Guided Goal Setting: The Logical Next Step to VENA

Presented by:Shirley H. Sword, MS, RD, LDN

PA Department of Health – Division of WICOctober 14, 2010

Objectives

• To gain insight on the history of the development of Guided Goal Setting

• To understand the research behind development of the Guided Goal Setting Module

• To learn the local agency perspective on how Guided Goal Setting is working in the clinics

Facts and Figures About PA

• 9th Largest WIC Program

• 44,817 square miles• 274 people per

square mile• One-third of our 12.4 million residents live

in rural areas, the largest non-urban population in the nation

• 2nd highest percentage of residents >65 years old in the country

Facts and Figures About PA WIC

• 67 Counties• 24 Local Agencies

– Community Action Programs

– Medical Centers– County Health

Departments– Private, Non-Profits

• 265,000 Monthly Caseload

Service Delivery System

• 329 Total WIC Clinics– 116 Primary Sites– 213 Satellite Sites

• Users in total - 832– 383 CPAs– 449 Non-CPAs

• 1767 WIC Authorized Stores• On-site, On-demand Check Printing

How It All Got Started

Special Project Grants• Special funding from USDA for special State

projects of regional or national significance to improve the services of the program

• Address issues of critical and timely importance

• Requires a rigorous evaluation component• Results are widely disseminated to other

States

Development and Evaluation of

Guided Goal Setting (GGS) as a

Behavior Change Approach and Monitoring Protocol

in Pennsylvania WIC

Our Special Project Grant

Partners in This Project

• PA WIC – Shirley Hsi Sword, Project

Director

• Indiana U of PA– Stephanie Taylor-Davis,

Principal Investigator– Mia M. Barker, Co-Investigator– William F. Barker, Evaluator– Pao Ying Hsiao, Research

Assistant

Goals of this Project• To enhance the quality of WIC services

provided to PA WIC participants• To further VENA initiatives via an

evaluated and measurable, participant-centered nutrition education counseling approach that:

• Maintains continuity from visit to visit• Empowers participants • Benefits the participant

The Basis for Goal Setting• Straight-forward behavioral change

approach that accommodates a variety of achievement levels

• Emphasizes small, progressive steps that are concrete

• Relevant to address emerging prevention-oriented public health concerns

• Supported in scientific and behavioral literature with a variety of populations and topic areas

Guided Goal Setting (GGS): Defined

An approach used by the nutritionist in conjunction with the participant that involves critical thinking based on assessment to develop strategies for goal setting to achieve desired participant outcomes

Central Mission• Identification, development,

implementation, and evaluation of GGS as a WIC counseling method to: – Increase participant-centered approach – Enhance staff competency and critical

thinking skills– Assess participant commitment to food-

based behavior change– Extend nutrition education by

supplementing contact points with targeted reinforcements

Results by Year2005-2008

GGS: Special Project Grant

Goals by Year• Year 1: “Profile Identification and WIC Evaluation”

– Assess the state of being in PA WIC with respect to goal setting as a nutrition education counseling approach

• Year 2: “Guided Goal Setting Practices & Assessment”– Formalize the GGS process through development and pilot

testing of a training module and assessment tools• Year 3: “Improvement – Nutrition Education &

Outcomes”– Project 1 = Provide standardized training to nutritionists to

improve staff competency– Project 2 = Run an experimental protocol with GGS that

uses reinforcement and is participant-centered and individualized

Year 1 Projects

1. Interview and survey WIC staff to identify nutrition education best practices and barriers to best practices (n=147)

2. Survey WIC participants (not initially in proposal) (n=4665)

• Demographic Survey • Written Surveys• Semi-structured interviews

– Face-to-face– Telephone

• Nutrition Education Services Survey• Director Survey• Nutrition Education Coordinator Survey• WIC Participant Survey

Year 1: Data Collection

Year 1: Research Study Participants

Constituency n

Average Years of Service in PA WIC

(range)

State Agency Staff* 5 14.5 years (2-24 years)

Local Agency Directors 24 19 years (3-31.5 years)

Nutrition Education Coordinators 18 9.5 years (<1-24 years)

CPAs/Nutritionists 100 8 years (<1-24.5 years)

Participants (all local agencies represented)

4665 n/a

Results:Year 1 – Staff Insights

• Common themes for implementing:– Time– Environment– Distractions– Training– Resources– Attitudes about goal setting

Results:Year 1 – Staff Insights

• Best practices:– Participant-centered – Committed and knowledgeable staff– Receptive participants– Good assessment with critical

thinking– Personalizing process – Establish expectation for goal setting

Results:Year 1 – Staff Insights

• Attributes:– Knowledge– Professional behaviors with participants– Professional behaviors within WIC– Program beliefs– Other– Professional values

Results:Year 1: Participant Insights

• Participant attitude different than staff perceptions

• Liked best • Helpful suggestions from nutritionist• Caring Staff• Handouts and brochures• Recipes

Results: Participant Insights (cont’d)

Selected 1 response

Selected more than 1

responseHelpful suggestions from nutritionist

1050 (23%) 2909 (62%)

Caring Staff 688 (15%) 2402 (52%)Handouts and Brochures

478 (10%) 2158 (46%)

Recipes 110 ( 2%) 890 (19%)

Participant Response (n=4,665) Regarding What They Like About WIC Nutrition Information

