This Guide has been written by:
The Massachusetts Department of Mental Health
Healthy Changes Task Force
July 29, 2009
Chair: Sally Reyering, MD
Cathy Andrews
Jeff Burke
Rosa Dominguez
Robert Karr
Rachel Klein
Patrice Levesque
Jane Musgrave
Dale Rauch
Ann Roy
Nick Simms
Virginia Stevens
Eileen Weber
Design: Michelle Cormier
Massachusetts Department of Mental Health
Health and Wellness Treatment Planning
The Massachusetts Department of Mental Health (DMH) recognizes the essential role of physical wellness in recovery from psychiatric illness. Recent data from Massachusetts and other states show that those with psychiatric disabilities die from treatable medical illnesses at rates that are significantly higher than those without psychiatric illness, dying up to 25 years earlier than the general population from cardiovascular disease, respiratory illness, and lung cancer. (NASMHPD 13th Technical Report, Morbidity and Mortality in People with Serious Mental Illness, October, 2006.) Inactivity, overweight and obesity, and cigarette smoking all contribute to heart and lung disease, diabetes, high cholesterol, and high blood pressure, resulting in increased chronic illness and premature death among individuals with serious mental illness. For the last 30 years, it has been well established that cigarette smoking is the single most significant modifiable risk factor for the illnesses which contribute to early death in the United States (Centers for Disease Control). Obesity is fast approaching the same risk level for early death as smoking. Increasing levels of physical activity has been found to have substantial health benefits including the prevention of premature death.
The Healthy Changes Initiative was established by DMH to address these modifiable risk factors for chronic illness and early death. The initiative emphasizes improved health care quality through screening, assessing, and providing evidence-based treatment throughout the system of care for nicotine addiction, obesity, and physical inactivity. The initiative strives to create a culture of wellness which supports individuals in making lifestyle changes. Health and wellness treatment planning is integral to this process.
Health and wellness treatment planning is based on the following concepts:
· A healthy lifestyle is an attainable goal and an important part of overall wellness and recovery from mental illness.
· A person-centered approach to health and wellness is key; any interventions must be sensitive to an individual’s cultural and linguistic background and other individual needs.
· An individual’s readiness to take action to move toward a healthy lifestyle is the basis for any goals, objectives, or interventions. The Stages of Change Model (Prochaska and DiClemente, 1984) is a method for measuring the process that people go through when they successfully make changes in their lives. The five stages of change are:
o pre-contemplative (not currently considering change);
o contemplative (ambivalent about change/not considering change within the next month);
o preparation (preparing to make a change/planning to act within one month)
o action (actively making a life change, practicing new behavior for three to six months);
o maintenance (continued commitment to sustaining the new behavior for six months to five years post change).
Motivational techniques can increase an individual’s desire to take action including motivational interviewing and motivational enhancement. Examples of Motivational Interviewing (Martino, S., et al. (2006) Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency. Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University) techniques include inviting the indiv. to share his position on the health lifestyle in focus; validating an indiv.’s lack of readiness to engage in a lifestyle change in a non-judgmental way; supporting individual choice and autonomy in deciding whether or not to engage in a lifestyle change. Examples of Motivational Enhancement (Ziedonis DM, et al, J Psychiatr Pract. 2005 Sep; 11(5):315-39).
tools include calculating the monthly cost of cigarettes with an individual, use of a carbon monoxide monitor, etc.
· Taking small steps (www.smallstep.gov) is the best way to achieve lifestyle changes. Living a healthy life is a process that does not happen overnight, but can be achieved through small steps.
· Peers provide hope, mutual support, and modeling of effective strategies for making healthy lifestyle changes.
· Healthy living can be fun, a source of leisure activity, and an opportunity for healthy competition.
Guidelines for Writing Health and Wellness Goals and Interventions on a Recovery and Treatment Plan*
The plan consists of 4 parts: problem or targeted health focus, LTG, STG, and interventions.
Problem or targeted health focus LTG: (1) To remove problem or improve health STG: (1-3) Steps toward
achieving LTG
Interventions: The treatment(s) that will facilitate the changes needed to achieve the STG.
To Construct Long Term Goals (LTG):
· Always personalize the goal for the individual.
· Assist the individual in choosing a health and wellness focus or problem, e.g. to stop smoking, lose weight, increase physical activity.
To Construct Short Term Goals (STG):
· Always personalize the goal for the individual.
· All STG’s start with: Individual will…
· Need to include identify the observable, measureable, quantifiable behaviors the individual will demonstrate.
· Need a time frame to achieve the STG,
o For inpatient treatment plans, this is usually a 1 week to 3 month max time span from the date of the writing of the Tx plan or the last review, and is placed in a section next to each goal called target date.
Example: Individual will be able to select a low fat alternative to high fat food 2 meals a day for 3 months.
