Brief Action Planning
Adapted from the work of Dr. Rahul Gupta, Margie Wiebe (RN)
& CCMI
www.pspbc.ca
Agenda
1.
2.
3.
Peer Sharing/Learning (30 mins)
Advanced Pain Tool Use (45 mins)
•
Comprehensive BAP
•
Patient Self-Manangement
•
Mindfulness/Relaxation Techniques
•
Practicing using techniques
Return to Function (30 mins)
Break (15 mins)
4.
Pharmacotherapy (45 mins)
•
Non-opioid pharmacotherapy
•
Opioid Management

5.
Comorbidity between addiction and pain
Case Study Application (30 mins)
•
Assessing Pain and creating a management strategy
6. Wrap up (15 mins)
•
Action period planning
2
Learning Objectives – LS 2
 Use appropriate tools to assess pain and plan a a
management strategy for 6 patients with chronic
pain
 Reflect on his/her delivery of pain tools and
develop a process improvement plan
3
Faculty/Presenter Disclosure
Faculty’s Name: Speaker’s Name
Relationship with commercial interest:
-Grants/Research Support: PharmaCorp ABC
-Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
-Consulting Fees: MedX Group Inc.
-Other: Employee of XYZ Hospital Group
4
Disclosure of Commercial Support
This program has received financial support from [organization name] in
the form
of [desribe support here – e.g. educational grant]
This program has received in-kind support from [organization name] in
the form
of [describe the support here – e.g. logistical support]
Potential for conflicts(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose products are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program. [Enter generic
and brand name here].
5
Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
6
Learning Objectives - BAP
 Define Brief Action Planning (B.A.P.) and
describe the process
 Explore a case study illustrating how B.A.P.
supports patient self-management
 Practice B.A.P. to develop comfort and skill
7
“ Everyone has a doctor in him or
her, we just have to help that
doctor in its work. The natural
healing force within each of us is
the greatest force in getting well.”
-Hippocrates (460-377 B.C.)
(c) Gupta 2013
8
What is Brief Action Planning?
 a highly structured
 patient-centered
 stepped-care
 evidence-informed
self-management support technique based on the
principles and practice of Motivational Interviewing.
Gutnick et al, 2014, Jrnl Clin Outcomes Mgmt
Reims et al, Brief Action Planning White Paper, 2014
both available at www.centreCMI.ca
9
Spirit of Motivational Interviewing




Compassion
Acceptance
Partnership
Evocation
Miller W, Rollnick S. Motivational Interviewing: Helping People
Change, 3ed, 2013
10
“Is there anything you would like to do for your health in the
next week or two?”
Behavioral Menu
SMART Behavioral Plan
Elicit a Commitment Statement
“How confident or sure do you feel about carrying out your
plan (on a scale from 0 to 10)?”
If Confidence <7, Problem Solve Barriers
“Would it be helpful to set up a check on how things are
going with your plan?”
Check on progress
11
Three Questions of B.A.P.
“Is there anything you would like to do for your health in the
next week or two?”
“How confident or sure do you feel about carrying out your
plan (on a scale from 0 to 10)?”
“Would it be helpful to set up a check on how things are
going with your plan?”
12
Five Skills of B.A.P.
Behavioral Menu
SMART Behavioral Plan
Elicit a Commitment Statement
If Confidence <7, Problem Solve Barriers
Check on progress
13
“Is there anything you would like to do for your health in the
next week or two?”
Behavioral Menu
SMART Behavioral Plan
Elicit a Commitment Statement
“How confident or sure do you feel about carrying out your
plan (on a scale from 0 to 10)?”
If Confidence <7, Problem Solve Barriers
“Would it be helpful to set up a check on how things are
going with your plan?”
Check on progress
14
Example Case
15
Example Case
62 year old female cashier with long history of severe
migraines, still debilitating 1x weekly (in bed 2 days). On
long-acting opioid, sumatriptan and codeine for BTP.
Continues to miss many afternoons at work due to
migraines
Low self-esteem, timid++, anxious, perfectionist
Frustrated, feels “at the mercy” of migraines, lots of
incompletions
Is there anything you would like to do for your health in
the next week or two?
16
Example Case
 “I want to make my mornings less stressful”
17
Stating Action Plans in the Positive
 We are trained to focus on what’s wrong with ourselves
 Preoccupation with “what’s wrong” means less focus on
what allows us to flourish
 The brain cannot visualize “negatives”
 The brain is continually responding to pictures
 Research suggests shifting focus to positive visuals
enhances cognitive abilities and inspires action




