Making a Plan

In the preparation stage, the goal is to work with your patient to create a plan that is specific enough to succeed. Action plans work best when patients identify their own goals, resources, support systems and coping strategies.

A common mistake clinicians make is to end the conversation when a patient agrees, in concept, to a change. “Yeah, I really should start exercising.” Without a specific plan that addresses a patient’s unique context, change is unlikely to occur.

“Don’t leave CHANGE on the table. Make a plan!”

SMART goals

One approach to planning is contained in a mnemonic borrowed from the business world. The SMART goal approach helps patients develop specific goals that are measurable and meaningful. When goals are too vague it can be hard to know where to get started and how to track your progress.

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Some ways to start the conversation around goal setting could include asking “What are some steps you would like to take?” “What is one step you could take this week?” “What is a step you think you could take now?” “If you were going to do this, how would you start?”

Once the conversation is started you can help the patient tailor their goals using the SMART approach. These are the key steps to developing a patient driven plan.

Specific: What does the patient want to do? What EXACTLY is their goal? Eating healthier sounds like a good idea. What does that mean to you? Any specific thoughts on changes you could make to your diet? What would you need to carry out that change?

Measurable: How will you and your patient measure progress? How will your patient know when they have reached their goal? Walking more sounds like a great idea. You mentioned walking three days per week. How long will you walk for to start? That sounds like a goal you can track.

Achievable: Is this goal realistic? Is it in your patient’s power to accomplish this goal? What barriers or obstacles does your patient anticipate? What is their back up plan? What type of support do they have or do they need? You mentioned cutting out sugar all together from your diet? Do you think that is something you can reasonably do? Are there certain foods that you may be able to decrease to help you cut down on your sugar intake?

Relevant: Will achieving this goal affect your patient’s health? Will they get the desired results? Can they realistically achieve their goal? You mentioned wanting to be able to keep up with your children on the playground. It sounds like increasing your exercise would help you reach that goal.

Timely: When would be a good time to start this plan? When do they hope to achieve their goal? When would it be helpful to come back or check in? It sounds like you want to quit smoking next week after you finish your last pack of cigarettes. Would it be helpful for us to set a visit for a few weeks from them to check on how things are going and to help troubleshoot any challenges you encounter?

The following video shows an example of setting a SMART goal around pre-diabetes management:

When developing a plan, the more specific, the better. Ask the patient to think specifically about how they will make the change happen. It is much better to spend some time troubleshooting one visit to the gym that actually happens than to make a lofty abstract goal. Actually visualizing the process functions as practice, and helps identify hurdles. Short term follow up can provide reinforcement and break the task into smaller parts.

In this case, we might ask “when in your schedule do you see adding exercise?” “What can you imagine getting in the way?” “What support do you need?” “Who/where could you get that support?” When will you go for the first time? What time on Monday? What if that doesnt work? As you imagine yourself waking to your alarm at 6 in the morning, what has to happen to get out the door?” “What has to happen the night before so that you can get up at 6?” “What equipment will you need?”

“How can I support you in this change?” “Would it help to send me a message after you go, or to have my nurse check in with you next week?”

The action phase is supported by anticipatory planning that builds in new cues, piggy backs on established habits, plans around friction points, and recognizes intrinsic reward.

One-Time Actions and Systemic Supports

The easiest time to make a change is right after deciding to do so. And it’s easiest to make a change when structural supports favor the new action. Information is also most useful when it applies to an immediate choice, for example, to receive a vaccine or sign up for a program. Put together, these factors suggest prioritizing systemic supports as part of the plan whenever possible.

For example, we can lower the barrier to performing an action after making a decision by having on-site services. For example, we can offer immunizations in the exam room, offer lab/x-ray onsite, deliver discharge medications to a patient in the ER, have a flexible schedule that allows us to place an IUD or perform a PAP at the time the decision is made. Referrals are completed more often if the appointment is made for the patient eliminating the need for frustrating phone tag. A warm-handoff reduces the barrier of following up with someone the patient doesn’t know.

Insurance companies reduce ER visits by providing 90-day pill supplies. As prescribers, we can also make sure to provide 90 day prescriptions when possible, with adequate refills.

Pregnancies are reduced when a year of birth control is dispensed at a time, or long-acting reversible contraception is placed. Adherence is better for pills that are taken once a day than four times a day and can be taken without regard to meals.

This is another reminder for humility in assumptions about the structural supports or barriers in a patient’s life. Tasks that may have tremendous structural support for one person (whose assistant makes appointments for them), may have tremendous structural barriers for another (no reliable transportation, high copays and 30 day supplies of medications).

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The Foundations of Clinical Medicine Copyright © by Karen McDonough. All Rights Reserved.