Therapeutic behavior management

Therapeutic behavior management (TBM) is a technology for creating a clinical environment that brings out the best in staff while generating the highest possible compliance outcomes for patients. The techniques and practices of TBM are derived from the field of applied behavior analysis, the term describing the scientific study of behavior.

The field of applied behavior analysis was clearly defined by Baer, Wolf, and Risley (1968).[1] Its subject matter is human behavior: why we act as we do, how we acquire habits, and how we lose them or change them, if change is needed. TBM is a branch of performance management that focuses on improving patient outcomes through improved compliance.

To understand behavior, behavior analysts use the same scientific methods that the physical sciences employ: precise definition of the behavior under study, experimentation, and consistent replication of the experimental findings. Basic research in this area has been conducted for over a century, however, applied research has been conducted only since the 1950s. Business, industrial, and government applications began in the late 1960s.

Purpose

That non-compliance represents a threat to the future of patients and providers is demonstrated by the disastrous statistics related to direct costs, over use of the system, unnecessary health service provided, and needless deaths (125,000 in the US per year).[2] Adherence to long-term therapies: evidence for action.[3] Counseling and education models developed over the years to improve patient understanding and compliance have failed to move the needle.[4] These models have been time tested and on the surface are straight forward, consistent, and logical. In spite of their clear appeal to “common sense” they are also not terribly effective.[5][6] Compliance today is about the same as it was in the middle of the 5th century and in the US it is the same as in any other first world country.

The Affordable Care Act (2010)[7] will continue to unfold and patient behavior will have a significant impact of the bottom line of care. Providers who fall below an arbitrary quality line can expect to have Medicare revenue recouped based on outcomes of care and will begin to look for ways to mitigate their risks.[8][9] Developing and implementing a well-managed TBM program targeting the 50% who are non-compliant and working with them to change their behavior may represent the best path towards reducing risk.

Origins

TBM grew out of conversations between Dr. Robert E. Wright, a registered nurse and behaviorists,[10] Aubrey Daniels, and Dr. Darnell Lattal as they looked for more efficient approaches to patient education [11] and behavior change. From their initial conversations came a dedicated approach for developing behavior based training programs. TBM became a carefully developed method for teaching this specialized branch of performance management to health services providers, patient advocates, and family members.[12]

Since behavior is common to everyone, TBM shows providers and patient educators how to most effectively influence their patient’s behavior regardless of their level of education or understanding of their disease. While we most often think of providers changing their patients’ behavior, the fact is that patients also change their providers’ behavior.[13] More fundamentally, regardless of education or status, every time we interact with others, we change and they change. Understanding this concept is central to appreciating the power we each have to change each other for good or for less than good.[14]

TBM is a technology of behavior change that has joined with patient education and advocacy that can change not only the behavior of patients, but support staff and providers as well. In most healthcare organizations patient education is a labor-intensive, highly somewhat punishing activity for the provider or patient educator and the patients.[15][16] It is an attempt to manage patient outcomes providing a sophisticated medical education. That it generally fails is evidenced by the fact that fifty percent or more of the total patient population is non-adherent to their provider’s orders.[17]

Other compliance programs

Other compliance systems and philosophies fail in comparison with TBM on two issues. First, compliance depends on the ability of providers to be fair and objective and to apply the standards of care to all patients. A significant portion of patient care is based on the provider’s judgment and memory of the individual patient’s efforts. Providers are required to pay close attention to what the patients do say and then record the observations in the plan of care. To expect that this will is generally done in any a systematic way in today’s overburdened healthcare environment is quite unrealistic. Second people are patients for a short window of time and then they are who they were for the years before they needed to use health services. Past performance is the best indicator of future performance unless there is significant behavior intervention and reinforcement of the desired behavior. Dr. Ivar Lovass famously reported in the mid 1960s that all behavior returns to baseline without reinforcement. Dr. Daniels in 2010 said, "Move the baseline." The only way to move the baseline is through positive reinforcement (e.g., TBM). "Where reinforcement goes… behavior flows." (Aubrey Daniels).[18]

Focus on behavior

Perhaps it is too much to expect that people who are otherwise unsophisticated about their biophysiology and the complexities associated with the disease process will stop to consider the effects of one course of action over another. The courts have determined that informed consent means that the patient has a clear understanding of the consequences of their behavior, both good and bad, and have made an “informed” decision of what needs to be done. Clearly with a 50% failure rate.[19] in following the doctor’s orders something in the message got lost in the behavior.

