On Call Magazine
June 26, 2007

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

Patients, not providers, are ultimately responsible for the day-to-day management of their own chronic condition. But figuring out what to do and being consistent about doing it is hard for almost everyone. Hilary Seligman, MD, MAS, is an assistant professor in the department of medicine at San Francisco General Hospital in California. Many of the patients she sees in her internal-medicine practice have limited literacy or English-language skills, yet regardless of their skill level, Seligman makes it a point to help them develop effective action plans that let them take charge of their own care. When I spoke with her recently, she outlined the principles she applies to make sure patients follow through with their self-care plans.

1) Patients need help understanding their role in self-care.

Many patients are accustomed to healthcare providers telling them what to do. But every day, they need to make decisions on their own. They need to think about the food they eat and how much activity they get. They need to decide how they take their medication and follow through on other routine aspects of self-care. Seligman wants her patients to understand their responsibility for making these decisions. To help them become more aware of their role, she asks them to think of one change they want to make to better manage their health. While many patients seem uncomfortable articulating this new task, Seligman says, initiating that first action-planning discussion, which is always the hardest, is a crucial step toward more effective self-care.

2) Patients may need prompting to come up with answers.

The first response Seligman often gets when she begins asking patients what they want to work on is silence. Oftentimes, patients lack the skills, experience, or confidence they need to think of themselves as self-managers. But after assuring them there are no wrong answers, Seligman helps her patients get beyond this doubt by asking questions such as, “What do you worry about most when you think about your health?” Then she waits in silence for a response, sometimes for as long as 30 seconds (which can feel a lot longer). At that point, patients may say something they have heard before such as, “I want to exercise more.” Or they may suggest something only indirectly related to their health such as, “I want to clean out the clutter in my house.”

No matter what their response, Seligman is supportive. She knows each answer has some specific meaning for a patient.

3) Actionable statements emerge when the general becomes specific.

Once patients start to talk, Seligman helps them make general statements more actionable. For instance, she might say, “That’s great that you want to exercise more. But it can be really hard. What’s one small step you think you can take to start?” If patients have a hard time coming up with an answer, she offers them alternatives. For instance, she might say, “Some people like to start by walking, dancing, or getting off the bus one stop early.” When patients select an action, Seligman helps them figure out how often they can do it and how to link that practice to other parts of their daily routine. Next, she raises potential problems a patient might encounter and helps brainstorm ways to overcome them. Finally, she reiterates the entire plan aloud and asks her patients to do the same.

To illustrate how the process works, Seligman recounts the case of a 63-year old man who was diagnosed with multiple chronic conditions including diabetes, hypertension, and obesity. While now out of shape, this man used to be athletic and took pride in doing sit-ups. Initially, he said he wanted to do 100 sit-ups each day. Seligman cautioned that this action plan might be overly ambitious since he hadn’t exercised in many years, so they agreed that he would do 10 sit-ups three mornings each week when he takes his medicine.

4) Success depends on patients’ confidence in their ability to follow through.

Before patients leave her office, Seligman assesses how confident they feel about following through on their action plan. She uses a picture of a ladder with 10 rungs and asks patients which rung they are on in terms of confidence. Patients on rung 7 or higher almost always follow through. The man with the sit-ups said he was an 8.

5) Follow-up, reinforcement, and revision are keys to success.

Seligman calls patients one week after they create an action plan. She doesn’t ask if they succeeded. Instead, she asks about what they did. No matter what a patient says, Seligman has something positive to say. Then, if necessary, she helps the patient revise the plan or explore problems and how to solve them. She says not only do patients “catch on” to the action-planning process after just two or three cycles, but many begin to apply the process to managing other parts of their life.

Seligman and her colleagues are studying the effect of action planning on patients and providers alike. More than two thirds of patients in the study still adhere to the plan after three months. The study has also shown that clinicians who are experienced in the planning process can help patients create action plans in as little as two minutes.

Ways to learn more

Hilary Seligman, MD, MAS, is an assistant professor in the department of medicine at San Francisco General Hospital in California. She can be reached by email at hseligman@medsfgh.ucsf.edu

Wallace AS, DeWalt DA, Arnold CL, Delgadillo A, Shilliday Betsy B, Bengal N, Palacios JL, Davis TC. “Developing low-literacy patient educational materials to facilitate behavior change.” American Journal of Health Behavior. 31(Suppl 1): S69-S78, 2007.

Helen Osborne, MEd, OTR/L, is president of Health Literacy Consulting [http://www.healthliteracy.com/]. Her column appeared regularly in On Call. You can contact her by e-mail at Helen@healthliteracy.com.