Sick Care Is Doomed To Failure How Behavior Change Transforms Primary Care SICK CARE IS DOOMED TO FAILURE How Behavior Change Transforms Primary Care Much has been made of the benefits of preventive care, especially in today’s reactive sick care environment. But preventive care isn’t the holy grail of health. If all we had to do was identify potential health issues, we’d all live to be a hundred years old. For example, we all know people who smoke. Maybe we smoke ourselves. Does the knowledge that we’re increasing our chances of getting cancer change our habit for us? Of course not. Facts don’t change health. They simply tell us what’s going on. That’s why behavior change matters. This eBook digs into exactly how we approach behavior change at Vera and why it’s so critical to whole health. It all starts with the (TTM) of change.

VERA | How Behavior Change Transforms Primary Care 02 Transtheoretical Model of Change Humans are naturally creatures of habit. Breaking out of typical behaviors and routines is a challenging process that takes time. It’s also individualized. What helps one person quit smoking may not work for another person. The TTM acknowledges these challenges and provides a framework for understanding and dealing with them.

Recognizing that change isn’t boiled down to a single action, the TTM establishes key stages of change to understand where a patient is at in their own journey. The model also identifies critical processes that are known to move patients toward the next stage. Using these tools in tandem, providers and health coaches can better serve their patients. The model creates a profile for each individual that acts as a roadmap for behavior change. Creating Long-Term, Sustainable Healthy, Lifestyles By employing the TTM to empower patients to take ownership of their own health, Vera not only improves health outcomes now but in the future. As patients learn to change their own behavior, they become healthier because they’ve learned to drive their own self-efficacy.

Each time an unhealthy behavior is changed, the positive experience becomes a resource that guides patients to create their own long-term, sustainable, healthy lifestyles. Combined with Vera’s commitment to understanding a patient’s true needs before prescribing medication, highly coordinated referrals, and primary care practices, behavior change imbues every clinical experience with something other healthcare systems don’t offer: the chance to transform healthcare.

In this eBook, We’ll Cover ... • Transtheoretical model of behavior change — We’ll find out what it is, why it works, and how Vera integrates it into a transformative clinical experience

• Barriers to behavior change in traditional — We’ll learn about the obstacles patients and providers face when trying to cultivate behavior change in traditional healthcare systems

• How Vera built its model to drive behavior change — From dedicated care teams to empathetic listening practices, we’ll see how Vera’s commitment to behavior change unfolds in the real world.

• How Vera health drives behavior change — We’ll take an in-depth look at Vera’s dedicated health coaches and the role they play in driving behavior change. We’ll also read about a real Vera patient to see how health coaching changed his life. You have to help identify what is motivating them. You have to help them recognize victories and use that to fuel movement.

Vera CEO | Ryan Schmid

Intro to the Transtheoretical Model At Vera, we use the transtheoretical model of change. Developed in 1977, the TTM is arguably the most widely recognized model for understanding how individuals progress through different stages of behavior change. What differentiates the TTM from other approaches to behavior change is the component of time. “Instead of treating change as a binary decision, where patients either take action to improve their health or don’t, the TTM recognizes that change happens over time.”

Core Components of the Transtheoretical Model The transtheoretical model consists of two main components: stages of change and processes of change. Stages of change represent where a patient is at in their journey of change. The processes of change highlight the most common behaviors used to move between stages.

Providers and health coaches who understand a patient’s current stage of change can tailor care approaches to align with a patient’s goals or lack thereof.

The processes of change help care teams understand the way in which a patient moves through the stages of change and include both overt and covert behaviors. Providers and health coaches who are versed in the processes of change can identify which process patients gravitate toward and build on that knowledge to encourage their behavior change.

VERA | How Behavior Change Transforms Primary Care 04 5 Stages of Change

1. Precontemplation At this stage, patients are not considering any action to change their behavior. In some cases, they may not even be aware that their current behavior is unhealthy or that they need to change. Typically, patients are in the precontemplation stage for at least six months before they take action to make changes.

2. Contemplation As patients begin to acknowledge that they need to change their behavior, they move into the contemplation stage. In contemplation, patients start weighing the pros and cons of changing their behavior but find that the pros are equally balanced with the cons. At this point, patients are usually planning to change their behavior within the next six months.

3. Preparation In the preparation stage, a patient intends to take action very soon, typically within a month. They may have already taken some action, like reading about nutrition, talking to a health coach, or joining a fitness program. At this point, patients are ready for goals that include specific actions.

4. Action When a patient reaches the action stage, they have made definite adjustments to improve their health. For example, a patient who has successfully changed their diet or integrated a new exercise regimen into their routine is in the action stage.

