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We’ve all experienced them in our clinics: Patients that show up for an appointment or two, then stop coming. Patients that achieve quick results, see great change in their lives, then fall back and lose all their gains. Patients that call to schedule an appointment, then never show up. Prospective patients who call to inquire about our treatment options, then never call back.

What gives?

Well, often it seems these patients stop coming, drop off treatment, or never call back because they “don’t see the need”. They feel that they can “do this at home” or “don’t need to do therapy.” While this can be a result of poor patient experiences, an overlooked factor is that patient’s readiness to change.

Think about it. Therapy treatments require patients to make real and challenging behavioral changes. Whether the patient is receiving treatment for a rotator cuff surgery, plantar fasciitis, weight loss, or wellness, participating in treatment challenges patients to change their activities, posture, habits, etc. And those changes are hard.

As I’ll argue below, a clinician’s main role involves guiding patients through a series of behavioral changes. Understanding the principles of behavioral change can greatly impact a clinic’s ability to retain patients, help patients achieve their goals, and attract new patients.

Is it really all about change?

Behavioral change plays a role in at least three patient-facing areas of any therapy practice or clinic:

  1. Acquiring new patients
  2. Retaining current patients
  3. Treating and helping patients achieve their goals

Let’s start with the first one: acquiring patients. Many times, outpatient therapy clinics feel that acquiring new patients depends on developing relationships with referring physician groups or workman’s comp organizations. While this does play a role in producing a steady stream of referrals for most outpatient practices, the world is changing. Today, more patients take an active role in selecting their healthcare providers. They use sites like Health Grades to screen potential providers, read —and sometimes write— reviews, and “shop” around for their healthcare provider. Understanding the principles and stages of behavioral change helps clinics and clinicians communicate with these prospective patients, nurture relationships, and become the provider that the patient chooses when they’re ready to seek treatment.

Arguably as important —if not more— as acquiring new patients is retaining current patients. As I’ve written about here, patient retention greatly impacts a clinic’s bottom line. Retaining current patients is often much more cost-effective than acquiring new ones. Again, initial patient experiences with staff and the clinic affect patient retention. But some negative experiences stem from staff and clinicians not understanding where a patient may be on the path towards change.

Maybe a patient books an appointment for back pain, knowing —at least in their mind— that your treatment can help. They aren’t necessarily sure that you’re the right fit, that you understand their situation, or even that they themselves are truly ready to commit to a specific clinician or treatment plan. If the clinician dives right into treatment planning and exercise prescriptions, odds are that patient walks out the door and doesn’t come back.

The last point often gets the most attention from clinical staff. The actual treating of patients and working with them towards their own goals occupies much if our time. But here, too, clinicians need to have a solid grasp of the elements and stages of behavioral change. If you are treating patient with chronic back or knee pain, and you and the patient have both identified that weight loss will make a large impact on their daily pain, you need to be able to guide them through establishing healthy behaviors to help them reach their goals. To do that, you need to understand where they are on the “circle of change” and how to guide them through to completion.

If done right, and these patients make great progress towards their goals, these patients can become great referral sources (helping you with area 1). They will also likely continue with their course of treatment, and be more willing to come back to your clinic if/when another problem surfaces (helping you with area 2).

Elements of Behavioral Change

Assuming you’re still on board with the idea that a main role of a clinic or healthcare organization is facilitating behavior change, a question arises: Where do you begin? You need to start by understanding the three most important elements in changing behavior [1]:

  • Readiness
  • Barriers
  • Relapse

To successfully alter behavior, the subject must possess the resources, knowledge, and desire to make a change (readiness). Barriers (or potential barriers) need to be identified and addressed. And, to maintain that new behavior, we need to understand what factors may cause a reversion in behavior.

On the surface, that may sound a bit intimidating. There are a lot of factors at play. Is the patient/client ready to change? Do they understand potential barriers or speed-bumps to their change? Are they at risk for relapse? Luckily, understanding the stages of change helps break down each step in the change cycle. It also helps clinics and clinicians gauge where a particular patient is along the path to change, and better understand how to communicate and meet them at their particular stage.

If a clinic or clinician understands where a particular patient or prospective patient is on their change path, they find it easier to affect real, lasting change. This can be influencing positive health behaviors, or it could be getting a prospective patient to pick up the phone and make an appointment.

The Circle of Change

After understanding the elements of change, the next step involves applying that knowledge to a framework for affecting change. Enter the circle of change. Now, this idea has been used in every area from social work to public health initiatives. It’s based on the transtheoretical model of change [2]. The image below illustrates this model of affecting change.