Interventions
· Always personalize the intervention for the individual.
o Interventions always starts with a specific discipline and the specific clinician (name/title or credentials) that is going to provide the specific service
§ IE: Rehab: Jane Musgrave MS OTR/L will
o Follows with an action word
§ Provide, refer, assess, administer etc.
o Follows with the Tx service provided
§ Individual Tx, group name Tx, medication, etc.
o Follows with the duration( how long: # of weeks/days) and frequency( how many times in duration ( 1x, 2x ,etc) of the service
§ 2 x’s a week for 12 weeks
o Follows with for the purpose of
§ This is the specific thing that WE are doing (Provide, refer, assess, administer etc) that allows the Individual the opportunity to reach their STG. So interventions and STG must be logically connected!
· Example: Rehab: Jane Musgrave MS, OTR/L, will provide Healthy Cooking Group 2x/wk for 12 wks for the purpose of education and increasing awareness of low fat choice ingredients as alternatives to high fat ingredients in cooking; increasing cooking skill; and assessing cooking/stove safety skills.
* Portions of this guide are modified from: Berghuis, D.J.,& Jongsma, A.E. Jr.(2008) The Severe and Persistent Mental Illness Treatment Planner: Practice Planner Hoboken, N.J.: John Wiley and Sons, Inc.
Examples of Smoking Cessation
Goals & Interventions for Pre-Contemplation Stage
Stage of Change/Long Term Goal (LTG) / Short Term Goal / Staff Intervention
(include frequency and duration)
Pre-Contemplation
In this stage the individual is not currently considering quitting smoking. Goal setting can be around general health or smoking depending on the interests of the individual.
LTG: Individual will identify 2-3 small steps s/he
can take toward healthy living (by target date).
LTG: Individual will advance to the contemplation stage (by target date). / STG: Individual will listen to and/or discuss healthy living, and the importance of overall wellness with others (by target date).
STG: Individual will identify 2-3 ways in which overall health and wellness is part of recovery from mental illness (by target date).
STG: Individual will learn about the health risks associated with cigarette smoking and the benefits of quitting during an educational session (1:1 or group) (by target date).
STG: Individual will join other patients in a group setting such as healthy living group and/or thinking about smoking group, to listen and talk about smoking routines/ history. (by target date).
STG: Individual will identify 2-3 small steps s/he can take toward healthy living (by target date). / Staff (name/title) will provide Individual with information about healthy living as a part of his/her recovery from mental illness (add frequency and duration).
Staff (name/title) will provide Individual with information (add frequency and duration) about the risks associated with smoking and the benefits of quitting smoking) (add frequency and duration).
Staff (name/title) will engage individual to talk (add frequency and duration) about the reasons/routines around smoking, pros and cons of smoking, their personal smoking history using motivational interviewing concepts (See page 1)(add frequency and duration).
Staff (name/title) will provide a healthy living group (add frequency and duration) and/or thinking about smoking group for the purpose of increased education regarding the health benefits of quitting smoking and awareness of healthy living as part of recovery from mental illness (add frequency and duration).
Medical Staff (name/title) will provide information (add frequency and duration) to the individual regarding their specific health risk associated with smoking (add frequency and duration) and that help is available when they are ready to consider quitting.
Examples of Smoking Cessation
Goals & Interventions for Contemplation Stage
Stage of Change/Long Term Goal / Short Term Goal / Staff Intervention(include frequency and duration) /
Contemplation
In this stage the individual is interested, but ambivalent about quitting smoking. S/he is not considering quitting within the next month, but perhaps within the next six months. S/he is not ready to take action now.
· LTG: Individual will identify at least one way in which tobacco is impacting his/her health (by target date).
LTG: Individual will advance to the preparation stage. / STG: Individual will identify 2-3 chemicals found in cigarette smoke by (by target date).
STG: Individual will identify 2-3 health risks associated with tobacco use (by target date).
STG: Individual will calculate how much s/he spends on cigarettes per year and will identify 1-2 alternative uses for the money (by target date).
STG: Individual will identify at least one smoking pattern that would be hard to give up and one way s/he could try to change this smoking pattern (by target date).
STG: Individual will identify any physical symptoms or medical problems s/he has that may be caused by his/her smoking (by target date).
STG: Individual will identify pros and cons
of smoking cessation (by target date). / Staff (name/title) will provide affirmation to the Individual for thinking about quitting and offer to help him/her (add frequency and duration).
Staff (name/title) will engage individual to talk (add frequency and duration) about the reasons/routines around smoking, pros and cons of smoking, their personal smoking history. (add frequency and duration).
Staff (name/title) will assist the Individual to calculate how much money s/he spends on cigarettes and to consider other things s/he could do with the money (add frequency and duration).