5. Maintenance In maintenance, patients are actively sticking to the behavior changes they committed to in their action stage and are working to prevent relapse into earlier stages. Depending on the goal, the maintenance stage can last anywhere from a few months to a few years. 10 Processes of Change

Cognitive Processes Behavioral Processes 1. Consciousness Raising (Get the 6. Self-Liberation (Make a Facts) — Absorbing information, Commitment) — Believing in seeking out educational resources, their ability to change and making and getting personal feedback on commitments to change based on healthy behavior that belief

2. Dramatic Relief (Pay Attention 7. Helping Relationships (Get to Feelings) — Experiencing fear and Support) — Locating people who stress about the consequences of are supportive of change, including unhealthy behavior and feeling hope providers, health coaches, friends, when presented with the positive and family behavior changes of others 8. Counter-Conditioning (Use 3. Self-Reevaluation (Create a New Substitutes) — Substituting unhealthy Self-Image) — Acknowledging that modes of thinking and acting with their healthy or unhealthy behaviors healthy ones influence their identify 9. Reinforcement Management 4. Environmental Reevaluation (Use Rewards) — Promoting the (Notice Your Effect on Others) — rewards that accompany healthy Acknowledging that their unhealthy behavior and demoting those behavior can have an effect on associated with unhealthy behavior others around them, including friends and family, and that improved health 10. Stimulus Control (Manage Your could have an equally impactful Environment) — Identifying and positive effect encouraging reminders and cues that promote healthy behavior in place 5. Social Liberation (Notice Public of those that promote unhealthy Support) — Acknowledging that behavior society supports positive, healthy behaviors

VERA | How Behavior Change Transforms Primary Care 06 I would say that the root cause of our broken healthcare system is the fact that we as a country are getting less and less healthy. If it’s true that 70% of healthcare costs are related to lifestyle, then it seems like we need to change our lifestyles.

Vera CEO | Ryan Schmid

Why Does All this Matter? Traditional healthcare models have failed. Healthcare costs are skyrocketing, and no one is getting healthier. The reason? The current system is set up to treat a patient only when their problems are acute or chronic. In essence, it’s not health care. It’s sick care. The only way to truly improve health is to change behavior.

Now this is where we’ve all been led to believe that the answer is preventive care. Everything will be ok if we can get in front of health issues before they arise, right? Not so fast. We’ll explain later why preventive care is just a means to an end. The only way to truly improve health is to change behavior. That where TTM comes in.

Even if patients want to get healthier, they often don’t know where to start. They still need help. The TTM offers a path forward, away from sick care. Using TTM as a tool, healthcare providers can provide patients with the resources they need to take ownership of their health, change their behavior, and get healthier.

VERA | How Behavior Change Transforms Primary Care 07 Barriers to Behavior Change in a Traditional Model Lots of Patients, Little Time In a traditional healthcare setting, providers are under pressure to see as many patients as possible in a single day. As a result, the average interaction between patients and providers lasts just 7 minutes nationally. In the time it would take to play two pop songs, patients are expected to describe all of their health concerns and still leave enough time for their provider to identify and communicate a treatment plan.

In actuality, patients usually divulge only their most acute problems and providers typically administer prescriptions because they’re the only treatment plan they have time to offer.

Treating Symptoms Instead of Causes Without the resource of time, providers are forced to treat a patient’s overt symptoms rather than their underlying causes. In many cases, this results in nothing more than a prescription. Because patients don’t get the treatment they need, issues are more likely to get worse and become chronic over time. In the end, providers are unable to provide patients with effective treatment plans that address the root cause of their health issues.

Even if patients reliably make preventive care visits, providers typically only have the time and resources to make recommendations for avoiding specific future problems. Eat better, lose weight, and stop smoking are the types of things providers might say in a preventive care visit. But, even if those suggestions take the place of goals, providers in a traditional healthcare system have no practical way to follow up and note whether those goals are being executed. Without these resources, patients cannot be empowered to change.

VERA | How Behavior Change Transforms Primary Care 08 Behavior Change Is the Key to Healthy and Sustainable Lifestyles The Vera Model

Vera’s clinical experience maximizes opportunities for behavior change. Here’s how:

• On-site clinics offer patients quick and easy access to care, empowering them to get the care and health coaching they need, when they need it. • Providers and health coaches are trained to esteem patients and empower them to take ownership of their own health through empathetic listening. • Every member of Vera’s staff is trained in the transtheoretical model, from health coaches to providers to medical staff. • Providers make in-person recommendation for health coaching using a technique dubbed the ‘warm handoff.’ • Vera’s Whole Health Council provides a forum where clinical staff and employees can share feedback, helping to drive behavior change across the broader community. • Vera integrates into the culture of organizations to better treat the population through increased understanding of their community.

