currently doing isn’t working, so we have to change something. What would you like to change? What can you change? Can you quit drinking alcohol or stop smoking? Can you eat smaller, more frequent meals?”
Drapkin also motivates through encouragement: “I tell them they have the body of an athlete whether or not they know it.”
The human species has succeeded, in part, because of its athleticism, he says.
“We can outrun most other animal species — not running faster, but we can outlast them,” he says. “I convince patients that they are becoming athletes because they’re exercising a little bit each week.”
Case managers can improve client motivation through strategies that include learning what is important to them and breaking up their overall goal into bite-sized steps.
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