3.5: The Self-management Care Plan Interview

David Featherston

Communication

Patients rate excellent communication skills as an essential quality for a psychiatrist and it has been shown that quality communication is directly linked to optimal self-care.^(1,2) A systematic review of the literature on the association of communication characteristics and patient outcomes is shown in the table.⁽³⁾

Verbal behaviours associated with positive patient outcomes	Verbal behaviours associated with negative patient outcomes
Interaction style:
Empathy Passive physician behaviour Dominant physician behaviour Tension release Friendliness Courtesy Listening Thinking at the patient’s level Attentiveness	Passive acceptance Negative social-emotional interactions Formal behaviour Antagonism Interruptions One-way information flow Directiveness Nervousness, anxiety or tension Irritation
Interaction content:
Statements of reassurance and support Encourages patient questions Provides explanations Asks questions of the patient Addresses psychosocial issues Shares medical data Discusses treatment effects Summarisations and clarifying statements	High rates of biomedical questioning Extensive feedback during the concluding part of the visit

Communication and CALD communities

A study that looked at the needs of people with chronic conditions and included and Māori and Pacific Island peoples, reported that all patients related stories of not being understood by health professionals and difficulties in understanding the health professional. The perception by Māori patients was that they were not heard or understood. The resulting outcomes included stress and confusion on managing their condition and feelings of not being cared for and a lack of trust.⁽⁴⁾

Māori and Pacific patients interpret poor communication (often leading to a misunderstanding) as a lack of cultural affinity. Trust, for Māori patients, is built through respect, listening and cultural understanding. If the clinician does not make an attempt to simplify language, this is perceived as a lack of respect.⁽⁴⁾

A perspective on carers of Culturally and Linguistically Diverse Backgrounds

What is recovery?⁽⁵⁾Marie offers the perspective of CALD carers which may help psychiatrists to better understand the needs of this group.

Dim lights Download

Greek carer reports, he believed his son’s illness was caused by the evil eye, he hadn’t told the doctor for fear of being ignorant. Carers often have different values and understandings of the role of mental health professionals. CALD families have a strong sense of values and commitment to the unwell family member and bear the burden of keeping them in the community perhaps using what may seem unorthodox ways. A Turkish carer reports, I want to send him back to Turkey, to marry a good Turkish girl. I know a good girl will take care of him and make him well. The role of the clinician here is to show understanding and address these family concerns in a culturally sensitive way, to support the carer to cope with fears of the future being what will happen to the loved one when they are gone.

Carers need access to language and culturally specific carers groups. A carer attending an Italian group reports, it is useful because it is in my language so I can communicate and be understood as well as understanding and learning from others. You realise you are not the only one who has a big cross to bear; sharing the cross with others provides energy and strength to confront another month.

CALD carers need culturally appropriate translated information. The Victorian Transcultural Psychiatry Unit have collaborated with CALD carers and the Carer network have collaborated with stakeholders to come up with a range of health tips for families and carers. These are culturally appropriate translated information designed to lessen the stress and provide suggestions that might help day to day dealings with their ill relative. This work is on line and downloadable from both the VTPU and the carer network websites.

CALD carers generally cry out for understanding and compassion. They need to be supported to express what they believe is happening, to vocalise their stress and air their confusion. The system needs to rise to the challenge to join in partnership with health carers so they can understand this notion of recovery and be a par of the process.

Assessing the capability of the patient and carer for self-management^(6,7)

Flinders Human Behaviour and Health Research Unit Self-management Program uses the Cue and Response Tool to make an assessment of self-management capabilities. This is a structured interview which asks questions on:

- knowledge of the condition, treatment and medication

- sharing in decisions

- ability to arrange and attend appointments

- understanding, monitoring, recording and managing symptoms

- managing impact of the condition on the physical, emotional and social aspects of life

- lifestyle and health.

An example of the Cue and Response Tool can be viewed here, Cue and Response Tool.pdf and an example is provided below.

The psychiatrist uses the responses to the interview to provide a score between 0–8 for each of the question categories and this is compared with the patient’s score.

Question & cue questions

Notes

Health professional’s score

Patient’s score

6. UNDERSTANDING SYMPTOM MONITORING

What are the symptoms that you observe, measure and record?
Tell me why you need to do this?

Not sleeping, tired, more cold – feet and hands, memory and concentration, increase in muscle ache

The first two steps of the 5 As model offer an alternative framework to assessing the self-management capabilities of the patient/carer.^(8,9) A guideline is offered below.