Within the last few years, the emphasis on outcomes and the targeting of reimbursement based on patient outcomes has become the focus of government based reimbursement systems. Where government payers go, the private sector is not far behind. Patient compliance has been a thing of concern dating back to the origins of the practice of medicine. Hippocrates warned colleagues in his time of the dangers of patients not following their directives or not being honest with their doctors. While science has progressed in ways totally unimaginable in the first century of modern medicine, the behavior of people has not. To quote the most famous current TV doctor, Greg House, "I don't ask why patients lie, I just assume they all do." People behave based upon the consequences of their actions. This is true of patients, staff and providers.

Emily Dickinson, almost a century before B.F. Skinner began to define the science of behavior, said "Behavior is what a man does, not what he thinks, feels or believes".[20][21] Behavior has existed since the beginning of time. The science is relatively simple. TBM proposes that applying the laws of behavior, similarly to performance management, to staff and patients can result in a measurable impact on the outcomes of patient care.[22]

References

  1. ↑ Baer, D.M., Wolf, M.M., & Risley, T.R., (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1, 91-97.
  2. ↑ Balkrishnan R, Rajagopalan R, Camacho FT, et al. Predictors of medication adherence and associated health care costs in an older population with type 2 diabetes mellitus: a longitudinal cohort study. Clin Ther. 2003;25:2958–71
  3. ↑ Geneva: World Health Organization. ISBN 92-4-154599-2
  4. ↑ Bond WS, Hussar DA. Detection methods and strategies for improving medication compliance.Am J Hosp Pharm. 1991;48:1978–88.
  5. ↑ Bartlett EE, Grayson M, Barker R, et al. The effects of physician communications skills on patient satisfaction; recall, and adherence. J Chronic Dis. 1984;37:755–64.
  6. ↑ Berghofer G, Schmidl F, Rudas S, et al. Predictors of treatment discontinuity in outpatient mental health care. Soc Psychiatry Psychiatr Epidemiol. 2002;37:276–82. [PubMed]
  7. ↑ Pub.L. 111–148, 124 Stat. 119, to be codified as amended at scattered sections of the Internal Revenue Code and in 42 U.S.C.
  8. ↑ http://jefflcohen.wordpress.com/2013/01/18/what-you-need-to-know-about-the-physician-feedback value-based-payment-modifier-program/
  9. ↑ http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Physician Feedback Program/Background.html
  10. ↑ http://www.bearstherapy.com
  11. ↑ Peter R. Kongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001, page 788 ISBN 0-8342-1726-0
  12. ↑ Horne R, Weinman J. Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res. 1999;47:555–67.
  13. ↑ Hooper, E.M., Comstock, L.M., Goodwin, J. M., & Goodwin, J. M., Patient Characteristics that Influence Physician Behavior. Medical Care, June 1982; 20:630-638.
  14. ↑ Kohlenberg, R.J.; Bolling, M.Y.; Kanter, J.W.; Parker, C.R. (2002). "Clinical behavior analysis: Where it went wrong, how it was made good again, and why its future is so bright". The Behavior Analyst Today 3: 248–53. ISSN 1539-4352.
  15. ↑ London, F. (2009). No Time To Teach: The Essence of Patient and Family Education for Health Care Providers. Atlanta: Pritchett & Hull
  16. ↑ Bastable, S.B, Grambet, P., Jacobs, K., Sopczyk, D.L. (2011). Health professionals as educator: Principles of teaching and learning. Sudbury, MA: Jones & Bartlett Learning, LLC.
  17. ↑ DiMatteo, M. R. Patient adherence to pharmacotherapy: the importance of effective communication. Formulary. 1995;30:596–8. 601–2, 605.
  18. ↑ Bringing out the Best in People, Aubrey C. Daniels. McGraw-Hill; 2nd edition. 1999. ISBN 978-0071351454
  19. ↑ DiMatteo M. R., Patient adherence to pharmacotherapy: the importance of effective communication. Formulary. 1995;30:596–8. 601–2, 605.
  20. ↑ http://www.goodreads.com/quotes/123695-behavior-is-what-a-man-does-not-what-he-thinks
  21. ↑ Skinner, B. F., (1953) Science and Human Behavior. New York, MacMillan
  22. ↑ Managing for Performance, Alasdair A. K. White. Piatkus Books, 1995.

See also


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