HealthcareInterviewBuilding a Better Behavior Change Model For Chronic Conditions

Garry Welch, PhD

Many patients living with a chronic disease are struggling to change deep-seated lifestyle habits and thinking. To learn more, we conducted an interview with Garry Welch, PhD. Garry is Chief Scientific Officer and Co-Founder at Silver Fern Healthcare, a digital healthcare startup. This dynamic company offers evidence-based behavior and psychosocial assessments, clinical decision support, and advanced data visualization that empowers clinicians and patients to work together to better prevent and control chronic diseases and improve outcomes. He has conducted 30+ years of clinical research with prestigious entities including Harvard Medical School, Tufts University School of Medicine, and Joslin Diabetes Center.

Many people are aware that poor lifestyle choices and habits lead to chronic conditions. What keeps them from changing such habits?

Traditionally, the focus of healthcare professionals is on the reasons patients won’t (or can’t) make the behavior changes clinicians suggest. However, the common lifestyle options available to patients in daily life today are often unhealthy ones, making it difficult for patients to make the right choices for their health. For example, 60 percent of the typical American diet now comes from ubiquitous highly processed, factory foods and sugar-sweetened drinks that humans are biologically not evolved to consume. These highly processed foods, combined with our modern culture of overeating and sedentary living, promotes obesity and fundamentally dysregulates our basic cardiometabolic and immune systems. Educating patients on the reality of this environment and helping them both navigate it and make smarter decisions should be a focus of treatment if we want them to succeed in living healthy.

Clinical healthcare teams can build healthier habits among patients by helping them connect suggested lifestyle or treatment behaviors with the patient’s personal life goals and interests. Clinicians can also benefit from having more robust data about patients’ current behaviors, barriers, goals, and treatment preferences, enabling them to offer tailored feedback and coaching through both traditional and newer digital communication methods.

Type 2 Diabetes is becoming increasingly common. The CDC’s National Diabetes Report for 2020 cited an estimated 34.2 million people in the U.S. have this chronic condition. What factors are contributing to these rising numbers?

It’s hard to ignore the rising type 2 diabetes numbers that we see today. This is due, in part, to an aging population, increased obesity (42 percent of Americans) and a rise in a more sedentary lifestyle (prompted by the mobile/digital world). The basic underlying clinical drivers of type 2 diabetes – out of range blood glucose, blood pressure, and blood lipids and related inflammation and insulin resistance – are creating the high type 2 diabetes numbers we see today.

Compounding this underlying problem is that the U.S. healthcare system has not responded to this chronic disease epidemic by investing in primary care services or prevention. Only five to seven percent of U.S. healthcare dollars are spent on primary care annually. We have focused mostly on building the acute care and the specialist parts of our healthcare system and healthcare institutions have not been financially incentivized to focus on the upstream lifestyle and obesity drivers of these high (and rising) diabetes prevalence numbers.

A positive trend that we’re seeing is that the American College of Lifestyle Medicine (ACLM) has emerged as a new U.S. medical subspecialty focusing on prevention and intensive lifestyle change as the primary treatment plan for chronic conditions. Remission of type 2 diabetes, for example, is a primary goal of treatment. This fresh and evidence-based approach for managing epidemic chronic conditions is highly encouraging as it shows how our health can dramatically improve if we change the way we live.

How can patients understand they have the personal control and ability to prevent type 2 diabetes as a chronic condition?

Clinicians can raise patient awareness and curiosity about their personal clinical and laboratory numbers. Patients need to understand, using simple and personalized language, the correlation between these results and their daily habits and quality of life.

Patients shouldn’t have to be “convinced” as much as be “empowered” by clinicians to make behavior changes that are doable and sustainable and that support a new way to think about themselves and their desired lifestyle. Key success factors include: building trust; showing empathy and genuine interest in the patient’s concerns and preferences; fighting on their behalf to provide access to ongoing support and resources; and consistently providing the personalized and tailored information, motivation, and behavior skills patients need to succeed in our complex, modern world.

What is behavior medicine and what common behavior change models does it use?
Behavior medicine includes the creation of clinical programs and techniques using psychology and science to help patients engage in wellness and healthcare.

There are many health behavior change models used in the field of Behavior Medicine. These include: Social Cognitive Theory; the IMB model, Self Determination Theory, the Health Beliefs Model; the Transtheoretical Model, COM-B, Motivational Interviewing, and the “5 As.”

