Health professionals, health coaches and others can make the support they provide more effective by using a number of specific evidence-based skills, techniques and approaches.
Research shows that more active support focused on confidence and behaviour works best to improve outcomes. Our brief animated video ‘Behind closed doors’ shows the difference between a traditional consultation and a consultation where the health professional uses self-management support skills and approaches.
The skills and tecniques we describe below can be used by health professionals, health coaches or others supporting people to self-manage. We have used the term ‘practitioner’ to cover anyone who is working with someone with a long term condition to help them better manage their own health.
The main techniques are:
Agenda setting At the start of the consultation, the practitioner and the person they are supporting agree the health issues they want to explore and the problems they want to solve. It signals from the beginning that the person with a long term condition is an active partner in their own care and that both parties will take a partnership approach.
Goal setting and action planning: In this stage of the appointment, the health professional or health coach supports the person to identify the goal they want to work towards and to break this down into small achievable actions.
Goal follow up: Crucial elements at this stage include the opportunity to develop problem solving skills and explore solutions to barriers and receive positive affirmation of progress and effort.
Agenda setting is about the health professional or coach working with the person to build rapport, understand the person’s perspective, explore priorities and expectations and co-produce the agenda for the consultation. It signals from the beginning that the person with a long term condition is an active partner in their own care and ensures that the key points from both a patient and professionals perspective can be covered, making the appointment as helpful/useful as possible..
Agenda setting sheets can be sent to patients in advance of the consultation, or given to them when they arrive, giving them time to think about what it is that they need from the meeting. See some example agenda setting sheets developed by other services.
It is important that through this conversation the practitioner elicits all the areas of concern for discussion and then shares their own agenda before negotiating how to proceed.
The health professional or coach might ask questions like:
- What would you like to talk about today?
- What is important to you today?
- What else/is there something else/anything else? (to ensure the person has identified all the areas that are important to them)
- What shall we focus on/what is your priority?
- What are you hoping we will achieve today?
The practitioner will also share their agenda and together they will negotiate and agree where to focus the consultation.
Some of the skills that are helpful to use during agenda setting are:
- Open-ended questions – questions that cannot be answered with a ‘yes’ or ‘no’
- Affirmation – ‘you told me you tried to change before – that shows great determination’
- Normalisation – helps people feel validated and that they are not alone ‘many people tell me they feel like you’
- Reflective listening – using words to let the person know you have heard what they said ‘so you are saying… it sounds like…’
- Empathy – let the person know you understand or are trying to understand how it feels for them
Some of the systems and processes that the service uses can also help people to think about what they talk about – for example by sending people their relevant test results in advance and an agenda-setting prompt sheet.
View some examples of agenda setting sheets people can use to help them think about what they would like to talk about at their appointment. Although these were designed for use in a clinical setting, they can be adapted for use in other environments and for other long term conditions.
Download our presentation on agenda-setting – these are the slides for workshop 1 of our Practitioner Development Programme.
Goal setting and action planning
In this stage of the appointment, the health professional or health coach supports the person to identify the goal they want to work towards and to break this down into small and achievable actions. They help the person reflect on their confidence to achieve the actions and supports them to identify the barriers – physical, psychological and emotional – that may prevent them from progressing.
Some of the skills include:
Understanding where the patient is – The health professional or coach might ask questions like:
- What has been working for you?
- What have you been doing that is contributing to your health?
- What do you know about living with…?
- What ideas/concerns/expectations do you have?
- What are your thoughts / ideas about what you can do?
Exploring importance – Importance is important – without something being important, it is hard to be motivated to work towards it. The key here is to emphasise that it is about what is important to them – not to the practitioner or the person’s family. The practitioner might say something like ‘On a scale of 0-10 how important is it to you right now to stop smoking with 0 being no importance at all and 10 being the most important thing in your life?’
Exploring confidence - Often importance is high, however confidence is low. Understanding and acknowledging that importance and confidence are two separate factors allows people to identify and access the things that they need in order to improve their confidence and enables those supporting them to understand how they can best offer helpful and proactive self-management support. A confidence of 7 or more suggests a good chance that they will achieve their goal – and further reinforces confidence for the next goal. If confidence is low, exploring why they are confident can help, then thinking about what could be changed about the goal set to bring confidence up
Supporting decision-making and working with ambivalence – Ambivalence is a normal part of life. Most of us make the changes that are easy for us and we are left with the things that we find harder. There is nearly always a cost to making these changes and sustaining change may require compromise and effort. It can be very helpful to support the individual to explore this from their own perspective when they consider their decisional balance.