Vera uses these resources to drive behavior change at every possible level. Our clinics aren’t just a place for quick, accessible preventive care. They’re centers of behavior change, where patients set and achieve goals that drive their own improved health outcomes.

VERA | How Behavior Change Transforms Primary Care 09 Our vision statement is to create a health revolution. If all we do is change how healthcare is delivered and paid for, we’re not successful. Our goal is to make people healthier.

Vera CEO | Ryan Schmid

Goals Go Beyond Preventive Care Prioritizing behavior change goes beyond the benefits of preventive care. Preventive care considers a patient’s health in the moment and attempts to plan for specific future problems. Patients are told to exercise or risk heart attack, change their diet or risk diabetes. But these consequence-based actions don’t consider a patient’s current stage of change. They don’t truly address all of a patient’s needs.

That’s not to say that the advice given during a preventive care visit isn’t valuable. But how often do we actually follow advice? Especially when we’re in an early stage of change, like precontemplation? Advice rarely leads to improvements for long-term health. Setting, maintaining, revising, and updating goals is the only way to keep patients focused on improving their health long term.

The point is assigning actions doesn’t change behavior and, therefore, doesn’t improve health. You have to meet patients where they’re at. That’s why our preventive care isn’t just preventive care; it acts as an entry point for engaging patients in behavior change. Our clinical experience, dedicated care teams, and empathetic listening practices pick up where preventive care ends.

VERA | How Behavior Change Transforms Primary Care 10 How Vera Supports Behavior Change

Health coaches are the most visible agents of behavior change at Vera. To understand how they’re able to conduct their work it’s important to understand how Vera supports behavior change on a larger scale. From dedicated care teams and personalized care plans to empathetic listening practices and other innovative clinical techniques, our model is built to support behavior change at every point in a patient’s journey.

If you really want to help folks change their behavior, you have to address their needs and meet them where they’re at, but you also must have the time to develop a relationship and establish a rapport with them. Vera CEO | Ryan Schmid

Dedicated Care Teams & Personalized Care Plans At Vera, every patient is assigned a dedicated care team that is made up of a provider, health coach, and medical staff members. We use the term “dedicated care team” because each member of the team is dedicated to working collaboratively on a personalized care plan for each patient. This creates a comprehensive approach to care that gives the patient the benefit of improved health from the perspective of both providers and coaches. To develop a personalized care plan, providers and health coaches partner with patients to understand and acknowledge the patient’s goals and barriers to better health. Dedicated care teams build on that shared understanding to esteem and empower patients to take ownership of their own health. Patients are more likely to adhere to those care plans because they have a part in the decision-making process. At the heart of this collaborative effort is empathetic listening.

VERA | How Behavior Change Transforms Primary Care 11 Understanding the Impact of Empathetic Listening Empathetic listening is deeply integrated into Vera’s approach to healthcare. Without it, behavior change cannot happen. Empathetic listening means that providers, health coaches, and medical staff take time to truly listen to patients. They ask sincere questions, encourage discussions, and make every effort to consider health issues from the patient’s point of view. Providers also aren’t overloaded with dozens of patients in a day so they have the time to allow for meaningful connections to form with their patients. Through empathetic listening, providers and health coaches meet a patient where they’re at, rather than merely doling out instructions. Patients don’t feel rushed to share symptoms. Most importantly, they feel heard. With learnings gained from empathetic listening, care teams accurately apply the TTM’s stages of change as well as the processes along with them. Providers and health coaches then develop an approach to care and goal-setting that aligns with those of the patient. Empathetic listening allows the TTM to work.

Providers Support Change When a patient engages with a Vera on-site clinic, providers listen for keywords that clue them into a patient’s readiness for change. “Providers might see a gap, or maybe they hear the patient say ‘I want to do this’ or ‘I should do this’ when talking about their own health. Keywords like that indicate that a patient is curious about change,” says Vera’s Coaching Operations Specialist, Cheridan Bryant. By listening empathetically, providers can make effective recommendations for health coaching. Because health coaches are Vera’s behavior change experts, Bryant notes, “when you recommend coaching, you’re recommending behavior change.”

The warm handoff Once a provider has determined a patient might be a good candidate for health coaching — and therefore behavior change — they make an in-person recommendation known as the warm handoff. The warm handoff happens when a provider literally walks a patient to the health coach’s office and introduces their patient to a health coach directly, so that the patient feels more comfortable working with that health coach. It also offers a way for the patient to experience the collaboration between providers and health coaches, an eye-opening introduction to the power of their dedicated care team.

