Background
Methods
Theoretical frameworks used to develop the model
Procedures
Results
Participants
Step 1: Define the problem to be addressed in behavioral terms
Step 2: Select the target behaviors most likely to bring about change to address the problem
Step 3: Specify the target behavior in as much detail as possible
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Who needs to perform the behavior? Psychiatrists or nurse practitioners.
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What do they need to do differently to achieve the desired change? Regularly assess whether patients are due for annual metabolic screening rather than defer this to primary care.
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When do they need to do it? When seeing patients taking antipsychotic medications
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Where do they need to do it? At the community mental health clinic.
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How often do they need to do it? Annually for each patient (likely about 10–15 times a month given a typical caseload for a full-time community psychiatrist.
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With whom do they need to do it? With all patients taking antipsychotic medications.
Step 4: What needs to change in order to achieve the target behavior?
Domains | Constructs | Barriers to target behavior |
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Attitudes | ||
Social/professional role and identity | Identity | It’s not my role to manage diabetes if I find an abnormality. |
Motivation and goals | Goal setting | My patients are so sick, diabetes screening is low on the priority list |
Beliefs about capabilities | Control of behavior and environment | My patients are too cognitively impaired to make it to the lab |
Self-confidence | I don’t know how to prescribe medications to treat metabolic abnormalities like diabetes | |
Beliefs about consequences | Outcome expectation | What if these medications to treat metabolic abnormalities cause serious adverse side effects? |
Subjective norms | ||
Social influences | Social/group norms | Nobody else is managing diabetes! |
Environmental context and resources | Resources/materials | The electronic systems are separate, so why bother? |
My medical director won’t want me to do this because we won’t be able to bill for the treatment | ||
Perceived behavioral control | ||
Knowledge | Knowledge | I don’t know exactly what the ADA/APA guidelines recommend |
Skills | Skills | I don’t know how to initiate medications if there are abnormalities |
Environmental context and resources | Resources/materials | I don’t have reminders to get the HgA1c. |
I can’t access primary care, so why bother? |
Step 5: Identify intervention functions
COM-B component | Theoretical domains and constructs | What needs to happen for the target behavior to occur? | Potential candidate intervention functions | Potential behavioral targets (responsible staff) |
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Physical capability | Skills | Physical skills to prepare lab slips | Not applicable | None: psychiatrists have physical skills to prepare and distribute lab slips. |
Physical skills to distribute lab slips | ||||
Environmental context and resources | Lab slips need to be readily available | Environmental restructuring | Make sure lab slips are fully stocked in all treatments rooms (clinic staff). | |
Psychiatrists must have access to all relevant laboratory data from the different systems in which they are served | Creation of a registry with laboratory data from several electronic records (clinic staff). | |||
Psychological capability | Knowledge | Psychiatrists need to know and can easily learn what specific metabolic labs to order | Education | Education about metabolic screening guidelines (primary care consultant). |
Education about medications (and side effects) to treat potential metabolic abnormalities (primary care consultant). | ||||
Persuasion | Using colorful and readable visual charts to motivate learning the cutoffs for different normal cardiometabolic levels (primary care consultant creates; clinic staff distributes). | |||
Psychiatrists need to know how to initiate treatment when metabolic abnormalities are identified | Training | Receive instruction on how to read and use the decision charts with algorithms in making treatment decisions (primary care consultant). | ||
Memory | Psychiatrists need to remember the algorithms for treatment | Enablement | Making algorithm decision charts readily available by distributing copies to all psychiatrists, posting copies in all treatment rooms, and making it accessible electronically (primary care consultant creates; clinic staff distributes). | |
Attention and decision processes | Psychiatrists need to have support for treatment decisions | Environmental restructuring | Providing access to a primary care consultant for clinical decision support through the electronic medical record (EMR) system (IT administrator). | |
Social role and identity | Psychiatrists need to believe that it is their role to screen and treat metabolic abnormalities. | Modeling | Medical director participates in trainings and uses algorithms and primary care consultant via EMR system for decision support around managing cardiometabolic lab results (clinic medical director). | |
Physical opportunity | Intentions and goals | Patients need to receive filled out lab slips from psychiatrists. | Enablement | Provide psychiatrists with completed lab slips monthly for patients with labs due and samples of completed lab slips in examination rooms; ensure that examination rooms are fully stocked with lab slips (clinic staff). |
