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Welcome to SocialPrescriberPlus™Care Navigation for Social Prescribers, Link

Workers & Community Support Coordinators

Module 2

Case Management Skills

& Techniques

Module 2

What’s Coming Up?

• Techniques and Skills:– Active Listening

– Motivational Interviewing

– Developing a Care Plan:

• Groups 4 Health

• Mind, Body, Spirit template

• Evaluation:– For whom?

– Methods

– National Guidance

Active Listening

Active Listening – Without Words

Non Verbal– Use nonverbal cues which show understanding:

• Nodding occasionally

• Keep eye contact (where culturally appropriate) – bridge of nose

• Smile

• Leaning forward

– Actively focus on listening to, and understanding the other person

– Adopt an open and inviting posture

– Don’t plan your response until they have finished talking

– It is okay to take brief notes but avoid writing while patient is talking to you

Active Listening – With a Few Words

Verbal • Open Questions: How? What? Where? Who? Why?• Summarising: A summary helps to show the individual that you

have listened and understood their circumstances and their feelings.

• Reflecting: Repeating back a word or phrase encourages the individual to carry on and expand.

• Clarifying: Sometimes an individual may gloss over an important point. By exploring these areas further we can help them clarify these points for themselves.

• Short Words of Encouragement: The person may need help to go on with their story – use words like ‘I see’, ‘Sure’, ‘Yes’, I know’ or‘Go on’.

• Reacting: We need to show that we have understood the situation by reacting to it –“That sounds like it is really difficult”.

Active Listening Exercise

• Working in pairs, take it in turns to recount a situation from one of your clients, as though it was your own story.

• Your partner will actively listen to your story and use all the Active Listening techniques to encourage you and to understand your situation.

• Once finished, the storyteller feeds back to the listener on how she felt the listener responded and encouraged her to share her story.

• Then swap over and repeat the exercise with the listener becoming the storyteller and vice versa.

Motivational Interviewing


What’s it for? Motivational Interviewing is a collaborative conversation between you and the patient to strengthen the patient’s own motivation for and commitment to change.

Why would I use it? Motivational Interviewing is a person-centred, collaborative conversation for addressing the common problem of ambivalence about change.

How does it work? Motivational Interviewing is a goal oriented method of communication with particular attention to the language of change. It is designed to strengthen an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change.

Motivational Interviewing - The Stages of Change

Motivational Interviewing Principles

The Social Prescriber/Link Worker practices motivational interviewing with five general principles in mind:

• Express empathy through reflective listening.

• Develop discrepancy between clients' goals or values and their current behaviour – identify ambivalence.

• Avoid argument and direct confrontation.

• Adjust to client resistance rather than opposing it directly.

• Support self-efficacy (a belief in yourself and in your ability to accomplish your goals successfully) and optimism.

Motivational Interviewing Techniques - OARS

The key techniques in Motivational Interviewing are:

• Open Questions O

• Affirmation A

• Reflective Listening R

• Summary Reflections S

• Empathy E

Motivational Interviewing Techniques – Open Questions

Closed vs Open Questions:

“Did you have a good relationship with your parents?”vs

What can you tell me about your relationship with your parents?

Examples of Open Questions:• How can I help you with ___?• Help me understand ___?• Could you share with me…?• How would it make you feel if……..?• How would you like things to be different?• What are the good things about ___ and what are the less good things about it?• When would you be most likely to___?• What do you think you will lose if you give up ___?• What have you tried before to make a change?• What do you want to do next?• How were you so successful last time?• Tell me more about…• How was that…?• What are you doing that you find helpful?...• When do you notice that?...• Who supports you in your day to day life?...

Motivational Interviewing Techniques - Affirmation

• Affirmations are positive statements and gestures that recognize client strengths and acknowledge the effort or achievement somebody has made.

• Affirmations build confidence in the client’s ability to change. A positive statement offering emotional support or encouragement.