VERA | How Behavior Change Transforms Primary Care 12 Health Coaching Drives Behavior Change What Is Health Coaching? At Vera, health coaches are our behavior change experts. Like all Vera practitioners, health coaches use empathetic listening practices to esteem patients and empower them to take ownership of their own health. But health coaches take it a step further by acting as a patient’s primary partner in establishing goals for behavior change. The warm handoff helps cement that role in a patient’s mind.

VERA | How Behavior Change Transforms Primary Care 13 Not Your Average Coach True health coaching is a powerful ally for patients seeking to improve their health through behavior change. It’s so powerful in fact that it has launched an entire industry of mimicry. From brief seminars to nonaccredited online programs, it’s easy for the average person to add coaching to their title or resume. With this in mind, it’s essential to be very transparent about the skills and expertise of Vera’s health coaches. Vera’s health coaches are: • National Board Certified Health & Wellness Coaches • Trained in the transtheoretical model and empathetic listening practices • Experts in behavior change • Full-time, fully integrated members of a patient’s dedicated care teams Vera’s health coaches are not: • Proprietors of bolt-on wellness programs • Self-help counselors • Therapists

Health Coaching and the Transtheoretical Model Using empathetic listening, health coaches help patients match their goals to their TTM stage of change to minimize resistance to change. For example, a patient who needs to lose weight but is in the contemplation stage is unlikely to respond to action-oriented goals like implementing an exercise regimen. Instead, a health coach might help them identify the benefits of weight loss or point them to educational resources. Again, empathetic listening plays a crucial role in allowing health coaches to determine a patient’s stage of change and to what processes of change they’ll respond. By suggesting stage-appropriate goals to patients, health coaches further their trust with a patient. When goals reflect a patient’s stage, it reinforces the idea that the health coach is attuned to their specific needs, goals, and barriers to health. This reinforcement promotes further engagement with a health coach because the patient sees them as an advocate for their needs, rather than just another healthcare professional telling them what to do without truly listening to them.

VERA | How Behavior Change Transforms Primary Care 14

Coaching in Action: Frank Garcia’s Lofty Goal

“People need to decide what they really want. I’m not getting any younger, and it’s not getting any easier. I knew what I needed to do. I just didn’t want to do it.” — Arizona school principal and Vera patient, Frank Garcia

Lose fifty pounds. That was Frank Garcia’s goal. When the Flagstaff principal saw that his school district was opening up a Vera clinic for staff members, he thought it sounded like a “cool idea” and decided to check it out. But it wasn’t the easy access to primary care that interested Frank. It was health coaching. Diabetes was common in his family and he knew that his weight made him all the more likely to follow in their footsteps. So, he made an appointment. Frank and his health coach started by implementing a simple exercise regimen into his weekly routine. Then they added in goals for improved nutrition and snacking habits. He bought a FitBit and started counting calories. But it didn’t stop there. Because he would exercise in the morning before school, Frank and his health coach worked on modifying his sleep schedule to ensure that his exercise wasn’t compromising a healthy night’s sleep. “We set exercise goals, we set nutrition goals, we set sleep goals, all of those things to try and make this a successful experience because most people give up at one point or another because it’s hard. It turned out actually not to be so hard,” says Frank. In the end, Frank achieved his lofty goal. “I feel better than I have in a long time,” says Frank. He had known for years that he wanted to lose weight, but health coaching gave him the boost he needed to get it done. Frank notes, “I think what it does is bring a level of accountability. People will say that it’s nice to have a workout partner when you work out. I don’t have a workout partner, but this has been something that’s helped keep me on track.” We can improve health. We can transform the healthcare system. But first, we have to change behavior. That’s why Vera’s model is built around it. Once again, here’s how:

In a healthcare system where brief appointments are the norm, we give patients and providers the time and resources they need to form meaningful connections. To facilitate those connections, every Vera staff member is trained in empathetic listening and the transtheoretical model to help identify and understand patient goals and barriers to better health. Providers use that information to develop personalized care plans that include smart goal-setting strategies driven by accredited health coaches. Tactics like the warm handoff ensure that providers, health coaches, and patients approach behavior change as a team.

Vera esteems patients through empathetic listening and empowers them to change their behavior and, by doing so, take ownership of improving their own health. It’s not just a model for better healthcare. It’s our mission.

• Are you tired of the traditional health care system failing? • Are you interested in providing your employees with the most innovative benefits available? • Are you committed to improving the health of your employees in the long term? • Are you ready to change behavior at your organization?

Start changing today. Contact us to learn more about what Vera can do for you.

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