Staff (name/title) will discuss the benefits of attending healthy Living group and/or thinking about smoking group to learn about healthy living as part of recovery from mental illness (add frequency and duration).
Staff (name/title) will arrange for the Individual to meet with a peer who has made healthy lifestyle changes (add frequency and duration).
Staff (name/title) will administer
motivational interviewing techniques (See page 1)to advance stage of change.
Staff (name/title) will engage individual to talk (add frequency and duration) about any physical symptom(s) or health issue(s) s/he is experiencing that may be related to smoking (add frequency and duration).
Examples of Smoking Cessation
Goals & Interventions for Preparation Stage
Stage of Change/Long Term Goal / Short Term Goal / Staff Intervention
(include frequency and duration) /
Preparation
In this stage the individual is “testing the waters” and wants to quit smoking within 30 days. S/he is interested in information/guidance on quitting, gathering tools to make a quit attempt, etc.
LTG: Individual will develop an individualized quit plan and make behavioral changes to prepare to quit (by target date).
LTG: Individual will advance to action stage. / STG: Individual will develop a quit plan while attending thinking about quitting group. (add frequency and duration).
STG: Individual will identify 1-3 people who can provide him/her with support when s/he quits (by target date).
STG: Individual will identify 1-3 trigger/ obstacles to quitting and alternatives to smoking (by target date).
STG: Individual will make 1-3 behavioral changes to prepare to quit smoking (by target date).
STG: Individual will decide (with assistance from his/her prescribing physician) if s/he will use medications (e.g., NRT or pharmacotherapy) to help him/her quit smoking (by target date).
STG: Individual will identify a quit date and take steps to plan for it (by target date). / Staff (name/title) will encourage Individual to attend thinking about quitting group and/or meet with the Tobacco Treatment Specialist to develop a quit plan (add frequency and duration).
Staff (name/title) will provide thinking about quitting group to educate the Individual regarding the steps needed to quit smoking, e.g. identifying supportive others, obstacles, etc. (add freq/dur).
Staff (name/title) will provide the Individual with “pack wraps” (form for monitoring smoking urges and triggers) to help him/her identify smoking patterns (add frequency and duration).
Staff (name/title) will assist the Individual to identify individuals, support groups, websites, etc. who can provide him/her with support, when s/he quits (add frequency and duration).
Staff (name/title) will assist Individual to problem solve regarding triggers to smoke and how to avoid them (add frequency and duration).
Staff (name/title) will role play with the Individual how s/he will refuse cigarettes ((add freq/dur)
Staff (name/title) will assist Individual to identify small steps (e.g., tapering, day or week long challenge) s/he can take to prepare to quit smoking (add freq/dur)
Primary Care/Prescribing Physician (name/title) will offer the Individual medication (e.g., NRT, pharmacotherapy) to help him/her quit smoking (add freq/dur)
Staff (name/title) will assist the Individual to set a quit date and prepare for it (add freq/ dur).
Examples of Smoking Cessation
Goals & Interventions for Action Phase
Stage of Change/Long Term Goal / Short Term Goal / Staff Intervention
(include frequency and duration) /
Action
In this stage the individual is engaged in their quit plan, practicing the new behavior of not smoking for 3-6 months, and most likely has frequent urges to smoke.
LTG: Individual will carryout his/her quit plan (by target date).
LTG: Individual will advance to the maintenance stage. / STG: Individual will utilize the individuals, groups, websites etc. who s/he identified for support (by target date).
STG: Individual will utilize NRT or pharmacotherapy to control urges to smoke (by target date).
STG: Individual will utilize alternatives to smoking (by target date).
STG: Individual will utilize 1-2 strategies to prevent weight gain that can result from quitting (by target date).
STG: Individual will quit smoking (by target date).
STG: Individual will be able to recognize the positive impact of smoking cessation in their lives.(by target date) / Staff (name/title) will provide support to the Individual regarding s/he quit efforts (add frequency and duration).
Staff (name/title) will discuss triggers with the Individual and how to cope with them (add frequency and duration).
Staff (name/title) will encourage/assist the Individual to use their NRT and/or pharmacotherapy (add frequency and duration).
Staff (name/title) will administer NRT and/or pharmacotherapy as prescribed (add frequency and duration).
Staff (name/title) will assist Individual to identify strategies to control weight gain that can result from quitting (add frequency and duration).
Staff (name/title) will provide Exercise Group to assist Individual with side effect of weight gain after stopping smoking (add frequency and duration).
Staff (name/title) will refer to Registered Dietician for weight management education.
Staff (name/title) will reinforce benefits of quitting (add frequency and duration).
All staff: Give verbal Praise /Recognition and more Praise to reinforce smoking cessation accomplishments daily.
Examples of Smoking Cessation