Examples of affirming responses:• You told me you tried to change before, that shows great determination• I appreciate that you are willing to meet with me today.• It took a lot of courage to come in today• You are clearly a very resourceful person.• You handled yourself really well in that situation.• That’s a good suggestion.• If I were in your shoes, I don’t know if I could have managed nearly so well.• You really care a lot about your family• You were successful in changing in the past• I’ve enjoyed talking with you today.

Motivational Interviewing Techniques – Reflective Listening

• Reflective Listening is the primary skill used to demonstrate empathy, interest and understanding. It begins with an interest in what the client has to say and a desire to truly understand how the client thinks.

• Using the person’s language helps them feel heard, builds rapport and ensures that the person is an active partner in the dialogue. It is also very powerful to have your own thoughts and words reflected back.

• The listener’s voice turns down at the end of a reflective listening statement. This leads to clarification and greater exploration, whereas questions tend to interrupt the client’s flow. Some people find it helpful to use some standard phrases:– So you feel…– It sounds like you…– You’re wondering if…

• There are three techniques for Reflective Listening:

– Repeating or Rephrasing: The Listener repeats or substitutes synonyms or phrases, and stays close to what the speaker has said:

• “So you feel as though there is no-one there to support you and that is making your anxiety worse.”

– Paraphrasing: The Listener makes a restatement in which the speaker’s meaning is inferred:• “What I think I understand you to be saying is that your anxiety is made worse by the lack of support.”

– Reflection: The Listener replays the message using their own words.

Motivational Interviewing Techniques – Summaries

• Summaries are special applications of reflective listening. They can be used throughout a conversation but are particularly helpful at transition points, for example, after the person has spoken about a particular topic, has recounted a personal experience, or when the encounter is nearing an end.

• Summarising helps to ensure that there is clear communication between the speaker and listener. Also, it can provide a stepping stone towards change.

Structure of Summaries

• Begin with a statement indicating you are making a summary. For example:– “Let me see if I understand so far…”– “Here is what I’ve heard. Tell me if I’ve missed anything.”– “Would now be a good time to sum up where we are?”

• Give special attention to summarising Change Talk or Change Statements made by the client that point towards a willingness to change. For example:– “You said that you recognised you have been drinking too much.”– “You explained to me about the negative impact on your family and how you wanted to address that.”– “You said you thought that getting out more would help your depression.”

• If the person expresses ambivalence, it is useful to include both sides in the summary statement. For example: – “On the one hand you recognised that your drinking was a problem, but on the other hand you also felt it

dulled the pain of your loss”.

• End with an invitation. For example:– “Did I miss anything?”– “If that’s accurate, what other points are there to consider?”– “Anything you want to add or correct?”

• Depending on the response of the client to your summary statement, it may lead naturally to planning for, or taking concrete steps towards the change goal.– “Given what we have just discussed, how do you think we might take that forward?”– “So shall we have a look now at how you might make that change happen?”

Empathy

• Empathy is the capacity to understand or feel what another person is

experiencing from their perspective, that is, the capacity to place oneself in

another's position.

• It is both a natural human quality and a learnable skill for understanding and

sharing the feelings of the client. It requires close attention to what the client

tells you.

• An empathic style:

• Communicates respect for and acceptance of clients and their feelings

• Encourages a non-judgmental, collaborative relationship

• Allows you to be a supportive and knowledgeable consultant

• Sincerely compliments rather than denigrates

• Listens rather than tells

• Gently persuades, with the understanding that the decision to change is the client's

• Provides support throughout the recovery process

Motivational Interviewing – Change Talk

• An important part of motivational interviewing is to guide the patient towards ‘Change Talk’. There are four types of change statements, all of which overlap significantly:

– Problem recognition: “My use has gotten a little out of hand at times.”

– Concern: “If I don’t stop, something bad is going to happen.”

– Intent to change: “I’m going to do something, I’m just not sure what it is yet.”

– Optimism: “I know I can get a handle on this problem.”

• You can encourage change talk by asking questions that prompt a change response:

Why do you want to make a change?

What are the reasons for you to change?

What would some of the benefits be?