The practitioner might ask questions like:
- What are the good sides of changing?
- What are the down sides of changing?
- What are the good sides of staying the same?
- What are the down sides of staying the same?
- What would you have to give up to bring about this change?
Inviting goals – Once the health professional or coach has worked with the person to explore the importance of the changes they have identified and their confidence to make them, they then support the person to consider an area that they wish to work on and help them set a goal and action plan around this. Behaviour changes can be daunting, so goals help to turn intentions into action.
The practitioner might ask questions like:
- Is there an area that you would like to work on?
- How might you go about that?
- What is the first step you can take towards that?
- How important is it to you?
- How confident do you feel?
Goals that are SMARTER (specific, measurable, achievable, resourced, time-bound, evaluated and re-evaluated) and actions that are small but achievable steps towards the goals can help build confidence and momentum. Unachievable goals can de-motivate and reduce confidence and do not change behaviour. People benefit from being supported to identify their own goals, with support to enable them to translate their intention into action.
The individual is then supported to set a SMARTER action plan which will help them progress towards their goals. Questions that are helpful at this stage include:
- What are you going to do before we next talk?
- How important is that to you? How confident are you that you can and will do this? (scaling techniques – ‘how confident do you feel on a scale of 0 to 10?’ – are a useful tool to support this).
- How often? How much?
- What challenges might you face?
- How could you manage and overcome those challenges?
It is important to:
- Acknowledge that ambivalence is normal.
- Empathise with the client’s situation and dilemma.
Download the presentation on goal-setting – these are the slides for workshop 2 of our Practitioner Development Programme.
Goal follow up
Conventional services are often not in contact with a person between routine appointments – which may be up to a year apart. Yet, evidence shows that unless goals are followed up within a fortnight, providing encouragement and support for people, they are less likely to progress towards and achieve their goals. Follow up is about providing encouragement when goals have been completed, and supporting thinking about the next steps the person wants to take.
Crucial elements at this stage include the opportunity to develop problem solving skills and explore solutions to barriers and receive positive affirmation of progress and effort. It is important to encourage the person to consider their own assets, community networks and third/voluntary sector support.
The practitioner might ask questions like:
- How did you get on?
- What challenges did you face?
- How did you overcome them?
- What can we learn from the challenges you faced?
- What are you going to do next?
- Should we think about other ways we can support you to manage in the future?
- What ideas do you have about where you can get support in your community?
- Who might you get support from within your family or friends to help keep you on track
The sessions also help practitioners to think about how they promote and enable people to better manage their own health through the policies and practices within the wider service in which they work.
Goal follow-up is perhaps the most challenging approach to embed, as health professionals and other support workers are often used to routine follow up appointments at six monthly intervals or longer and service systems and processes are not geared for rapid follow up and support. But there are other resources that people can use to support them in this follow-up, such as self-management websites and community support as well as friends and family. Practitioners and the wider service should also consider what mechanisms apart from face-to-face consultations you can use to deliver follow up.
Simple and effective ways of building systems and processes for rapid follow up include:
- e-mails or texts can be typed up at the end of a consultation and set up to send automatically a couple of weeks later
- skype consultations might replace face-to-face consultations
- group sessions are often well liked by people using services
- digital approaches to helping people monitor their own health, such as apps, or something as simple as a pedometer
- administrators as well as clinical staff can make follow-up phone calls, also helping them feel more a part of the team
- general practice can follow up on progress after a hospital appointment when the patient sees the GP or practice nurse about their condition or some other ailment.
Watch a seven minute video on how East London NHS Foundation Trust use a combination of Florence (‘Flo’ – a telehealth system) and consultations via Skype to increase the quality of care and convenience.
We also know from a wide variety of evidence that maintaining change can be very challenging for some people and in certain circumstances so we also need to be mindful of the possibility of relapse.
NHS Bolton are implementing a relapse prevention programme that uses mobile phone technology. The programme consists of multiple phases that can overcome communication barriers between the client and the service, and provide contact during the periods between formal appointments, when the client is most in danger of relapsing. Read The Bolton Alcohol Relapse Prevention Project: 20 Month Analysis
Download the presentation on follow up – these are the slides for workshop 3 of our Practitioner Development Programme.