Brief action planning to facilitate behavior change and support patient self-management

Abstract

• Objective: To describe Brief Action Planning (BAP), a structured, stepped-care self-management support technique for chronic illness care and disease prevention. • Methods: A review of the theory and research supporting BAP and the questions and skills that comprise the technique with provision of a clinical example. • Results: BAP facilitates goal setting and action planning to build self-efficacy for behavior change. It is grounded in the principles and practice of Motivational Interviewing and evidence-based constructs from the behavior change literature. Comprised of a series of 3 questions and 5 skills, BAP can be implemented by medical teams to help meet the self-management support objectives of the Patient-Centered Medical Home. • Conclusion: BAP is a useful self-management support technique for busy medical practices to promote health behavior change and build patient self-efficacy for improved long-term clinical outcomes in chronic illness care and disease prevention.

Full text

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ABSTRACT
s Objective: 4O DESCRIBE "RIEF !CTION 0LANNING "!0
ASTRUCTURED STEPPEDCARESELFMANAGEMENTSUPPORT
TECHNIQUEFORCHRONICILLNESSCAREANDDISEASEPREVEN
TION
s Methods: !REVIEWOFTHETHEORYANDRESEARCHSUPPORT
ING"!0ANDTHEQUESTIONSANDSKILLSTHATCOMPRISETHE
TECHNIQUEWITHPROVISIONOFACLINICALEXAMPLE
s Results: "!0FACILITATES GOALSETTINGANDACTIONPLAN
NING TO BUILD SELFEFFICACY FOR BEHAVIOR CHANGE )T IS
GROUNDEDINTHEPRINCIPLESANDPRACTICEOF-OTIVATIONAL
)NTERVIEWINGANDEVIDENCEBASEDCONSTRUCTSFROMTHE
BEHAVIORCHANGELITERATURE#OMPRISEDOF A SERIES OF
 QUESTIONS AND  SKILLS "!0 CAN BE IMPLEMENTED
BYMEDICALTEAMS TOHELPMEETTHESELFMANAGEMENT
SUPPORT OBJECTIVES OF THE 0ATIENT#ENTERED -EDICAL
(OME
s Conclusion: "!0 IS A USEFUL SELFMANAGEMENT SUP
PORTTECHNIQUEFORBUSYMEDICALPRACTICESTOPROMOTE
HEALTHBEHAVIORCHANGEANDBUILDPATIENTSELFEFFICACY
FOR IMPROVED LONGTERM CLINICAL OUTCOMES IN CHRONIC
ILLNESSCAREANDDISEASEPREVENTION
Chronic disease is prevalent and time consuming,
challenging, and expensive to manage [1]. Half
of all adult primary care patients have more than
2 chronic diseases, and 75% of US health care dollars
are spent on chronic illness care [2]. Given the health
and financial impact of chronic disease, and recogniz-
ing that patients make daily decisions that affect disease
control, efforts are needed to assist and empower patients
to actively self-manage health behaviors that influence
chronic illness outcomes. Patients who are supported
to actively self-manage their own chronic illnesses have
fewer symptoms, improved quality of life, and lower use
of health care resources [3]. Historically, providers have
tried to influence chronic illness self-management by
advising behavior change (eg, smoking cessation, exer-
cise) or telling patients to take medications; yet clinicians
often become frustrated when patients do not “adhere”
to their professional advice [4,5]. Many times, patients
want to make changes that will improve their health but
need support—commonly known as self-management
support—to be successful.
Involving patients in decision making, emphasizing
problem solving, setting goals, creating action plans (ie,
when, where and how to enact a goal-directed behavior),
and following up on goals are key features of successful
self-management support methods [3,6–8]. Multiple
approaches from the behavioral change literature, such
as the 5 A’s (Assess, Advise, Agree, Assist, Arrange) [9],
Motivational Interviewing (MI), and chronic disease self-
management programs [10] have been used to provide
more effective guidance for patients and their caregivers.
However, the practicalities of these approaches in clinical
settings have been questioned. The 5A’s, a counseling
framework that is used to guide providers in health be-
havior change counseling, can feel overwhelming because
it encompasses several different aspects of counseling
[11,12]. Likewise, MI and adaptations of MI, which have
been shown to outperform traditional “advice giving”
in treatment of a broad range of behaviors and chronic
conditions [13–16], have been critiqued since fidelity to
Brief Action Planning to Facilitate
Behavior Change and Support Patient Self-
Management
Damara Gutnick, MD, Kathy Reims, MD, Connie Davis, MN, ARNP, Heather Gainforth, PhD, Melanie Jay, MD, MS,
and Steven Cole, MD
REPORTS FROM THE FIELD
From the New York University School of Medicine, New York,
NY (Drs. Gutnick and Jay), University of Colorado Health
Sciences Center, Denver, CO (Dr. Reims), University of Brit-
ish Columbia, BC, Canada (Dr. Davis), University College
London, London, UK (Dr. Gainforth), and Stonybrook
University School of Medicine, Stonybrook, NY (Dr. Cole
[Emeritus]).