How might you go about making a change?

What would be your first steps?

Motivational Interviewing – Listening for Change Talk

Replies to your questions to encourage change talk may prompt a change response. Listen carefully for change talk:

l might, I should, I wish, I want, I can, I will…

The reasons are……

It would solve a problem…..

I’ve thought about….

My wife/husband mentioned……

I read about…

Table Exercise

Encouraging Change Talk

Encouraging Change Talk

Instructions

• Pick someone to start. That person reads out the first statement below to the rest of the table. The person to the left then asks an Open Question about the statement, the person to their left then makes an Affirming Statement, the person to their left a Reflection and the person to their left Summarises the conversation so far.

• Once all four techniques have been used, the table can briefly discuss the interventions, making sure each meets the requirements of that type of intervention.

• The process then starts again, with the person to the left of the previous summariser reading the next statement below. Then continue around the table to the left until all statements have been read out.

Motivational Interviewing Strategies

Social Prescribers can use 9 strategies for Motivational Interviewing to build trust with patients, engage them in their own care, and help them find motivation to adhere to their

care plans

Motivational Interviewing – Strategy No. 1

Ask a question that will prompt change talk as an answer. For example:

“What are some things you can do to make sure you take you medication regularly?”


Ask about the Positives & Negatives, Pros & Cons, Advantages & Disadvantages of the target behaviour:

Positive:“How will taking your medication improve your condition?”

Negative:“What are the negative impacts of taking your medication (e.g., cost,

side effects)?”

Pros:“How will taking your medication lower your risk of hospital

readmission?” Cons:

“How will another hospital readmission (i.e., continuing to miss medication doses) impact you?”


When the patient expresses change talk, ask for more details:

“In what way could that happen? Could you tell me a little more about that? When was the last time that happened?”


Ask about a time before the patient enrolled in the scheme:

“How were things different before you agreed to our sessions?”


Look forward. Ask what may happen if the patient makes the changes according to their care plan:

“If you follow all your care plan, what will be different?” How do you see your health five years from now?”


Ask about extreme outcomes:

“What are the worst things that might happen if you don’t follow the care plan we have worked on?”

“What are the best things that might happen if you follow the plan?”


Offer ways to clearly measure the impact of making a change. For example:

“On a scale from one to 10 (where one is not at all important and a 10 is extremely important), how important is it to you

to improve your health?

What do you think you can do to get closer to a 10?”


Ask about the patient’s main health goals. For example:

“Do you want to be healthy enough to travel this summer?”

“What upcoming family events do you want to attend?”


Think like the patient and reframe any barriers into a positive strategy:

“You mentioned that taking your medication every night before bed is a hassle. How about taking it in the morning instead?”

Motivational Interviewing – 9 Strategies

1. Ask a question that will prompt change talk as an answer.

2. Ask for the Pros & Cons, Positives & Negatives of both changing and staying the same.

3. Ask for more details when change talk theme emerges.

4. Ask about a time before the patient enrolled in the scheme.

5. Ask what may happen if the patient makes the changes according to their care plan.

6. Ask about extreme outcomes.

7. Offer ways to clearly measure the impact of making a change.

8. Ask about the patient’s main health goals.

9. Reframe any barriers into a positive strategy.


Question Development Exercise

Question Development

• Whilst the interview/session should always be flexible enough to respond to the needs of the patient and develop organically, it is always useful to have a structure in mind and a number of key questions, based on your knowledge of the patient or previous engagement with them.

• Using the information on the Referral Form provided and working as a team, use the flip chart to write 9 questions using the 9 strategies, that you could keep to hand if the interview develops according to your estimation.


Closing the Session and Setting Goals

Relapse Prevention

ASK: ‘Thinking about the next few weeks, what might get in the way of you achieving your goals and carrying out your action plan?’

• Identify Triggers:

– Holidays

– Injury

– Stress/emotional situations

– Pain

– Small lapses into old habits

– Low motivation

– Bad weather

Taking action

Maintaining

RelapsingThinking

Preparing

How to Move to Action

• People must believe:– They have a plan

– They can enact it

– They can stick with it

• Support people to develop a plan for change:– What’s the change I want to make?