Utilize phlebotomy services that are located near clinic. | Persuasion | Distribute map of identified lab screening locations and transportation route to all patients with labs due to increase motivation to follow through on obtaining labs (clinic staff). | ||
Patients who are disorganized or have physical disabilities should receive assistance to obtain phlebotomy services | Environmental restructuring | Ensure the availability of a peer navigator as a physical resource for assistance with patients that require assistance in obtaining labs (peer navigator). | ||
Social opportunity | Social influences | Staff psychiatrists observe senior health providers ordering and managing metabolic labs. | Modeling | Local clinic medical director participates in and helps with designing the intervention (clinic medical director). |
Psychiatrists need support to manage abnormalities and access to primary care services | Enablement | The intervention has the support of local champions and leadershipin the form of additional resources that aid psychiatrists in managing cardiometabolic labs (clinic medical director). | ||
Reflective motivation | Optimism | Psychiatrists need to believe that regular metabolic lab screening and treatment will lead to better care | Education | Provide education about improved health outcomes after screening and treatment, and give examples from prior studies to show that it is possible for patients with SMI to have metabolic labs managed in community mental health settings (primary care provider). |
Beliefs about consequences | Psychiatrists need to believe that their work will decrease mortality rates among this population | Persuasion | ||
Automatic motivation | Reinforcement | Need an established routine for reminding psychiatrists about labs and providing feedback for following through on labs. | Enablement | Automated system for reminding psychiatrists which patients have labs due (IT administrator). |
Incentivization | Provide regular performance monitoring to show proportion of patients for each provider that receive lab draws over time and reward providers in their efforts to order lab draws in their patients (IT administrator) | |||
Education | Provide information regarding improved health outcomes for patient population (primary care consultant). |
Step 6: Identify policy categories
Intervention function | Policy category | Candidate policies to support the delivery of the intervention functions |
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Education | Guidelines | Treatment protocols for management of metabolic disorders were distributed (on-line and laminated). |
Persuasion | Communication/marketing | Mugs and birthday cards with logo for clinic staff; logo on algorithms |
Incentivization | Fiscal measures | Treats (e.g., cookies) were provided to the team with the highest metabolic screening rates. |
Coercion | Service provision | Treatment teams knew which teams were the “best” and might be coerced to compete |
Training | Guidelines | A primary care physician reviewed guidelines and protocols for management of metabolic disorders. |
Service provision | Established a support service of a primary care consultant for psychiatrists to access on-line | |
Environmental restructuring | Environmental/social planning | Restructuring the clinic to include in pre-completed lab slips in all interview rooms. |
Stepped care approach where peer navigators could assist patients in going to phlebotomy services. | ||
Modeling | Service provision | Medical Director adopts behavior change and becomes the champion and role model for other staff. |
Enablement | Environmental/social planning | Changing roles where psychiatrist can safely initiate treatment of common metabolic abnormalities. |
Step 7: Identify behavioral change techniques
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Additional resources: psychiatrists would need additional resources to ease the process of ordering metabolic labs, specifically a monthly registry of patients who are due for screening labs and pre-completed laboratory slips.
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Social support: two new team members will provide social support: (1) peer navigator to help complete lab slips, assist patients to phlebotomy services, and enter data into the electronic medical record, and (2) a primary care consultant to help provide clinical decision support for psychiatrists initiating medications to treat metabolic abnormalities.
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Goal setting: regular performance monitoring will help ensure that 80% of all patients receive annual metabolic screening.
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Problem solving: psychiatrists will have immediate electronic access to a primary care consultant to provide clinical decision support.
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Action planning: algorithms help provide psychiatrists with a plan for any abnormal values identified on screening metabolic labs.
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Self-monitoring: performance monitoring of metabolic screening status on the panel of each individual psychiatrists.
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Review of behavior and outcome goals: conduct a quarterly panel review for all patients with labs due over a three-month period to troubleshoot complex cases and to receive feedback from psychiatrists and ancillary staff on the intervention.