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January 2014 Vol. 21, No. 1
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BRIEF ACTION PLANNING
this approach often involves multiple sessions of training,
practice, and feedback to achieve prof iciency [15,17,18].
Finally, while chronic disease self-management programs
have been shown to be effective when used by peers in
the community [10], similar results in primary care are
not well established.
Given the challenges of providers practicing, learning,
and using each of these approaches, efforts to develop
an approach that supports patients to make behavioral
changes that can be implemented in typical practice set-
tings are needed. In addition, health delivery systems are
transforming to team-based models with emphasis on
leveraging each team member’s expertise and licensure
[19]. In acknowledgement of these evolving practice
realities, the National Committee for Quality Assurance
(NCQA) included development and documentation of
patient self-management plans and goals as a critical fac-
tor for achieving NCQA Patient-Centered Medical Home
(PCMH) recognition [20]. Successful PCMH transforma-
tion therefore entails clinical practices developing effective
and time eff icient ways to incorporate self-management
support strategies, a new service for many, into their care
delivery systems often without additional staffing.
In this paper, we describe an evidence-informed, ef ficient
self-management support technique called Brief Action
Planning (BAP) [21–24]. BAP evolved into its current form
through ongoing collaborative efforts of 4 of the authors
(SC, DG, CD, KR) and is based on a foundation of original
work by Steven Cole with contributions from Mary Cole in
2002 [25]. This technique addresses many of the barriers
providers have cited to providing self-management support,
as it can be used routinely by both individual providers and
health care teams to facilitate patient-centered goal setting
and action planning. BAP integrates principles and practice
of MI with goal setting and action planning concepts from
the self-management support, self-efficacy, and behavior
change literature. In addition to reviewing the principles
and theory that inform BAP, we introduce the steps of BAP
and discuss practical considerations for incorporating BAP
into clinical practice. In particular, we include suggestions
about how BAP can be used in team-based clinical practice
settings within the PCMH. Finally, we present a common
clinical scenario to demonstrate BA P and provide resource
links to online videos of BAP encounters. Throughout the
paper, we use the word “clinician” to refer to professionals
or other trained personnel using BAP, and “patient” to refer
to those experiencing BAP, recognizing that other terms
may be preferred in different settings.
What is BAP?
BAP is a highly structured, stepped-care, self-management
support technique. Composed of a series of 3 ques-
tions and 5 skills (reviewed in detail below), BAP can
be used to facilitate goal setting and action planning to
build self-efficacy in chronic illness management and
disease prevention [21–24]. The overall goal of BAP
is to assist an individual to create an action plan for a
self-management behavior that they feel confident that
they can achieve. BAP is currently being used in diverse
care settings including primary care, home health care,
rehabilitation, mental health and public health to assist
and empower patients to self-manage chronic illnesses
and disabilities including diabetes, depression, spinal
cord injury, arthritis, and hypertension. BAP is also
being used to assist patients to develop action plans for
disease prevention. For example, the Bellevue Hospital
Personalized Prevention clinic, a pilot clinic that uses a
mathematical model [26] to help patients and providers
collaboratively prioritize prevention focus and strate-
gies, systematically utilizes BAP as its self-management
support technique for patient-centered action planning.
At this time, BAP has been incorporated into teaching
curriculums at multiple medical schools, presented at
major national health care/academic conferences and is
being increasingly integrated into health delivery systems
across the United States and Canada to support patient
self-management for NCQA-PCMH transformation. We
have also developed a series of standardized programing
to support fidelity in BAP skills development including a
multidisciplinary introductory training curriculum, tel-
ephonic coaching, interactive web-based training tools,
and a structured “Train the Trainer” curriculum [27]. In
addition, a set of guidelines designed to ensure f idelity in
BAP research has been developed [27].
Underlying Principles of BAP
BAP is grounded in the principles and practice of MI
and the psychology of behavior change. Within behavior
change, we draw primarily on self-efficacy and action
planning theory and research. We discuss the key con-
cepts in detail below.
The Spirit of MI
MI Spirit (Compassion, Acceptance, Partnership and
Evocation) is an important overarching tenet for BAP.
Compassionately supporting self-management with MI
spirit involves a partnership with the patient rather than

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a prescription for change and the assurance that the
clinician has the patients best interest always in mind
(Compassion) [17]. Exemplifying “spirit” accepts that
the ultimate choice to change is the patient’s alone (Ac-
ceptance) and acknowledges that individuals bring exper-
tise about themselves and their lives to the conversation
(Evocation). Adherence to “MI spirit” itself has been
associated with positive behavior change outcomes in
patients [5,28–32]. Demonstrating MI spirit through-
out the change conversation is an essential foundational
principle of BAP.