– Reasons for changing are…?

– Steps I’ll take are…?

– People will help me by…?

– I’ll know it’s working if…?

– Things that could get in the way are…?

– Things I’ll do to limit this are…?

Goal Setting

Goal Area What do you want to change?

Your Goals

Actions for Me Actions for Other

Looking after myself/Taking exercise/Getting out

Practicalities of life -Money/Housing/Benefits

Transport

My work/Hobbies/Volunteering

Happiness with LifestyleDesired social activity

Overall mental well-beingFeeling good about myself

Supported by Family/Friends/Groups

Thinking positively/Feeling optimistic

Managing symptoms & unhealthy behaviours/Taking medication

Motivational Interviewing – Commitment Talk

• An equally important part of motivational interviewing is to guide the patient towards a commitment to achieve a positive goal – ‘Commitment Talk’.

• Expressed at the end of a motivational interviewing session, commitment talk seals the patient’s commitment to a care management goal:

“I will discuss it with my wife/husband.”

“I am going to take my medication every day, as prescribed.”

“I will come to the class if you come with me.”

“I will try not to have alcohol on Wednesdays.”

Motivational Interviewing – Commitment & Consistency

• Once trust has been established, and if you feel the relationship is strong enough, consider use of the “Will you?” question.

• Social Psychology tells us that when we make a commitment to someone, and we do so verbally, we are much more likely to be consistent in following through:

“Will you try to make Wednesdays an alcohol free day, as we discussed?”

“Yes, I will.”

Groups 4 Health

Groups 4 Health

• Social Group belonging, and the sense of social identity that it provides, has been shown to be a key source of self-esteem, feelings of control, access to social support, and a sense of purpose and meaning.

• Groups 4 Health is an evidence-based psychological intervention designed to improve health by providing people with the knowledge, skills, and confidence to increase their social connectedness, and in particular, their group-based social identifications.

• The programme is designed for anyone who is concerned about feeling isolated and disconnected from others in their present life or immediate future.

• This includes people with a clinical diagnosis (e.g. depression, chronic pain) as well as people experiencing normal life transitions (e.g. relocation, retirement, transition to parenthood, etc).

• For those receiving the programme, 83 per cent showed an improvement in loneliness and 71 per cent an improvement in depression.

The Stages of Groups 4 Health

• Stage 1 – Why your Social Group ties matter?– Increases awareness of the role that social groups play in our lives

– Helps people to discover the benefits of social groups

• Stage 2 – Mapping your social world– Help users to visualise and illustrate their social group networks and

relationships between them

– This will be used to identify any areas that can be strengthened and developed further

• Stage 3 – How to make the most of existing social networks– Discovering the best ways to make the most of their group ties

– Identifying key ways to reconnect with old group ties

• Stage 4 – Building new connections– Identifying groups that the user would like to join

– Developing the confidence to join new groups

The Stages of Groups 4 Health

• Stage 1 – Why your Social Group ties matter?– Increases awareness of the role that social groups play in our lives– Helps people to discover the benefits of social groups

• Stage 2 – Mapping your social world– Help users to visualise and illustrate their social group networks and

relationships between them– This will be used to identify any areas that can be strengthened and

developed further

• Stage 3 – How to make the most of existing social networks– Discovering the best ways to make the most of their group ties– Identifying key ways to reconnect with old group ties

• Stage 4 – Building new connections– Identifying groups that the user would like to join– Developing the confidence to join new groups

• Stage 5 – Ensuring the user’s group ties endure– Troubleshooting any issues encountered in managing social groups

Social Identity MappingHelping people to create a visual representation of the Social Groups in their lives

Groups 4 Health Exercise

Groups 4 Health Exercise

• Work in pairs, where one is the service user and the other the Community Care Coordinator – the service user adopts the persona of one of their previous clients.