Transtheoretical Model of Change

Around the circle, lie 6 phases or stages:

  •  Precontemplation
  •  Contemplation
  •  Planning
  •  Action
  •  Maintenance
  • Termination or Relapse

Each phase represents a specific point along the path to change. Patients and prospective patients all fall somewhere around this circle. Our job as clinicians and clinic owners is to understand where a particular patient or prospective patient sits and then communicating in the most effective way to reach that individual at that particular stage or phase.

The Transtheoretical Model

Also referred to as the Stages of Change Model, the Transtheoretical Model was developed in the late 1970s through research and study about smokers who quit on their own vs those requiring additional treatments [2]. It is not a theory, but a model that focuses on the decision-making of an individual and intentional change.

The transtheoretical model makes one major assumption: people do not make changes to behaviors quickly or decisively [2]. Instead, the transtheoretical model posits that people make changes to their behaviors —especially habitual behaviors— in a continuous, cyclical process. It breaks this process into the six stages mentioned above, and shown around the circle in the image.

The 6 Stages of Change

Let’s take a look at the 6 stages of change described by the transtheoretical model and the characteristics of each [2].

Precontemplation comes first. People in this stage do not intend to take any action or make any change in the immediate future (generally within the next 6 months). If a need for change exists (dysfunction, problem behaviors, etc), people in this stage often do not recognize that their behavior is problematic or has negative affects. People in this stage also tend to underestimate the benefits of changing behavior, and generally overestimate the discomfort, difficulty, or cons of making that change.

Next, comes the Contemplation stage. People in this stage now intend to make a change or take action in the immediate future (within 6 months). If there is a need for change due to problematic or negative behaviors or activities, people in this stage recognize that. They also take more realistic view of the pros and cons of making the change, usually with an equal or balanced emphasis on both the positive and negatives. Despite this, people in this stage sometimes still feel uncertain or undecided about change.

Determination follows the contemplation stage. This stage is referred to as Preparation or Planning. People in this stage are ready to take action, usually within the next 30 days or so. They may take smaller steps towards that change, and believe that making that change will be an overall positive to their life.

Action comes next. People in this stage make the leap to alter their behavior or make a change. They intend to keep moving forward with this change. This may involve modifying the problem behavior or acquiring new habits or behaviors to replace it.

After someone changes or modifies a behavior, some sort of Maintenance must be enacted to prevent relapse. People in this stage have sustained a given change for at least 6 months. They intend to maintain this change going into the future. People in this stage work to prevent relapse or reversion to the previous behavior.

Next, two outcomes exist: Termination or Relapse. If the person falls back into previous patterns or into the same old habit, they relapse. If the behavior change is successful, the person transitions through to termination. People who have progressed this far in the behavioral change cycle have no desire to return to old habits or behaviors. They are also sure that they will not relapse. Termination is rarely met, and most people end up staying in the maintenance stage.

It must also be noted that, as the image illustrates, people can enter and exit the circle of change at any of the stages. For example, a smoker who quit smoking, reached maintenance, then began smoking again may not necessarily need to go through precontemplation or contemplation. They may jump right into planning/determination or even action.

Processes of Change

To progress through each stage of change, people can use different strategies or processes. There are ten stages that have been identified, with some being more effective at different stages of change. Learning these processes can help clinicians develop strategies to both assist patients in making changes and in marketing to potential patients.

Below are the 10 stages [2]:

  • Consciousness Raising:
    • This involves increasing awareness of the benefits of the desired change
  • Dramatic Relief:
    • This involves stimulating some kind of emotional arousal or stimulation about the desired change
  • Self-Reevaluation:
    • The person making the change completes some self-appraisal to determine whether the change is part of who they want to be
  • Environmental Reevaluation:
    • The person observes their social connections or environment to see how their change, or lack of change, affects those around them
  • Social Liberation:
    • For this process, social proof is used to show the person making the change (or considering change) that society is supportive of the change-
  • Self-Liberation:
    • Through this process, the person becomes committed to change by believing that change truly is possible
  • Helping Relationships:
    • Using supporting relationships with people who encourage the desired change
  • Counter-Conditioning:
    • The person substitutes healthy or desired behaviors and thoughts for unhealthy behaviors and thoughts
  • Reinforcement Management:
    • This involves rewarding desired behavior and reducing any perceived rewards that come from the negative or undesired behavior
  • Stimulus Control:
    • The person redesigns or modifies their environment to cue and reinforce the desired behavior and remove any cues or prompts for the undesired behavior

Some of these processes or strategies work better in certain stages of change. For example, when marketing to prospective patients, it may be more effective to utilize a strategy that involves consciousness raising and/or dramatic relief. Strategies based on those two processes can influence a potential patient to make initial contact with you clinic to inquire about services, accept a free consultation, or even schedule an initial appointment.