Action Planning and Self-Efficacy
In addition to the spirit of MI, BAP integrates 2
evidence-based constructs from the behavior change
literature: action planning and self-efficacy [4,6,33 –36].
Action planning requires that individuals specify when,
where and how to enact a goal-directed behavior (eg,
self-management behaviors). Action planning has been
shown to mediate the intention-behavior relationship
thereby increasing the likelihood that an individual’s in-
tentions will lead to behavior change [37,38]. Given the
demonstrated potential of action planning for ensuring
individuals achieve their health goals, the BAP frame-
work aspires to assist patients to create an action plan.
BAP also aims to build patients’ self-efficacy to enact
the goals outlined in their action plans. Self-efficacy refers
to a patient’s confidence in their ability to enact a behav-
ior [33]. Several reviews of the literature have suggested
a strong relationship between self-efficacy and adoption
of healthy behaviors such as smoking cessation, weight
control, contraception, alcohol abuse and physical activity
[39–42]. Furthermore, Lorig et al demonstrated that the
process of action planning itself contributes to enhanced
self-efficacy [8]. BAP aims to build self-efficacy and ul-
timately change patients’ behaviors by helping patients to
set an action plan that they feel confident in their ability
to achieve.
Description of the BAP Steps
The f lowchart in Figure 1 presents an overview of the
key elements of BAP. An example dialogue illustrating
the steps of BAP can be found in Figure 2.
Three questions and 3 of the BAP skills (ie, SMART
plan, eliciting a commitment statement, and follow-up)
are applied during every BAP interaction, while 2 skills
(ie, behavioral menu and problem solving for low confi-
dence) are used as needed. The distinct functions and the
evidence supporting the 3 questions and 5 BAP skills are
described below.
Question 1: Eliciting a Behavioral Focus or Goal
Once engagement has been established and the clinician
determines the patient is ready for self-management plan-
ning to occur, the first question of BAP can be asked:
“Is there anything you would like to do for your
health in the next week or two?”
This question elicits
a person’s interest in self-management or behavior change
and encourages the individual to view himself/herself as
someone engaged in his or her health. The powerful link
between consistency of word and action facilitates devel-
opment and commitment to change the behavior of focus
[43]. In some settings a broader question such as
“Is
there anything you would like to do about your current
situation in the next week or two?”
may be a better fit,
or referring to a more specific question may flow more
naturally from the conversation such as
“We’ve been
talking about diabetes, is there anything you would like
to do for that or anything else in the next week or two?”
Although technically Question 1 is a closed-ended
question (in that it can be answered “yes” or “no”), in
actual practice it generates productive discussions about
change. For example, whenever a patient answers “yes”
or “no” or something in-between like, “I’m not sure,”
the clinician can often smoothly transition to a dialogue
about change based on that response. Responses to
Question 1 generally take 3 forms (Figure 1):
1) Have an Idea. A group of patients immediately
present an idea that they are ready to do or are ready
to consider doing. For these patients, clinicians can
proceed directly to Skill 2—SMART Behavioral
Planning; that is, asking patients directly if they are
ready to turn their idea into a concrete plan. Some
evidence suggests that further discussion, assess-
ment, or even additional "motivational" exploration
in patients who are ready to make a plan and already
have an idea may actually decrease motivation for
change [17, 32].
2) Not Sure. Another group of patients may want or
need suggestions before committing to something
specific they want to work on. For these patients,
clinicians should use the opportunity to offer a
Behavioral Menu (Skill 1).
3) No or Not at This Time. A third group of patients
may not be interested or ready to make a change at this
time or at all. Some in this group may be healthy or
REPORTS FROM THE FIELD

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BRIEF ACTION PLANNING
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already self-managing effectively and have no need
to make a plan, in which case the clinician acknowl-
edges their active self-management and moves to
the next part of the visit. Others in this group
may have considerable ambivalence about change
or face complex situations where other priorities
take precedence. Clinicians frequently label these
individuals as "resistant." The Spirit of MI can be
very useful when working with these patients to ac-
cept and respect their autonomy while encouraging
ongoing partnership at a future time. For ex-
ample, a clinician may say
“It sounds like you are
not interested in making a plan for your health
right now. Would it be OK if I ask you about this
again at our next visit?”
Pushing forward to make
a "plan for change" when a patient is not ready
decreases both motivation for change as well as the
likelihood for a successful outcome [32].
Other patients may benefit from additional motiva-
tional approaches to further explore change and ambiva-
lence. If the clinician does not have these skills, patients
may be seamlessly transitioned to another resource
within or external to the care team.