• The Community Care Coordinator engages the service user in looking at the social groups that are important to them:– Talk about the benefits of groups in social activity

– Encourage the user to visualise the groups in their lives

– Illustrate on a flip chart using PostIt Notes and mark the strength of relationships with lines

– Discuss how to connect with old group ties

– Discuss what new groups the user would like to have in the illustration and how you might jointly make that happen

• Then swap over roles.

Self Care Plans

Self Care Plans - Principles

• Co-produced with Patient

• Topic areas agreed with client – edit topics as needed

• Make it colourful and personal, not ‘official’

• The client’s to keep and use – not recorded or copied

• Regular review at each meeting – basis for completing Prism and discussing, “How has it been for you since we last met?”

I can relax my body and mind by….

I can look after myself by…

People & Groups important to me…

___________________________________’s Self Care PlanMy interests….

I can be a good friend by…

I would like to meet up and spend some time with….

I can meet other people by…

I could volunteer…

Evaluation and Reporting

Evaluation – Who For?

• There are at least five stakeholder groups for whom evaluation of Social Prescribing is important:– The benefits to the Patient/Client

– The commissioners of the service and funders (if different)

– The GP/Practice/Organisation providing the referral

– The service/organisation/Community Group the patient/client is referred to

– The Social Prescribing Scheme itself

Evaluating and Reporting the Benefits to the Client/Patient/Service User

Evaluating the Benefits to the Patient/Client

• Reviews of existing Social Prescribing schemes highlight the challenges of persuading service users to complete or take part in formal evaluation.

• There are many points based evaluation schemes out there, most developed from an academic standpoint – and most too long, too complex or cover a narrow dimension of health and wellbeing.

Tools Used in Evaluation of Social Prescribing Schemes

• New Economics Foundation (NEF) Five Ways to Wellbeing, (New Economics Foundation, 2008)

• Warwick-Edinburgh Mental Well-being Scale (WEMWBS;21,26 ,32)

• Hospital Anxiety and Depression Scale (HADS;18)

• General Anxiety Disorder-7 (GAD-7;27)

• Patient Health Questionnaire-9 (PHQ-9;27)

• Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM;22)

• Work and Social Adjustment Scale (WSAS;21 ,22)

• General Health Questionnaire (GHQ-12;22)

• COOP/WONCA.

NICE Endorsed SP Evaluation Tool

Evaluating the Benefits to the User

• Reviews of existing Social Prescribing schemes highlight the challenges of persuading service users to complete or take part in formal evaluation.

• There are many points based evaluation schemes out there, most developed from an academic standpoint – and most too long, too complex or cover a narrow dimension of health and wellbeing.

• Therefore, consider treating the need to evaluate the engagement as an opportunity to regularly review progress with the patient, not as an end in itself.

The Health and Well-being Prism

Happiness with LifestyleDesired social activitySupported by Family/

Friends/Groups

Thinking positivelyFeeling optimistic

Managing symptoms &unhealthy behaviours

Taking medication

My workHobbies/Volunteering

Looking after myselfTaking exercise/Getting out

Overall mental well-beingFeeling good about myself

Practicalities of life -Money/Housing/Benefits/Transport

Evaluating and Reporting the Benefits to the Commissioning Organisation

Data Capture and Evaluation

• NHS(E) emerging Best Practice suggest that the following metrics are recorded:– Number of SP sessions required before discharge

– Number of GP appointments in previous year

– Number of GP appointments during programme

– Number of GP appointments during 6 months after discharge

– Prism (or other tool) scores at each session and on discharge

– Percentage improvement on each Prism (or other tool) measure

Evaluating the Benefits to the Commissioning Organisation

• Make a pragmatic assessment of what will deliver continued funding/support for the scheme

• Devise a data collection process that meets the needs of both commissioners and the scheme

• Agree qualitative/quantitative metrics and targets with commissioner that will be used for evaluation

• Devise means of delivering improvement in metrics without affecting scheme performance in other areas

• Use SNOMED codes to deliver hard data on performance• Use Patient Activation Measure (PAM) to deliver subjective data on

success• When reporting, use words such as Increase, Growth, Improve, Expand,

Enhance, Build, Enlarge to demonstrate performance.• Always link Outcomes to Output• Include Stories and Testimonials to support hard data.