It just takes a little bit of thinking to determine who you are trying to communicate with, where on the circle of change they are most likely to be, and then using the best strategy from the list above to motivate that person towards the desired action or behavior change.

How Behavioral Change Affects Clinical Practice

Now, all of this information is well and good, but how can we apply it to clinical practice? To answer that, let’s revisit an idea from the beginning of this article: the main role of a clinic or clinician is to help guide a patient (or prospective patient) through a series of behavioral changes. Whether it is educating a patient about healthy lifestyle choices, influencing a patient to complete their home exercises, modifying a work or leisure task to prevent injury, or simply convincing them to make an appointment, clinicians are in the behavioral change business.

Since clinics and clinicians are ultimately change agents, it stands to reason that a practical understanding of behavioral change exists at the clinic or organization. Individual clinicians should be trained on the principles of behavior change and how to facilitate that on behalf of their patients. This helps those clinicians have a real and meaningful impact on their patients’ lives.

Two good examples of how this understanding of behavioral change affects clinical practice are initial assessment or interviews and patient education. Taking a behavioral change approach to an initial assessment means that the clinician implements techniques like motivational interviewing that help guide a patient to identifying and committing to some change. With patient education, clinicians need to understand what stage of change a patient is in in order to effectively both communicate the value of the services they provide and motivate that patient to make the necessary changes.

Motivational Interviewing

Here is the definition of motivational interviewing: “Motivational interviewing (MI) is a client-centered, directive therapeutic style to enhance readiness for change by helping clients explore and resolve ambivalence.” [5] At its core, motivational interviewing focuses on moving patients towards change. It is a person-centered counseling approach that gets the patient to explore their own motivations and resistance to change. Motivational interviewing helps patients identify what they really want and explore how their current behavior or situations are either helping or hindering them in achieving those goals.

A clinic that understands the principles of behavioral change are able to use the initial appointment and interview to fully explore a patient’s desires and goals for treatment. This results in the patient feeling valued and listened to, and —more importantly— results in the patient being more actively engaged in treatment. This means that patient is more likely to attend their appointments, adhere to home programs, and complete their plan of care. This helps the patient reach their goals and achieve the outcomes they want, and it also helps the clinic financially as well. Engaged patients generally complete their plans of care and save their clinical providers the headaches of no-shows, cancellations, and noncompliance.

Patient Education

As I’ll describe a bit further down, the clinicians play three distinct roles in the behavior change process: educating, inspiring/motivating, and reassuring. All three of these roles come into play when providing patient education. For example, as I’ve written about here, how we provide information or education to patients can affect clinical outcomes, patient experience, and engagement.

By understanding where someone is on the circle of change, what stage they are at, clinicians can better tailor the education they provide patients. For example, let’s say a patient is being seen for low back pain and the clinician identifies that weight loss would be a beneficial step in managing it. If the clinician simply educates the patient on the affect of being overweight and how it influences back pain and then encourages the patient to lose weight, is that really effective? Will that patient be more likely to take that advice to heart? I’d say that there is probably evidence out there to show that is not the case.

Role of the Clinician For ChangeWhat if instead, the clinician explored the factors affecting low back pain with the patient and then identified weight loss as one of the most important factors? The clinician then used motivational interviewing techniques to guide the patient to discovering their goal (to decrease back pain etc) and how their current behaviors were impeding their progress. The patient and the clinician both brainstorm together about different strategies to help lose some weight, different exercises that can be completed, and a treatment plan that will likely help the patient achieve those goals. Is that patient more likely to follow the recommendation to lose weight? I definitely think they’d be more actively involved and engaged in reaching that goal, especially if along the way that clinician was there to help motivate and reassure the patient as obstacles and barriers presented themselves.

The Impact on Business & Growth

Now understanding this framework for change also can help clinics acquire new patients and grow their businesses. Above, I wrote that the main role of a clinic is to educate, inspire/motivate, and reassure patients. This is an idea that Blair Enns from Win Without Pitching talks about a lot on the business development (marketing/selling) side of things. He posits that the main role of a salesperson or marketer is to educate the unaware, inspire the motivated, and reassure the intent. He says by following this framework, business can guide a prospective customer —or in our case, patient— from being unaware of their problem to purchasing a product or service. In our case, that may be booking an initial appointment or attending a wellness class or the like.