Skill 1: Offering a Behavioral Menu
If in response to Question 1 an individual is unable
to come up with an idea of their own or needs more
information, then offering a Behavioral Menu may be
helpful [44,45]. Consistent with the “Spirit of MI,” BAP
attempts to elicit ideas from the individual themselves;
however, it is important to recognize that some people
require assistance to identify possible actions. A behav-
ioral menu is comprised of 2 or 3 suggestions or ideas
that will ideally trigger individuals to discover an idea of
their own. There are 3 distinct evidence-based steps to
follow when presenting a Behavioral Menu.
1) Ask permission to offer a behavioral menu. Asking
permission to share ideas respects patient autonomy
and prevents the provider from inadvertently assum-
ing an expert role. For example:
“Would it be OK if
I shared with you some examples of what some other
patients I work with have done?”
2) Offer 2 to 3 general yet varied ideas all at once
(Figure 2, entry 5). It helps to mention things
that other patients have decided to do with some
success. Using this approach avoids the clinician
assuming too much about the patient or allowing
the patient to reject the ideas. It is important to
remember that the list is to prompt ideas, not to
find a perfect solution [17]. For example:
“One
patient I work with decided to join a gym and
start exercising, another decided to pick up an old
hobby he used to enjoy doing and another patient
decided to schedule some time with a friend she
hadn’t seen in a while.”
3) Ask if any of the ideas appeal to the individual as
something that might work for them or if the pa-
tient has an idea of his/her own (Figure 2, entry
5). Evocation from the Spirit of MI is built in wit h
this prompt [17]. For example:
“These are some
ideas that have worked for other patients I work
with, do they trigger any ideas that might work
for you?”
Clinicians may find it helpful to use visual prompts
to guide Behavioral Menu conversations [44]. Diagrams
with equally weighted spaces assist clinicians to resist
prioritizing as might happen in a list. Empty circles
alongside circles containing varied options evoke patient
ideas, consistent with the Spirit of MI (Figure 3, Visual
Behavioral Menu Example) [44].
Skill 2: SMART Planning
Once an individual decides on an area of focus, the clini-
cian partners with the patient to clarify the details and
create an action plan to achieve their goal. Given that indi-
viduals are more likely to successfully achieve goals that are
specific, proximal, and achievable as opposed to vague and
distal [46,47], the clinician works with patient to ensure
that the patient’s goal is
SMART
(specific, measurable,
achievable, relevant and time-bound). The term
SMART
has its roots in the business management literature [48] as
an adaptation of Locke’s pioneering research (1968) on
goal setting and motivation [49]. In particular, Locke and
Latham’s theory of Goal Setting and Task Performance,
states that “specif ic and achievable” goals are more likely
to be successfully reached [47,50].
We suggest helping the patient to make smart goals by
eliciting answers to questions applicable to the plan, such
as “what?” “where?” “when?” “how long?” “how often?”
“how much?” and “when will you start?” [51]. A resulting
plan might be
“I will walk for 20 minutes, in my neighbor-
hood, every Monday, Wednesday and Friday before dinner.”
Skill 3: Elicit a Commitment Statement
Once the individual has developed a specific plan, the next
step of BAP is for the clinician to ask him or her to “tell
REPORTS FROM THE FIELD

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BRIEF ACTION PLANNING
Mrs. Brown is a 64-year-old woman with obesity, poorly controlled diabetes, hypertension and depression.
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MEMBERSHIPEVERYMONTHANDJUSTNEVERMAKEITTHERE)TSTIMETHAT)
STARTGOING
9$R 3OMEPEOPLEFINDITHELPSTOGETREALLYSPECIFICABOUTTHEIRPLANWHAT
DOYOUTHINKABOUTTHAT
3PIRITOF-)ACCEPTANCE
 0T 3URE
11 $R 7HENWOULDYOULIKETOSTAR TGOING
 0T )THINK)CANGOTOMORROW
13 $R 4HATgSGREAT7HATTIME
 0T $EFINITELYINTHEMORNINGLETSSAYAM
 $R 7ONDERFUL(OWLONGWILLYOUSTAYANDWHATWILLYOUDOWHILEYOUARE
THERE
16 0T )CANSTAYFORANHOURANDTAKEAZUMBACLASS)REALLYLOVEZUMBAAND
HAVENTGONEINMORETHANAYEAR
 $R 4HATSOUNDSLIKEFUN(OWFREQUENTLYDOYOUTHINKYOUCANDOTHIS
18 0T %VERYDAY
19 $R 'REAT*USTSOTHAT)AMSURETHAT)UNDERSTANDYOURPLANCANYOU
PLEASEREPEATTHEDETAILSOFYOURPLANTOME
%LICITATIONOF#OMMITMENT3TATEMENT
 0T 3URE3TARTINGTOMORROW)WILLSTAR TGOINGTOTHEGYMEVERYMORNINGAND
SPENDHOURTAKINGAZUMBAORSOMESORTOFAEROBICCLASS
 $R 4HATSOUNDSLIKEAGREATPLAN/NASCALEOFWHEREISNOTATALL
CONFIDENTORSUREANDISEXTREMELYSUREHOWSUREAREYOUTHATYOU
WILLCOMPLETEYOURPLANv
1UESTION3CALINGFOR#ONFIDENCE
 0T (MMHONESTLYPROBABLYAORA)GUESSTHATISNOTSOGOOD
Figure 2.!NNOTATEDCLINICALVIGNETTEDEMONSTRATING "!0ANDFOLLOWUP)NTHISTEAMBASED CLINICALPRACTICERESPONSIBILITY FOR
FOLLOWINGUPWITHTHEPATIENTTELEPHONICALLYISDELEGATEDTOTHEMEDICALASSISTANT-!