Assess (beliefs, behaviour and knowledge)

- Use a pre-visit questionnaire

- Ascertain the level of knowledge on the chronic condition

- Determine if your patient is adopting healthier behaviours

- Identify patient challenges and concerns

- Ask which self-management issues are important to discuss

Advise (provide specific information about health risks and benefits of change)

- Find out what they know first

- Provide brief but informative information without medical jargon

- Provide evidence-based information

- Have a key message for each diagnosis or symptom

- Link patient symptoms or any laboratory results to behaviour

- Consider behaviour and cultural issues

Case study – the self-management care plan interview⁽⁶⁾

Kelly’s two main illnesses are anorexia nervosa and depression. Having suffered from anorexia nervosa for eleven years she has now been diagnosed with osteoporosis, which causes significant pain. This video extract begins talking about the Partners in Health Scale questionnaire. This is a form that the patient completes either before or during the interview. The questions are the same as those on the Cue and Response Interview form. The example used in the video is question 6, Understanding Symptom Monitoring. The completed Cue and Response form is shown at the end of the video.

Dim lights Download

Psychiatrist Now I will put that aside for now. The aim of today is for you to think about what you are currently doing and that is what the questions on this form have done and for you to think about the different areas of self-management. So what I will do now, this next form is called the Cue and Response Interview. Basically it is a series of what is called cue questions which are the same questions that you have just answered there but having a conversation about them to get a bit more information. Once we have done this process we will talk about which issues on here are coming out as the most important ones for you and talk about whether you would like those things on the (self-management) care plan. What I will do is take notes and where I can I will try and use your own words because it is your process basically.

Psychiatrist Now the next few questions are around your symptoms – what happens and what you know and what you do. The first one is about your understanding of your symptom monitoring. You’ve got a few things happening that impact on each other a little bit – what are the early warning signs of symptoms for you?

Patient Not sleeping very well, feeling tired all the time or feeling more cold than normal.

Psychiatrist Do you actually feel cold?

Patient Yes, I will notice when I am becoming more unwell that I will need to wear more layers.

Patient Does that start in a particular place, the coldness, like usually your feet and hands first?

Patient Yes they are usually the worst in the cold weather. My concentration is something that usually goes pretty quickly as well and I will start to get increasing muscle aches.

Psychiatrist So there are quite a few things. So you have told me a little bit about the early warning signs but can you tell me why you need to know what’s happening with warning signs?

Patient So that I can sort of start putting strategies in place to stop myself from becoming worse.

Psychiatrist Next step now is I have given a score on each of those things and what I will do is I will now look at yours and we will compare them and we can talk about where we might agree and where we might not agree or where there might be differences in our scores and that will help to determine if there are still issues that you might want to work on. I will just enter your scores now.

Reflective exercise

Reflect on a recent interview with a patient. If you were to conduct the interview again:

References

Sevick MA, Trauth J, Ling B, Anderson R, Piatt G, Kilbourne AM, Goodman RM. Patients with complex chronic diseases: perspectives on supporting self-management. J Gen Intern Med. 2007;22(Suppl 3):438–44.
Piette JD, Schillinger D, Potter MB, Heisler M. Dimensions of patient–provider communication and diabetes self-care in an ethnically diverse population. J Gen Intern Med. 2003;18(8):624–33.
Beck RS, Daughtridge R, Sloane PD. Physician–patient communication in the primary care office: a systematic review. J Am Board Fam Pract. 2002;15(1):25–38.
National Advisory Committee on Health and Disability. Meeting the needs of people with chronic conditions. Wellington, New Zealand, 2007.
DVD ‘Recovery in Mental Health’. RANZCP Production.
Flinders Human Behaviour & Health Research Unit Self-management Program. The Flinders Model DVD.
Battersby M, Lawn S. Capabilities for supporting prevention and chronic condition self-management: a resource for educators of primary health care professionals. Flinders University, Adelaide: Australian Government Department of Health & Ageing, 2009.
Glasgow RE, Emont S, Miller DC. Assessing delivery of the five ‘As’ for patient-centered counseling. Health Promotion International 2006;21(3):245–55.
Glasgow et al, Whitlock et al. 5 A’s Behavior Change Model Adapted for Self-Management Support Improvement. 2002. Available from http://www.ihi.org/IHI/Topics/PatientCenteredCare/SelfManagementSupport/EmergingContent/5AsBehaviorChangeModel.htm

Continue to Module 3.6: Setting the Tasks