South Kingstown, RI – May 31, 2013. From research gleaned through 30 population-based randomized clinical trials, Pro-Change has found that there are six phases and five factors on a continuum of patient engagement.
The six phases of patient engagement are:
REACH → RECRUIT → RETAIN → PROGRESS → SUCCESS → SUSTAIN
The five factors that drive those phases are: proactivity, stage of change, communications, incentives, tailoring, and transforming.
Most health professionals have been trained to passively wait for patients to reach out to them for help with high-risk and high-cost behaviors like smoking, unhealthy diets, and sedentary lifestyles. Unfortunately, few patients reached out because they were not experiencing pain, illness, or distress from these “silent killers.” Now, with Accountable Care Organizations and pay for performance models, health professionals need to be trained to proactively reach out to entire populations, not just those ready to change.
Once recruited, retention is the next challenge. Historically, discontinuation or drop-out from action-oriented interventions ranged from 70% to 80% for weight management and addictive behaviors, and about 50% for use of prescribed medications. The number one factor that predicted who was recruited and who was retained was stage of change. This factor needs to drive the design of behavior change programs and the health communications used to engage patients.
The historic model for behavior change of large percentages of patients (and of professionals) has been an action model, in which individuals are seen as changing when they quit smoking or start taking their medications as prescribed. If professionals are trying to engage them in a disease prevention or management program, patients assume it is action oriented. Why should patients agree to participate in a program for which they are not prepared? Programs need to be appropriate for patients in all stages of change.
Patient communications needs to convey that “Wherever you are at, we can work with that!”TM Using a traffic light as an icon for readiness to change, communications can let patients know “red light = not ready, yellow light = getting ready, green light = ready. Ready or not, we can be of help.” Of course, the program must actually be designed to respect wherever the patients are at.
Incentives are an increasingly important factor to engage populations. Employers particularly rely heavily on such extrinsic motivations, because most employees are not prepared to participate but they are prepared to trade time for money. The problem is that populations can simply go through the motions for money, without putting in the effort. Transforming from extrinsic to intrinsic motivation is the next driving factor. This begins the progress phase, as individuals advance from one stage to the next as a result of having received tailored feedback. Once patients progress, it means they are engaged not just in the treatment process but also in the change process. Historically, we equated treatment with change, but many people can remain in treatment and not progress. Programs need valid, brief measures that assess progress that would not be observable to participants. For example, the sooner patients receive feedback that their cholesterol is decreasing, the more likely they will continue to adhere to cholesterol lowering drugs.
Over time, progress leads to success as patients change their health status for costly behaviors. To maximize success, programs need to sustain engagement from one year to the next. The greater the percentage of populations engaging in treatment and change processes over time, the more programs can reduce risks and costs, and increase health, well-being and productivity.
The bottom line: It’s time to use the lessons we have learned from the science of behavior change to increase patient engagement, rather than repeating history.