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Vol. 21, No. 1 January 2014
JCOM
23
Figure 2. continued
back” the specifics of the plan. The provider might say
something like,
“Just to make sure we understand each
other, would you repeat back what you’ve decided to do?”
The act of “repeating back” organizes the details of the
plan in the persons mind and may lead to an unconscious
self-reflection about the feasibility of the plan [43,52],
which then sets the stage for Question 2 of BAP (Scal-
ing for Confidence). Commitment predicts subsequent
behavior change, and the strength of the commitment
language is the strongest predictor of success on an action
plan [43,52,53]. For example saying “I will” is stronger
than saying “I will try.”
REPORTS FROM THE FIELD
 $R !CTUALLYAORISALOTMORECONFIDENTTHANASO THATISGREAT$OYOU
HAVEANYIDEAABOUTHOWYOUCOULDMODIFYYOURPLANTOINCREASEYOUR
CONFIDENCETOAORMORE
#OLLABORATIVE0ROBLEM3OLVINGFOR,OW
#ONFIDENCE
 0T 7ELLTRUTHFULLY)THINKITWILLBEREALLYDIFFICULTTODOTHISEVERYDAY)TAKE
CAREOFMYGRANDSONON4UESDAYSAND4HURSDAYSAND)PROBABLY
WONTHAVETHETIME
 $R 4HATgSUNDERSTANDABLE
 0T -AYBE)SHOULDJUSTPLANTODOTHISTIMESAWEEKFORASTART,ETSSAY
-ONDAYS7EDNESDAYSAND&RIDAYS
 $R 4HATSOUNDSLIKEAGREATIDEA7HATWOULDYOURCONFIDENCEBEAFTER
ADJUSTINGYOURPLANLIKETHAT
 0T )THINKTHATMAKESITAN
 $R 'REAT4HENEXTSTEPISARRANGINGSOMEWAYTOCHECKINTOSEEHOWTHE
PLANWENTFORYOU7HATWOULDWORKFORYOU
1UESTION!RRANGING!CCOUNTABILITY
 0T 0ERHAPSWECANDOTHATBYPHONENEXTWEEK
31 $R 'REATIDEA(OWABOUTIFMYMEDICALASSISTANT#LARAGAVEYOUACALL
THISTIMENEXTWEEKTOSEEHOWTHINGSGO
 0T 9ESTHATWOULDWORKFORME
The following week, Dr. Gutnick’s medical assistant calls Mrs. Brown at home to check in.
33 -! (I-RS"ROWN4HISIS#LARA$R'UTNICKS-!$R'UTNICKASKEDME
TOCALLTOCHECKIN ANDSEEHOWTHINGSWENTWITHYOURPLANTHISWEEK
(OWDIDITGO
&OLLOWINGUP5SINGOTHERMEMBERSOFTHE
CARETEAMTOASSISTWITHFOLLOWUP
 0T 7ELL)DIDGOTOTHEGYMA-ONDAYAND7EDNESDAYBUT)WASJUSTTOO
TIREDON&RIDAY-YGRANDSONREALLYWOREMEOUT7HOKNEWTHATA
YEAROLDCOULDHAVESOMUCHENERGY
 -! )TSGREATTHATYOUHADSUCCESSWITHYOURPLANON-ONDAYAND7EDNES
DAYANDITSOUNDSLIKEYOUGOTAFAIRBITOFEXERCISEWITHYOURGRAND
SONTOO7HATWOULDYOULIKETODONEXT
2ECOGNIZINGANDAFFIRMINGPARTIALSUCCESS
TOINCREASEPATIENTSELFEFFICACY3PIRITOF
-)EVOCATION
36 0T )REALLYWANTTOCONTINUETODOTHISANDFITINTOMYDRESSNEXTMONTH)
GUESS)JUSTNEEDTOBEREALISTICTHAT&RIDAYS)MIGHTBETOOTIRED)WILL
FOCUSONGETTINGTOTHEGYMON-ONDAYSAND7EDNESDAYANDITWILLBE
ABONUSON&RIDAYSIF)AMUPFORIT
 -! 3OUNDSGREAT(OWSUREAREYOUTHATYOUWILLBEABLETODOTHIS 3CALINGFOR#ONFIDENCE
38 0T 6ERYSURE
39 -! 4HATgSWONDERFUL)TSOUNDSLIKETHISISAPLANTHATISREALLYGOINGTO
WORKFORYOU7OULDYOULIKETOARRANGEANOTHERCHECKINTOSEEHOW
ITGOES
!FFIRMSTRENGTHOFCONFIDENCE
 0T 9ES4HATWOULDBEGREAT)TWASREALLYHELPFULKNOWINGTHATYOURWERE
GOINGTOCHECKIN#ANYOUCALLMEAGAINNEXTWEEK
!RRANGING!CCOUNTABILITY
 -! 3URE)CANDEFINITELYDOTHAT

24
JCOM
January 2014 Vol. 21, No. 1
www.jcomjournal.com
BRIEF ACTION PLANNING
Question 2: Scaling for Confidence
After a commitment statement has been elicited, the
second question of BAP is asked.