Example: “I want to stop being in so much pain”.
Physician: What would you prefer to experience?
“I want to feel more comfort in my body”.
“I want to feel energetic”.
Frederickson & Branigan. Cognition and Emotion, 2005;19, 313-332.
18
Example Case
“I want to make my mornings less stressful”.
What would you prefer?
To feel more at ease in the mornings.
How will you start?
Don’t know.
19
Skill #1
Behavioral Menu
Offer a behavioral menu when needed or requested.
20
Behavioral Menu
1. “Is it okay if I share some ideas from other people who are working on
something similar?”
2. If yes, share two or three varied ideas briefly all together in a list. Then
say…
3. “Maybe one of these would be of interest to you or maybe you have
thought of something else while we have been talking?”
Physical
Activity
Healthier
eating
Better Sleep
Adapted from Stott et al, Family Practice 1995; Rollnick et al, 1999, 2010
21
Example Case- Behavioural Menu
 Is it ok to share some ideas?
 You might consider working on becoming more
assertive, or getting better at completing things.
 Does one of these ideas interest you, or maybe
you have thought of something else?
 “I want to make my mornings less stressful”
22
Skill #2
SMART Behavioral Plan
Action Planning is “SMART”: Specific, Measurable,
Achievable, Relevant and Timed.
With permission:
• What?
• When?
• Where?
• How often/long/much?
• Start date?
Based on the work of Locke (1968) and Locke & Latham (1990,
2002); Bodenheimer, 2009
23
Example Case: SMART goal-setting
“I want to make my mornings less stressful”.
Would it be okay to get more specific?
Sure
What would you like to do?
To feel more at ease in the mornings.
How will you start?
Don’t know.
24
Example Case: SMART goal-setting
“I want to feel more at ease in the mornings”.
Can I share some ideas that have worked for others?
You might pace yourself differently, or reduce your
expectations. Does that trigger any thoughts?
I will not answer my phone til noon, I will say NO to
unreasonable requests for my time, I will break tasks into
30 minute chunks.
What’s enough for the first 2 weeks?
5 mornings “of ease” per week.
25
Skill #2
SMART Behavioral Plan
Is her plan “SMART”?
 Specific, stated in positive
 Measurable
 Achievable
 Relevant
 Timed
Locke & Latham. Building a Practically Useful Theory of Goal Setting & Task
Motivation. American Psych, 2002;57, 705-717
Frederickson & Branigan. Cognition and Emotion, 2005;19, 313-332.
Bodenheimer. Goal-Setting for Behavior Change in Primary Care. Pt Educ Couns
2009;76(2):174-80
26
Elicit a Commitment
Statement
Skill #3
 After the plan has been formulated, the clinician
elicits a final “commitment statement.”
The strength of the commitment statement
predicts success on action plan.
Aharonovich, E. Cognition, commitment language, and behavioral
change…Psychology of Addictive Behaviors, 2008;22:556-562
Amhrein PC. Client commitment language during motivational interviewing predicts
drug use outcomes. Journal of Consulting and Clinical Psychology, 2003;71:862-878
27
Example Case:
Eliciting a Commitment Statement
 Just to make sure we both understand the details of
your plan, would you mind putting it together and saying
it out loud?
 “Over the next 2 weeks, I will make my mornings feel
more at ease. I will not answer the phone til noon, I will
say NO to unreasonable requests, and I will break tasks
into 30 minute segments. I will do this 5x per week.”
28
Three Questions of B.A.P.
“How confident or sure do you feel about carrying out your
plan (on a scale from 0 to 10)?”
29
Skill #4
Problem Solving
Problem-solving is used for confidence levels less
than 7.
Note: If the patient indicates his/her level is <7, the
likelihood of a successful behavioural change is low.
Bandura, 1983; Lorig et al, Med Care 2001; Bodenheimer
review, CHCF 2005; Bodenheimer, Pt Ed Couns 2009.
30
Self-efficacy
People’s beliefs about their
capabilities to perform
specific behaviors and
their ability to exercise
influence over events that
affect their lives. Selfefficacy beliefs determine
how people feel, think,
motivate themselves and
behave.
- Albert Bandura
Mt Frosty, BC by C. Davis
31
Problem solving
Confidence <7
“A __ is higher than a zero, that’s good! We know people
are more likely to complete a plan if it’s higher than 7.”
“Any ideas about what might
raise your confidence?”
Yes
No
Behavioral Menu
Assure improved confidence.
Restate plan and rating as needed.
32
Example Case: Problem Solving
“I want to feel more at ease in the mornings”.
 Considering a scale of 0-10, how sure are you about
completing your plan?
 “4/10.”
 OK, 4 is better than 3! When confidence is greater than
7, people are more likely to succeed. Do you have any
ideas about how you might raise your confidence to a 7
or greater?
 “If I expect myself to do it even 2x per week, that feels
more possible.”
 How sure are you now?
 “8/10.”
33
“Would it be helpful to set up a check on how things are
going with your plan?”
34
Skill #5
Check on progress
Checking on the plan builds confidence.
Check often with new action plans and
decrease frequency as behavior is
more secure.
When working with a clinician
Regular contact over time is better than
1x intervention.
Follow-up builds a trusting relationship.
Resnicow, 2002; Artinian et al, Circulation, 2010
35
Checking On Plan with Clinician
“How did it go with your
plan?”
Completion
Partial
completion
Did not carry out plan
Recognize
success
Recognize partial
completion
Reassure that this is
common occurrence
“What would you like to do
next?”
36
“Is there anything you would like to do for your health in the next
week or two?”
Have an
idea?
With permission:
What?
When?
Where?
How
often/long/much
?
Start date?
Not sure?
Behavioral Menu
SMART Behavioral Plan
Elicit a Commitment
Statement
Not at
this time
Permission to
check next
time
1) Ask permission
to share ideas.
2) Share 2-3 ideas.
3) Ask if any of
these ideas or one
of their own
ideas might work.
“How confident or sure do you feel about carrying out your plan
(on a scale from 0 to 10)?”
Confidence
≥7
Confidence <7,
Problem Solving
“Would it be helpful to set up a check on how things are going with
your plan?”
How?
When?
Check on Progress
37
The client does the most
talking in Brief Action Planning
38
EXERCISE –Practicing B.A.P.
Use “Worksheet” as your guide
Divide into groups of 2 (patient & provider)
Spend 5 minutes in each role, then switch
PATIENT: Choose something real you want to do
in the next week or two
 PROVIDER: Use 5 minutes to practice approach




