Using motivational interviewing and brief action planning for adopting and maintaining positive health behaviors.

Lifestyle medicine practice can be enhanced with interpersonal communication skills to help patients adopt and maintain positive health behaviors, such as improving diet or initiating exercise. We review two approaches that incorporate evidenced-based skills for this purpose: motivational interviewing and brief action planning (BAP). Motivational interviewing involves four processes conducted in a climate of compassion, acceptance, partnership, and empowerment. First, "engaging" (or connecting) with patients uses the "relational" skills of active listening and empathic communication. Second, "focusing" elicits patients' full spectrum of concerns, expectations, and desires to negotiate a collaborative agenda. Third, "evoking motivation," utilizes uniquely innovative skills (e.g., "softening sustain talk" and "cultivating change talk") to increase intrinsic motivation of patients with ambivalence (or resistance) to become more open to choosing healthier behaviors for themselves. Fourth, "planning for change," uses collaborative goal-setting skills to help patients specify concrete action plans for health. To this end, brief action planning (BAP) has been developed as a specific pragmatic algorithmic approach, utilizing collaborative "SMART" (specific, measurable, achievable, relevant, and time-based) action planning, encouragement of patient commitment statements, scaling for confidence, problem-solving to reduce barriers for change, fostering patient accountability, and emphasizing follow-up. BAP can be introduced at any point in a patient encounter when patients are ready or nearly ready for change.

Double-disease management or one care manager for two chronic conditions: pilot feasibility study of nurse telephonic disease management for depression and congestive heart failure.

This study assessed the feasibility of a telephonic nurse double-disease management program (DDMP) for patients with depression and congestive heart failure. Thirty-five patients with depression and congestive heart failure were entered into a novel DDMP modeled after Wagner's chronic illness care model and implemented as part of a 13-month Breakthrough Series Collaborative administered by the Institute of Healthcare Improvement. Twenty-four patients remained in the program long enough to complete at least one follow-up assessment (ie, 6 weeks or longer). Patients were entered into the program based on depression severity scores from either the interactive voice response (IVR) version of the Hospital Anxiety and Depression Scale (HADS) or the self-administered (or telephonic) Patient Health Questionnaire (PHQ). Because use of the IVR version of the HADS was eliminated after several weeks into the program (because of poor patient acceptance), 19 patients had both entry and follow-up scores on the same instrument (PHQ). Depression "response" was defined as a 50% improvement in PHQ score. Mixed models regression was used to test the statistical significance of change in PHQ scores over time. Patient and clinician reports were obtained to evaluate program acceptability and satisfaction. Eighty-two percent of patients (n = 11) with Major Depressive Disorder (MDD) responded, and 75% of patients (n = 8) with "other depression" (PHQ score < 10) responded. Mean change in PHQ scores for the sample as a whole improved significantly over the 24 weeks of the program (p < 0.0003), as well as for those with major depression and other depression considered separately (p < 0.01 for both). In some patients who refused medication, depression seemed to respond to self-management support interventions of the care manager. Based on patient acceptance and clinicians' reports, the program appeared feasible and possibly effective. DDMP appears feasible and possibly effective. Future clinical trials are warranted.

Ziprasidone for agitation or psychosis in dementia: four cases.

OBJECTIVE: These case reports examine the potential efficacy and safety of ziprasidone for the treatment of agitation or psychosis in dementia. METHOD: The authors performed a retrospective chart review of three patients with DSM-IV diagnoses of dementia, treated with ziprasidone for agitation/psychosis on an academic psychiatric inpatient unit in 2002-2003. In addition, these three case reports are supplemented by a clinical report of the first outpatient with DSM-IV diagnosis of dementia completing a prospective open-label six-week study in 2004 evaluating the use of oral ziprasidone for agitation/psychosis in dementia. Qualitative descriptions of clinical improvement provide outcome data for these case reports. RESULTS: Four patients with dementia with agitation/psychosis experienced marked behavioral improvement after receiving oral doses of ziprasidone (20-160 mg/day), without any evidence of problematic cardiac or other side-effects. Two of the four patients had final EKGs and both of these patients demonstrated no change of QTc interval after administration of ziprasidone. CONCLUSIONS: These case reports suggest that oral ziprasidone may be an effective and safe medication for the treatment of agitation or psychosis in patients with dementia.

ACare: a communication training program for shared decision making along a life-limiting illness.

OBJECTIVE: This article describes an innovative 8-h training program that provides clinicians with the competencies necessary to conduct efficient, effective, and compassionate advance care planning discussions throughout the trajectory of life-limiting illnesses. METHOD: The Advance Care Training Program (ACare) includes 6 h of group workshops and 2 h of one-on-one faculty-learner interaction. In this article, we describe the (1) objectives of ACare; (2) structure, training procedures, and educational rationale of ACare training; and (3) educational outcome studies in progress. RESULTS: ACare training in various forms has already been provided to over 100 medical professionals (medical students, medical residents, oncology and geriatric fellows, medical attendings, social workers, and nurses). Formative outcome data indicate considerable trainee satisfaction. Emerging summative outcome data indicate improved skills. SIGNIFICANCE OF RESULTS: Widespread adoption of the program could increase the frequency and quality of advance care planning discussions between patients with life-limiting illnesses, their health care providers, and families.

Three principles to improve clinician communication for advance care planning: overcoming emotional, cognitive, and skill barriers.

BACKGROUND: Medical care of patients with life limiting illness remains fraught with serious deficiencies, including inadequate advance care planning, delayed hospice referral, and continued delivery of aggressive treatment that is overtly counter to patients' preferences. OBJECTIVE: This paper describes clinicians' emotional, cognitive, and skill barriers to shared decision-making with seriously ill patients and their loved ones. DESIGN: Thematic literature review. RESULTS: Based on a literature review, as well as clinical and educational experience, we articulate three principles to address these barriers and guide future professional communication training for advance care planning. CONCLUSIONS: We argue that these barriers must be overcome before deficiencies in end-of-life care can be fully ameliorated.

Psychosocial predictors of non-compliance in haemodialysis and peritoneal dialysis patients.

BACKGROUND: Non-compliance with prescribed therapy significantly impacts dialysis patient care and outcomes. The underlying psychosocial issues leading to non-compliance are not well understood, especially in peritoneal dialysis (PD) patients. METHODS: A multicentre cohort of 119 haemodialysis (HD) patients and 51 PD patients was studied. In-person interviews were conducted with patients and clinical and laboratory data were obtained from medical records. Missed and shortened dialysis treatments/sessions and excessive serum phosphate values provided indicators of non-compliance. Patients' perceived health status, perceived self-health care, depression, perceived control over future health, social support, and disease-specific perceived quality of life were measured, along with current smoking status. Associations of predictor variables with non-compliance indicators were examined in univariate and multivariable analyses. RESULTS: Approximately one-third of both HD and PD patients were non-compliant on at least one indicator. Logistic regression models identified a significant association between smoking and each non-compliance indicator. Patient age (younger) also predicted missed treatments. Perceived (negative) effects of kidney disease on daily life, and (decreased) perceived control over future health also predicted shortened treatments. No significant association was found between dialysis modality (HD vs PD) and non-compliance. CONCLUSION: Smoking, one marker of priority placed on health status, and intrusiveness/control issues should be addressed in intervention efforts to improve compliance in patients treated by HD and PD.