“How conf ident or
sure do you feel about carrying out your plan on a
scale from 0 to 10, where 0 is not confident at all
and 10 is totally confident or sure?”
Conf idence
scaling is a common tool used in behavioral inter-
ventions, MI, and chronic disease self-management
programs [17,51]. Question 2 assesses an individual’s
self-efficacy to complete the plan and facilitates dis-
cussion about potential barriers to implementation in
order to increase the likelihood of success of a personal
action plan.
For patients who have difficulty grasping the concept
of a numerical scale, the word “sure” can be substituted
for “confident” and a Likert scale including the terms
“not at all sure,” “somewhat sure,” and “very sure”
substituted for the numerical confidence ruler, ie, “
How
sure are you that you will be able to carry out your plan?
Not at all sure, somewhat sure, or very sure?”
Alterna-
tively, people of different cultural backgrounds may find
it easier to grasp the concept using familiar images or
experiences. For example, Native Americans from the
Southwest have adapted the scale to depict a series of
images ranging from planting a corn seed to harvesting a
crop or climbing a ladder, while in some Latino cultures
the image of climbing a mountain (
“How far up the
mountain are you?”
) is useful to demonstrate “level of
confidence” concept [54].
Skill 4: Problem Solving for Low Confidence
When confidence is relatively low (ie, below 7), we sug-
gest collaborative problem solving as the next step [8,51].
Low conf idence or self-eff icacy for plan completion is a
concern since low self-efficacy predicts non-completion
[8]. Successfully implementing the action plan, no mat-
ter how small, increases conf idence and self-eff icacy for
engaging in the behavior [8].
There are several steps that a clinician follows when
collaboratively problem-solving with a patient with low
confidence (Figure 1).
s 2ECOGNIZE THAT A LOW CONFIDENCE LEVEL IS GREATER
than no confidence at all. By affirming the strength
of a patient’s confidence rather than negatively fo-
cusing on a low level of conf idence, the provider
emphasizes the patient’s strengths.
s #OLLABORAT IVELY EXPLORE WAYS THAT THE PLAN COU LDBE 
modified in order to improve confidence. A Behav-
ioral Menu can be offered if needed. For example, a
clinician might say something like:
“That’s great that
your confidence level is a 5. A 5 is a lot higher than
a 1. People are more likely to have success with their
action plans when confidence levels are 7 or more.
Do you have any ideas of how you might be able to
increase your level confidence to a 7 or more?”
s)FTHEPATIENTHASNOIDEASASKPERMISSIONTOOFFER
a Behavioral Menu:
“Would it be ok to share some
ideas about how other patients I’ve worked with
have increased their confidence level?”
If the pa-
tient agrees, then say...
“Some people modify their
plans to make them easier, some choose a less am-
bitious goal or adjust the frequency of their plan,
and some people involve a friend or family member.
Perhaps one of these ideas seems like a good one
for you or maybe you have another idea?”
Question 3: Arranging Accountability
Once the details of the plan have been determined and
confidence level for success is high, the next step is to ask
Question 3:
“Would you like to set a specific time to
check in about your plan to see how things are going?”
This question encourages a patient to be accountable
for their plan, and reinforces the concept that the physi-
cian and care team consider the plan to be important.
