By Teresita Buenrostro, RD, CDE
VMS BioMarketing Clinical Educator
As Clinical Educators who work in the healthcare field, we are in the ideal position to talk with our patients about setting healthy goals at any time of the year. However, many people are particularly motivated at the start of a new year, so why not make the most of that?
Originally developed for smoking cessation, the “Five As” (assess, advise, agree, assist, and arrange) have been used by the U.S. Public Health Service to report on high-quality, controlled clinical trials in tobacco cessation, but they have also been applied in primary care settings to address a broad range of behaviors and health conditions 1, 2. As outlined below, the Five As may help Clinical Educators address sensitive topics while enhancing their patient’s ability to create healthy behaviors and improve self-management of chronic illnesses.
1. Assess. Start by finding out the patient’s agenda for the new year. Allow the patient to express any concerns or areas of focus. Focusing on the patient’s top health concerns at the beginning of the visit can foster clinical partnership, promote the therapeutic relationship, and encourage success in improving health behaviors. Furthermore, adequate assessment can help the clinician gauge the patient’s beliefs, behaviors, and readiness to change. It is important to assess not only how convinced a patient is that a behavioral change is important, but also the skills necessary to achieve that change. Patients may not be ready to develop an action plan in one area, but instead may be ready to work on another problem that is more meaningful to them. Ask the patient: “Is there something you would like to work on during the next two to three weeks to continue to improve your health in the new year?” This will provide an opportunity to reflect on relevant goals and the steps they will need to achieve them, thus increasing the likelihood that your patient will follow through and succeed.
2. Advise. Once you have identified a patient’s readiness to work on a specific goal, help them realize the importance of a specific action plan. Make your patients aware of the different options and choices available to them. Familiarizing yourself with the patient’s priorities and health beliefs makes it easier to collaborate on the development of the action plan. Let’s pretend that you show your patient a handout by the National Heart, Lung, and Blood Institute which lists five steps to lower high blood pressure. After reviewing that list, your patient decides that now is a good time to work on increasing physical activity, because he has more time to do so and he recently received a treadmill from his children. Furthermore, he realizes that he can cut back on his sodium intake, as he admits he’s been eating out too much since retirement. Excellent! You just made your patient aware of a few lifestyle changes when it comes to his current eating and the importance of activity to lower his blood pressure. Additionally, your patient has selected two things that he is willing to work on from a list of options.
3. Agree. This is where both the patient and clinician work collaboratively to come up with health-related goals that are Specific, Measurable, Attainable, Relevant and Time-bound. When coming up with SMART goals, make sure the patient is both convinced and confident that he or she can achieve these goals. When you are setting goals, ask the patient: what exactly do you want to achieve? Where? How? When? With whom? What are the conditions and limitations? Why, exactly, do you want to reach this goal? What are possible alternative ways of achieving the same outcome? One easy question to start this process is to ask: “Is there anything you would like to do in the following two weeks to improve your blood pressure, based on the ideas addressed in this handout we just went over?” One examples of a SMART goal could include the following: “For the next two weeks, every Monday through Friday at 7:00 in the morning, I will get on the treadmill for fifteen minutes. On Saturday and Sunday mornings at 9:00, I will get on the treadmill for thirty minutes.“ Another example could be: “I will cut back on my sodium intake by limiting fast foods and packing my own lunch from home, making sure I include one vegetable and one fruit.”
4. Assist. Once a self-management goal and action plan have been agreed upon, the clinician can help the patient to identify personal barriers and resources. Explore any prior experiences to troubleshoot obstacles, use resources and materials such as apps and diaries to keep track of goal practices, find support on social media, and try other helpful management techniques such as family support, nutrition or fitness training classes, or one-on-one counseling with the dietitian, counselor, or certified diabetes educator to keep the patient motivated and accountable.
5. Arrange. Arrange for follow-up to reinforce effective patient self-management behaviors and to respond to the changing challenges of chronic disease management. If available and if possible, enroll the patient in a telephone-based support program or case management program to provide between-visit self-management support. If appropriate, calling, texting, or emailing between office visits may be helpful to maintain contact with the patient and to offer support, including a referral to a more intensive or specialized treatment.
1 Whitlock EP et al. Behavioral Counseling Interventions: An Evidence-based Approach. U.S. Preventive Services Task Force.
2 Self-Management Goal Setting Technique. University of Michigan Health System.