The interventions and programs applying these models help clinicians empower and motivate patients to do what is in their own best interests to optimize their health and make more informed decisions and lifelong plans.

Why is it hard for clinicians to apply health behavior change models in their practice?

Health behavior change models come out of clinical research settings and are often weighed down with technical jargon and academic concepts not familiar or useful to front-line clinicians.

Additionally, the traditional professional training of most frontline clinicians focuses on biomedical issues. The majority of clinicians are not provided with the necessary skills, tools, financial incentives, team support, or modern digital technologies needed to easily apply health behavior change models in routine care. Also, clinical teams typically work with electronic medical records (EMRs) designed principally for insurance billing and revenue capture and for in-person acute care episodes. These systems are not well designed for the management of chronic care conditions requiring long-term patient behavior change and support.

As a result of disruption from the Covid-19 pandemic, patient contact and communication has increased in a positive way between clinical teams and patients using telehealth monitoring technologies. Twenty percent of visits are now virtual. Extended chronic care teams, including nurses, health coaches, and care navigators, with MDs as their quarterbacks, could be trained to incorporate practical behavior change models and digital technologies into these new workflows and improve clinical skills, care quality, access to care, health outcomes, and potentially help control healthcare costs.

What is an example of a more accessible behavior model for clinicians? Can you provide some information about the model?

Silver Fern’s Practical Behavior Change Model was designed to translate the behavior change models used in the field of Behavior Medicine into a model that is accessible and applicable in the healthcare marketplaces. Silver Fern’s behavior change model focuses on the need for our healthcare system to provide more practical and tailored information, motivation, and behavior skills to support patients and help them address and overcome changing life circumstances and emerging needs over time.

Patient outcomes improve when they have access to information in several fundamental areas:

  • Foundational knowledge that our modern culture and daily lifestyle habits – particularly what we eat, drink, and ingest into our bodies– is driving obesity and today’s epidemic chronic conditions.
  • An understanding and clear interpretation of key clinical terms, with lab results delivered in simple language that anyone can understand, free of complicated medical jargon.
  • Information and help navigating insurance issues and costs to individuals and their families, and advice for making smarter healthcare choices that fit the patient’s goals.
  • Motivation from clinical care teams to help evaluate the benefits and risks of any proposed lifestyle or treatment changes and answer their question: “Why should I do this?” Additionally, patients need help exploring and overcoming barriers to personal change, answering the practical question, “How can I do this (behavior) and get help with the behavior change journey?”
  • In addition to information and motivation, patients need to develop relevant behavior skills such as how to replace highly processed foods with healing foods closer to their original state, find ways to get quality sleep, and/or accessing mental health support that fits their needs.

Exploring these topics as part of basic information planning for patients creates building blocks for a highly individualized approach that can lead to healthy lifestyle change and treatment engagement.

How can such models be more accessible and actionable to clinicians?

For current health behavior change models to be implemented at scale, the system needs to incentivize clinicians to prioritize whole person care and prevention. This will happen if we continue to invest in value-based care initiatives and to invest in technologies that help us personalize care at scale.

At Silver Fern, we know that getting this depth of information about patient behaviors, barriers, goals, and preferences into the care plans of individual patients in an efficient and systematic way is a challenge, especially given the time constraints on providers in the current system. We’ve invested in building products that enable care teams to synchronously or asynchronously deliver assessments to patients that unlock key information about their current behaviors and their psychosocial barriers so that this information can quickly become part of the patient’s record and care plan – similarly to how biometric and pharmaceutical information is currently collected, stored, and included in treatment planning.

Making this information actionable for clinicians starts with giving them tools to access it efficiently and utilize it effectively. We’ve used the best research from the field of Behavior Medicine and our own Practical Behavior Change Model to design an approach that not only assesses patient behaviors and barriers systematically but that delivers suggested clinical actions and referrals that are aligned with the specific items illuminated by the assessments. This saves clinicians time and allows them to utilize the precious time that they have with patients to focus on solutioning and problem solving.

We envision a world where clinicians have this information and these resources at their fingertips for all patients, because helping patients take control of their health starts with personalizing care and getting patients the information, motivation, and skills they need to modify their behavior is the best way to prevent and reverse chronic disease trends.

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