Research supports that people are more likely to follow
through with a plan if they choose to report back their
progress [43] and suggests that checking-in frequently
earlier in the process is helpful [55]. Ideally the clinician
Figure 3.6ISUAL"EHAVIORAL-ENU%XAMPLE
)NCREASE
PHYSICAL
ACTIVITY
%ASTSERVINGS
OFFRUITOR
VEGETABLESDAILY
2EDUCE
SCREENTIME
'ETENOUGH
SLEEP
!VOID
SUGARSWEETENED
BEVERAGES

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Vol. 21, No. 1 January 2014
JCOM
25
and patient should agree on a time to check in on the
plan within a week or two (Figure 2, entry 29).
Accountability in the form of a check-in may be ar-
ranged with the clinical provider, another member of
the healthcare team or a support person of the patient’s
choice (eg, spouse, friend). The patient may also choose
to be accountable to themselves by using a calendar or a
goal setting application on their smart phone device or
computer.
Skill 5: Follow-up
Follow-up has been noted as one of the features of suc-
cessful multifactorial self-management interventions and
builds trust [55]. Follow-up with the care team includes
a discussion of how the plan went, reassurance, and next
steps (Figure 4). The next step is often a modification
of the current BA P or a new BAP; however, if a patient
decides not to make or work on a plan, in the spirit of
MI (accepting/respecting the patient's autonomy) the
clinician can say something like, "It sounds like you are
not interested in making a plan today. Would it be OK if
I ask you about this again at our next visit?"
The purpose of the check-in is for learning and adjust-
ment of the plan as well as to provide support regardless
of outcome. Checking-in encourages reflection on chal-
lenges and barriers as well as successes. Patients should be
given guidance to think through what worked for them
and what did not. Focusing just on “success” of the plan
will be less helpful. If follow-up is not done with the care
team in the near term, checking-in can be accomplished
at the next scheduled visit. Patient portals provide an-
other opportunity for patients to dialogue with the care
team about their plan.
Experiential Insights from Clinical Experience
Using BAP
The authors collective experience to date indicates that
between 50% to 75% of individuals who are asked Ques-
tion 1 go on to develop an action plan for change with
relatively little need for additional skills. In other studies
of action planning in primary care, 83% of patients made
action plans during a visit, and at 3-week follow-up 53%
had completed their action plan [56]. A recent study of
action planning using an online self-management sup-
port program reported that action plans were successfully
completed (49%), partially completed (40%) or incomplete
(11% of the time) [35].
Another caveat to consider is that the process of
planning is more important that the actual plan itself.
It is imperative to allow the patient, not the clinician, to
determine the plan. For example, a patient with multiple
poorly controlled chronic illnesses including depression
may decide to focus his action plan around cleaning out
his car rather than disease control such as dietary modi-
fication, medication adherence or exercise. The clinician
may initially fail to view this as a good use of clinician
time or healthcare resources since it seems unrelated to
health. However, successful completion of an action plan
REPORTS FROM THE FIELD
Figure 4.&OLLOWUPONTHE"RIEF!CTION0LAN
(OWDIDITGOWITHYOURPLAN
7HATWOULDYOULIKETODONEXT
3UCCESS 0ARTIALSUCCESS $IDNOTTRYORNOSUCCESS
2ECOGNIZESUCCESS 2ECOGNIZEPARTIAL
SUCCESS
2EASSURETHATTHISIS
COMMONOCCURENCE

26
JCOM
January 2014 Vol. 21, No. 1
www.jcomjournal.com
BRIEF ACTION PLANNING
is not the only objective of action planning. Building self-
efficacy, which may lead to additional action planning
around health, is more important [4,46]. The challenge
is therefore for the clinician to take a step back, relinquish
the “expert role,” and support the goal setting process
regardless of the plan. In this example, successfully clean-
ing out his car may increase the patient’s self-efficacy to
control other aspects of his life including diet and the
focus of future plans may shift [4].
When to Use BAP
Opportunities for patient engagement in action planning
occur when addressing chronic illness concerns as well as
during discussions about health maintenance and preven-
tive care. BAP can be considered as part of any routine
clinical agenda unless patient preferences or clinical acu-
ity preclude it. As with most clinical encounters, the flow
is often negotiated at the beginning of the visit. BAP
can be accomplished at any time that works best for the
flow and substance of the visit, but a few patterns have
emerged based on our experience.
BAP f its naturally into the part of the visit when the
care plan is being discussed. The term “care plan” is com-
monly used to describe all of the care that will be provid-
ed until the next visit. Care plans can include additional
recommendations for testing or screening, therapeutic
adjustments and or referrals for additional expertise.
Ideally the patients “agreed upon” contribution to their
care should also be captured and documented in their
care plan. This is often described as the patients “self-
management goal.” For patients who are ready to make a
specific plan to change behavior, BAP is an eff icient way
to support patients to craft an action plan that can then
be incorporated into the overall care plan.