Collective Voice:Year 1 Findings

– TIME– Staff issues– Perceptions – Participant issues– Training issues

– Resources– Sites– Information – Communication

Year 2 Projects

• Develop & test a standardized, yet flexible, theory-based, user-friendly training module and associated instrumentation that will strengthen staff skills and competencies to facilitate the GGS Process

General Concept of GGS Module Development

GGS Module Units & Objectives

Agency Staff LA Directors Nutrition Ed Coordinator

Nutritionists Participants

GGS Practices Assessment Instruments

Literature

Theoretical Basis: GGS Framework

Additional Year 1 Project Findings Incorporated

• “Key principles, assumptions and expected components of a GGS contact” document

• Recommendations regarding time and delivery system to support nutritionist and paraprofessional training

• Best practices and success story reports from semi-structured interviews

The GGS Module

• Ten, 15 to 20-minute hands-on units• Activity rich• Case study oriented• Learner workbook• Evaluations: pre, one minute, post,

workshop evaluation, and 6 week follow-up with “skill set use”

• Pilot tested using facilitated group training

GGS Module: Units 1-5

1. Definition and Relevance2. Counseling Strategy for Behavior

Change3. Assessment and the Contribution of

the WIC Staff4. Personalizing the Process5. Linking Risk Codes to Participant Goals

GGS Module: Units 6-10

6. The Team Approach and Goal Priority7. Structure of Measurable Goals8. Documentation9. Follow-Up and Goal Achievement10. Action Plan

Year 3 Projects

1.Staff Training using GGS module

2.Experimental protocol to test effectiveness of GGS with participants

Year 3 Results: Staff Training

• Alpha testing (February 2008) n=10

• Beta testing (July 2008) n=12

Pre- and post-training surveysOne minute evaluations for each unitOverall workshop evaluationSix week follow-up “skill set use” survey

GGS Training Evaluations

GGS Evaluation:“Most Important Things Learned”

α Site β SiteHow to set goal with more emphasis on client perspective

Participant satisfaction is a goal we want to maintain; be more supportive to our participants

Different approaches to clients OK to brainstorm Examples of dialogue with participants

Effective communication for effective goal setting

The importance of goal setting and the way you present yourself

How to organize information

Allowing the participant to set goal

To include the WIC participant when making goals

Making the goals more specific, the who, action, number, etc.

How to make proper goals and documentation How to effectively and realistically develop customer based goals

I really enjoyed the concept maps Mapping

GGS Evaluation: “Least Important Things Learned”

α Site β SiteMapping MappingNutrition documentation example

Documentation

Unit 1 and 2

GGS Evaluation:“How Use Information”

α Site β Site

Plan to use all aspects Share with team

Documentation procedures

Better understand staff’s job

Mapping to show problem areas visually

Daily counseling

To bring together aspects of the visit

Reinforcing positives

Suggestions after Pilot Testing

Based on α Site

• Modified the units to make them more consistent in presentation style

• Added a small amount of time to each unit

• Most substantial revision was to Unit 6 – TEAM approach

• Modified the way the documentation template was introduced in Unit 8

• Added the ‘Modified’ response option to Skill Set Survey Instrument

Based on β Site

• Spend more time on the last five units and less time on the overview

• Split into two sessions• More examples of goals and

documentation• Fewer evaluations or group

them• Good information but could

go at faster pace

Conclusions after Pilot Testing

• By establishing a baseline and a consistent structure for participant goal setting within PA WIC, there are now parameters upon which to evaluate the nutritionist-participant interaction and assess the efficacy of this counseling method to support participant behavior change.

• The GGS Training Module and Assessment Instruments provide a mechanism to address staff (both CPA/Nutritionist and Other Staff) competency to facilitate the goal setting process with WIC participants.

The Local Agency Perspective

The Old Days

The New Age - GGS

Staff Reaction

•Better working relationship with the clients

•More open communication between staff and clients

•More aware of the client’s perception of their family’s nutritional needs

Client Reaction

• “Your nutritionist was very well informed and offers great ideas and information.”

• “Staff was very friendly and explained everything in detail and offered excellent help.”

• “Staff made us feel comfortable with her advice and help.”

• “The Staff spoke to me, not at me.”

Hurdles to Cross

•Don’t jump to conclusions!•Set small, achievable goals•Time•Documentation

Effect on Clinic Operations

•No change in staff duties•No operational changes

within the clinic•Continuing education for

professional and paraprofessional staff

Our Results

Number of Participants with a Goal Established

Number of Participants with

Follow-up Completed

Number of Clients who achieved their

Goal

360/360 323/353 218/323

100% 91.5% 67%

Acknowledgements

• USDA, Food and Nutrition Service• FNS Project Officers

– Cherisa Toomer (May 2007 – December 2008)– Carol Stiller, MS, RD (September 2005 – April

2007)– Home Nursing Agency staff and participants– Adagio Health, Inc.

• PA Department of Health, Bureau of Information Technology and Ciber, Inc.

Contact Information

Shirley H. Sword, MS, RD, LDNssword@state.pa.us

Stephanie Taylor-Davis, PhD, RD, LDNstdavis@iup.edu

Mia Barker, PhDmabarker@iup.edu

Tracy Kelleytkelley@homenursingagency.com