The Patient Activation Measure

NHS(E) Evaluation Measure of Choice


• The PAM® is a validated, licensed tool that measures people’s knowledge, skills and confidence (referred to as ‘patient activation’) in managing their own wellbeing. It is expected that by understanding a patient’s activation level, care can be planned appropriately with the individual, leading to improved wellbeing and fewer episodes of unplanned and emergency care.

• The PAM® is a validated questionnaire comprising 13 questions and is licensed from Insignia Health LLC. The responses match the respondents to one of four levels of ‘activation’, each of which reveals insight into a range of health-related characteristics, including behaviours and outcomes.


• The PAM® is a validated, licensed tool that measures people’s knowledge, skills and confidence (referred to as ‘patient activation’) in managing their own wellbeing. It is expected that by understanding a patient’s activation level, care can be planned appropriately with the individual, leading to improved wellbeing and fewer episodes of unplanned and emergency care.

• The PAM® is a validated questionnaire comprising 13 questions and is licensed from Insignia Health LLC. The responses match the respondents to one of four levels of ‘activation’, each of which reveals insight into a range of health-related characteristics, including behaviours and outcomes.

• The PAM® should be used in conjunction with care and support planning and a range of interventions to support self care.

Patient Activation Measure

Analysis Converting responses into PAM® scores and the four levels of activation is controlled by Insignia and is part of the licence agreement with NHS England. The scores are recorded on an interactive spreadsheet provided by Insignia and the results are then entered onto the patient record. Keeping the original response sheet (or scanned version) is useful as individual answers may be used as prompts in coaching sessions.

Information Governance For any data collection exercise involving personal data to be lawful, you must establish a clear legal basis for its use and inform patients about its proposed use. Collecting data for one stated purpose and using it for another is unlawful and unethical. Your information governance lead can support you to manage these risks.

The service/organisation/Community Group the patient/client is referred to

Evaluating the Benefits to the Referred Service

• Your referral may be welcome in that it adds attendees and may make the service viable – or it may be unwelcome in that it puts additional strain on scarce resources/increases waiting times for users

• Always provide positive feedback to the service on the experiences of your users

• Arrange regular meetings with services to understand pressures

• Look for opportunities for synergies and funding opportunities you can help with.

Evaluating the Benefits to the Practice or Referring Organisation

Benefits to the Practice or Referrer

• Don’t underestimate the importance of providing positive informal and formal feedback to referrer organisations.

• Schedule regular feedback during the year and arrange several face to face reviews with lead GP/PMs.

• Share positive stories and testimonials with staff as well as management

• Using SNOMED codes, write a report for the Practice on their Social Prescribing engagement and outcomes.

Record Keeping – Electronic SNOMED Codes

• NHS(E) has worked with NHS Digital to create National Social Prescribing codes for use in GP IT systems to capture Social Prescribing referrals.

• When working with patients/clients referred by GP Practices, Social prescribers should use the following SNOMED CT6 codes for Social Prescribing:

– 871691000000100 | Social prescribing offered (finding)

– 871711000000103 | Social prescribing declined (situation)

– 871731000000106 | Referral to social prescribing service (procedure).

Professional Resources

• Future NHS Collaboration Platform – Personalised Care Group – Request membership via [email protected]

• Social Prescribing Network - https://www.westminster.ac.uk/patient-outcomes-in-health-research-group/projects/social-prescribing-networkand @SocialPrescrib2

• Twitter Social Prescribing Wednesday - @SocialPresHour

• Monday Social Prescribing email meet-up [email protected]

• National Association of Link Workers www.connectlink.org Christiana Melam [email protected]

mailto:[email protected]

https://www.westminster.ac.uk/patient-outcomes-in-health-research-group/projects/social-prescribing-network


http://www.connectlink.org/


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