Another variation of when to use BAP is the situation
when the patient has had a prior action plan and is being
seen for a recheck visit. Discussing the action plan early
in the visit agenda focuses attention on the work patients
have put into following their plan. Descriptions of success
lead readily to action plans for the future. Time spent dis-
cussing failures or partial success is valuable to problem
solve as well as to affirm continued efforts to self-manage.
BAP can also be used between scheduled visits. The
check-in portion of BAP is particularly amenable to follow-
up by phone or by another suppor ter. A pre-arra nged follow-
up 1 to 2 weeks after creation of a new action plan [8] pro-
vides encouragement to patients working on their plan and
also helps identify those who need more support.
Finally, BAP can be completed over multiple visits.
For patients who are thinking about change but are not
yet committed to planning, a brief suggestion about the
value of action planning with a behavioral menu may
encourage additional self-reflection. Many times patients
return to the next visit with clear ideas about changes
that would be important for them to make.
Fitting BAP into a 20-Minute Visit
Using BAP is a time-efficient way to provide self-
management support within the context of a 20-minute
visit with engaged patients who are ready to set goals for
health. With practice, clinicians can often conduct all
the steps within 3 to 5 minutes. However, patients and
clinicians often have competing demands and agendas
and may not feel that they have time to conduct all the
steps. Thus, utilizing other members of the health care
team to deliver some or all of BAP can facilitate imple-
mentation.
Teams have been creative in their approach to BAP
implementation but 2 common models involve a multi-
disciplinary approach to BAP. In one model, the
clinician
assesses the patient readiness to make a specif ic action
plan by asking Question 1, usually after the current sta-
tus of key problems have been addressed and discussions
begin about the interim plan of care. If the patient indi-
cates interest, another staff member trained in BAP, such
as an medical assistant, health coach or nurse, guides
the development of the specific plan, completes the
remaining steps and inputs the patient’s BAP into the care
plan.
In another commonly deployed model, the front desk
clerk or medical assistant helps to get the patient think-
ing by asking Question 1 and perhaps by providing a
behavioral menu. When the
clinician
sees the patient,
he follows up on the behavior change the patient has
chosen and affirms the choice.
Clinicians
often f lex
seamlessly with other team members to complete the
action plan depending on the schedule and current patient
flow.
Regardless of how the workf lows are designed, BAP
implementation requires staff that can provide BAP with
fidelity, effective communication among team members
involved in the process and a standardized approach to
documentation of the specif ic action plan, plan for check-
in and notes about follow-up. Care teams commonly test
different variations of personnel and workf lows to f ind
what works best for their particular practice.

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Vol. 21, No. 1 January 2014
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Implementing BAP to Support PCMH
Transformation
To support PCMH transformation substantial changes
are needed to make care more proactive, more patient-
centered and more accountable. One of the common ele-
ments for PCMH recognition regardless of sponsor is to
enhance self-management support [20,57,58]. Practices
pursuing PCMH designation are searching for effective
evidence-based approaches to provide self-management
support and guide action planning for patients. The
authors suggest implementation of BAP as a potential
strategy to enhance self-management support. In addi-
tion to facilitating meeting the actual PCMH criteria,
BAP is aligned with the transitions in care delivery that
are an important part of the transformation including
reliance on team-based care and meaningful engagement
of patients in their care [59,60].
In our experience, BAP is introduced incrementally
into a practice initially focusing on one or two patient
segments and then including more as resources allow.
Successful BAP implementation begins with an organi-
zational commitment to self-management support, deci-
sions about which populations would benefit most from
self-management support and BAP, training of key staff
and clearly defined workflows that ensure reliable BAP
provision.
BAP’s stepped-care design makes it easy to teach to
all team members and as described above, team-based
delivery of BAP functions well in those situations where
clinicians and trained ancillary staff can “hand off ” the
process at any time to optimize the value to the patient
while respecting inherent time constraints.
Documentation of the actual goal and follow-up is
an important component to fully leverage BAP. Goals
captured in a template generate actionable lists for action
plan follow-up. Since EHRs vary considerably in their
capacity to capture goals, teams adding BAP to their
workf low will benef it from discussion of standardized
documentation practices and forms.
Summary
Brief Action Planning is a self-management support tech-
nique that can be used in busy clinical settings to sup-
port patient self-management through patient-centered
goal setting. Each step of BAP is based on principles
grounded in evidence. Health care teams can learn BAP
and integrate it into clinical delivery systems to support
self-management for PCMH transformation.
Corresponding author: Damara Gutnick, MD, New York
University School of Medicine, New York, NY, damaragut-
nick@gmail.com.
Financial disclosures: None.
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BAP Resources
Videos
The 3 core questions and 2 of the 5 skills of BAP:
ww w.youtube.com/watch?v=w0n-f6qyG54
An example of BAP involving a patient with osteo-
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REPORTS FROM THE FIELD