Precontemplation

So how would this work for clinicians? Well the basic principles remain the same, and they each correlate to where a patient or prospective patient may be on the circle of change. For example, a patient may be experiencing shoulder pain or limitations, but feel that it may just be old age, stiffness, etc. This patient would be in the precontemplation stage of behavior change. They aren’t necessarily aware that there may be an underlying cause of their shoulder discomfort. A clinic that specializes in treating shoulders may create educational content (videos, blogs, etc) that detail common causes or factors that may influence shoulder pain. They may provide online tools or resources that help guide that prospective patient from being unaware of their problem through the contemplation and planning stages of change.

Planning & Determination

Once a prospective patient has reached the planning or determination stage, perhaps they opt in to receive a free report from that clinic’s site, or schedule a free phone consultation. Once the patient takes this step, the clinic then must change the communication strategy. No longer do they provide this prospective patient with educational material. Now, they focus on painting a picture of what life without shoulder pain could be like. They also provide testimonials, case studies, and social proof. The patient then moves to the action stage of change, perhaps by scheduling an initial assessment/appointment.

Action & Maintenance

Once the prospective patient takes the leap to become a patient and schedules their first appointment, the communication strategy again changes. At this first appointment, the clinic must not only provide a competent and evidence-based assessment, they must also take time to reassure the patient that continuing treatment will help them achieve their goal of a pain-free shoulder.

The reality is, once someone takes action (or decides to purchase), they immediately begin to feel doubts and/or regrets. Call it buyer’s remorse, but their mind begins to run through the many reasons why this service or treatment may not work. If these concerns are not addressed at the first appointment, that patient may continue to dwell on them, begin to cancel appointments, and maybe even fall off the schedule altogether.  A clinic that understands this is able to provide the reassurance that this patient needs when they come into that initial appointment.

From there, the clinician will likely need to move between education, inspiration, an reassurance throughout the treatment process and plan of care. Once a patient reaches one milestone, education takes place about the next. This may also involve having to motivate and reassure the patient to take that next step. This process continues until the patient has met their goal, has returned to baseline, or has plateaued in their progress.

Summary

Clinicians are in the change business. We help guide our patients and prospective patients from a place of unawareness through to achieving their goals and improving their health and function. This requires a deep understanding of the process of behavioral change and how it impacts patient acquisition, patient education, treatment planning, and patient retention.

Clinics that understand the process of behavioral change and are able to modify their communication and treatment strategies to meet each patient where they are on the circle of change may find improved clinical outcomes, higher patient engagement levels, and higher retention rates. It will also help them in marketing to prospective patients and acquiring new patients. And between improving patient retention and increasing new patient acquisition, those clinics may noticed improved financial metrics as well.

Does your clinic implement some of the principles of behavioral change in your practice? Share any additional resources that you found helpful in the comments below!

For more informational reads, check out our Blog to see all the articles we’ve published to date. Click here to head over to our resources section and check out our variety of clinical and professional resources aimed at increasing your knowledge and skills. If you’d like to make some changes in your clinic or health center, and would like some help, check out our consulting and advisement services or contact us to see how we can help you break out of the norm and provide a truly impactful patient experience.

Rafael E. Salazar II, MHS, OTR/L is the president and CEO of Rehab U Practice Solutions. He has experience in a variety of rehab settings, working with patients recovering from a variety of injuries and surgeries. He worked as the lead clinician in an outpatient specialty clinic at his local VA Medical center. He also has experience as an adjunct faculty instructor at Augusta University’s Occupational Therapy Program, as a Licensed Board Member on the GA State OT Board, has served on several committees for the national OT Board (NBCOT), and as a consultant working for the State of Georgia’s DBHDD. He is also on the Board of Directors for NBCOT. He works to help healthcare clinics and organizations deliver uniquely impactful patient experiences by improving service delivery through training & advisement.

Read his full bio Here. Read about Rehab U Here.

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References

[1] Cherry, K. (2019, April 06). The 6 Stages of Behavior Change. Retrieved from https://www.verywellmind.com/the-stages-of-change-2794868

[2] Behavioral Change Models. (n.d.). Retrieved from http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories6.html

[3] Marcus, B. H., Banspach, S. W., Lefebvre, R. C., Rossi, J. S., Carleton, R. A., & Abrams, D. B. (1992). Using the Stages of Change Model to Increase the Adoption of Physical Activity among Community Participants. American Journal of Health Promotion, 6(6), 424-429. doi:10.4278/0890-1171-6.6.424

[4] Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational Interviewing. Annual Review of Clinical Psychology, 1(1), 91-111. doi:10.1146/annurev.clinpsy.1.102803.143833