39
EXERCISE –Practicing B.A.P.
De-Brief
40
Tips For Using These Tools
1. Practice and get feedback.
2. Set SMART goals for yourself.
3. Choose easy patients to start with.
4. Work over multiple appointments.
5. Focus on the spirit of the interview.
41
Mindfulness Based Stress Reduction
(MBSR)
 Program started in 1979 at U Mass Medical School by Dr.
Jon Kabat-Zinn
 8 week group program, usually 2.5 hour class with all-day
retreat
 Trainings include breath/body awareness, developing
acceptance of present moment, and understanding stress
physiology
 Over 30 years of research, documenting its value in
improving patient self-management and the capacity to
more effectively deal with stress & illness
42
MBSR & Chronic Pain
 Chronic Pain Vowles & McCracken 2005, 2008
 108 & 171 patients respectively, intensive programs
 demonstrated improvements pre- to post- treatment on
measures of pain, depression, pain-related anxiety,
disability, medical visits, work status and physical
performance
 Chronic Pain: Simpson & Mapel 2011
 RCT with 32 people: mix of FM, arthritis, IBS, migraines etc
 Significant positive changes around rumination,
magnification and helplessness (better able to manage pain)
43




MBSR-Chronic Back Pain
Low Back Pain: Morone, Greco & Weiner 2008
RCT with 37 people: greater acceptance,
engagement in activities and overall physical
functioning
Failed Back Surgery Syndrome: Esmer et al
2010
Single-center, prospective, randomized trial with
25 people: clinically significant increase in pain
acceptance, sleep & QoL measure, decrease in
pain, functional limitation & frequency of
use/potency of analgesics
44
MBSR & Fibromyalgia
 Fibromyalgia: Kaplan, Goldenberg & Galvin-Nadeau 1993
 Pre-post assessments with 59 people: improved sleep, pain,
fatigue, well-being, coping and FM symptomatology (SCL-90R)
 51% responders (moderate to marked improvement)
 Fibromyalgia: Weissbecker et al. 2002
 RCT with 91 women: improved sense of coherence*, lower
perceived stress and less depression
*Sense of Coherence: disposition to experience life as meaningful
and manageable
45
How might you bring Mindfulness to the
Clinical Encounter?
 Mindful Listening (to self and patient)
 Use CBIS handouts on body scan and mindfulness
 Give mindfulness options for behavioural menu
options (do one thing at a time, slow down,
“nothing” time, breath awareness)
 Suggest books
 Be aware of local mindfulness programs
46
Suggested Books
Mindfulness Resources
 CBIS handouts (body scan, mindfulness meditation,
relaxation)
 Mindfulness-Based Chronic Pain Management
www.neuronovacentre.ca
 The Mindfulness Solution to Pain (Dr. Jackie GardnerNix)
 MBSR courses being held around BC www.mbsrbc.ca
 Pain BC www.painbc.ca
 Center for
Mindfulnesswww.umassmed.edu/cfm/stress/index.asp
x
48
Introducing Mindfulness to Patients
 It is common for those dealing with chronic pain to focus
on past issues (good or bad) , future concerns or
judgments about the present
 Mindfulness is the capacity to BE WITH and IN the
constant flow of present moment
 It allows for a clearer understanding of how thoughts and
emotions can impact health and quality of life
 This capacity is inherent with each person, and can be
cultivated through practice
 Would you like to hear some options for exploring
mindfulness, or do you have some ideas of your own?
49
Questions?
50
Resources
 Center for Comprehensive Motivational
Interventions www.centreCMI.ca
 Patient Self-Management Module (VCH) of PSP
51