Last week our team published a paper exploring the scope to improve the advice offered to patients (i.e. to change the behaviour of the practitioner). We focused on people with dementia who present with challenging behaviours because so much more is on offer to patients living with this condition than is promoted by doctors. The team explored the practitioners’ perspective on the issues with reference to simulations. Referring back to Lewin’s equation, B = ƒ(P, E) i.e. behavior is a function of the person in their environment. Professional behaviour change is also subject to Fogg’s model so behaviour is a function of motivation, ability and trigger (B=MAT).
In addition any consultation with a health care practitioner motivation is highest when the practitioner is:
- Rewarded for action (A) in those circumstances.
- Able to act within the time (T) available
- Has the scope to reduce risk (R) to the patient but also the risk of litigation or complaint
M = A+T+R
The ability (A) to do the needful is a function of:
- Cost (C) of the treatment or intervention
- Effort (E) required to access it
A = C+E
Finally the Trigger (T) to adopting the requisite behaviours are determined by:
- Recognising the patient (P) for whom the action is indicated
- Knowing (K) what is available in the circumstances
With this lens our data suggests that an intervention to increase referral to community support agencies (the desired behaviour) should consider the following:
A: Some participants in the study expressed the view that care coordination would be unrewarding.
T: This was not specifically explored in relation to these scenarios however it is possible, that people presenting with such problems to a doctors office would require more time than is available in short primary care consultations.
R: Feedback to the practitioners on individual scenarios highlighted the risk of medicolegal consequences of a failure to act. There was a marked improvement in the proposed management plans when this was pointed out.
C: There was no cost to the practitioner or the patient in making a referral to a community support agency. However practitioners expressed the view that care coordination in this setting is ineffective.
E:In many cases it was considered difficult to coordinate the care of patients with behavioural problems in the context of a dementia diagnosis, however the level of difficulty was not a factor in the decision to coordinate care for this group of patients. The data also suggests that older practitioners were more cynical about their ability to coordinate care.
P:Some scenarios where the scope to assist was apparent were not recognised.
K: When practitioners were made aware of what was available to them, they were more likely to act.
Therefore an intervention that could promote referral to community support agencies for people exhibiting behaviour change in the context of dementia would have all of the following characteristics:
1. Emphasise the responsibility of primary care practitioners to act in these circumstances, including the medicolegal consequences of a failure to act.
2. Make it easier to find and refer to voluntary and statutory support agencies and
3. Where the motivation and ability has been optimised include reminders that specific patients would benefit from support – for example the driver whose cognitive function is a risk to other road users.
Picture by nhuisman