“Thinking, Feeling, Behaving”: Jeff Rubin on creating positive behavior change in healthcare
Pager and our clients are critically focused on building trust and credibility to facilitate meaningful healthcare engagements with members. We believe that positive behavior change is the key to improving health. And, if there is one thing we’ve learned, it’s that behavior change is tough.
That’s why we’re excited to talk with Jeff Rubin, Ed.D., a behavior change expert who has developed several advocacy models currently in use across many industries, including in healthcare and finance. Dr. Rubin previously served as the Senior Training Consultant and Data Scientist at Blue Health Intelligence, and as Vice President, Clinical Development and Vice President, Clinical Operations at CIGNA Behavioral Health, among other roles.
Dr. Rubin’s behavior change models focus on identifying a person’s emotional motivators to accomplish a goal and the barriers they face to achieving it. In order to help a person succeed in changing their behavior, the models encourage staff to listen critically and to refrain from using scripts in order to create more personable engagements. His models are tailored toward specific industries and organizations, including his LEARN2 model used by Accolade and featured in our previous interview with Alan Spiro.
We took the opportunity to learn more in our sit down with Dr. Rubin about the key ways to encourage behavior change, how health plans can improve the member experience, and how technology can supercharge human interactions in healthcare.
Tell us a little about your background. What motivated you to build a career in healthcare and to focus on behavioral change?
I'm a psychologist by training and practice. We say that you go into psychology to cure yourself or to someone in your family. In my case it might've been a little of myself. My dad was an alcoholic, so I grew up with Alcoholics Anonymous, which probably saved my life. Then, I moved to California and thought, "I love this stuff. I'm going to go work in a psych hospital." Well, I had no degree, and I was working in a psych hospital, and I was scared to death the whole time. I thought there must be a better way to do this, so I went back to school.
When I was at school, I saw why my father struggled so much. He said what it took him to get finally sober was the many rehabs, appointments, and meetings. It made me ask myself, "What is the difference between people who can carry out difficult behavior changes and people that don't?" This ended up driving my dissertation, and I never really strayed far from this idea.
At Pager, we’re always thinking about ways to build trust and rapport that encourage members to take the right actions for their health. How do your behavior change models work? Why are they especially powerful in healthcare?
What we call “behavior” is people thinking, people feeling, and people living in the context of their lives and their environment. They have thoughts and feelings about what happens in the world, and then they act on those thoughts or feelings. When they act, the whole cycle starts all over again, with many such cycles of ‘think-feel-behave’ happening simultaneously.
We're taught early on that logic is the best way to come to an answer, but emotions play a part in that too. Unfortunately, most behavioral models don't look at emotion whatsoever.
That's how Richard Thaler won his Nobel prize with behavioral economics. According to Thaler, people don't keep their best interest in mind; they're driven by emotional factors, usually found in the context of people's lives. This is true in healthcare, in finance, and anywhere a person is making a decision.
Behavior change models work well in healthcare because there are very specific behaviors to change: how the patient complies with treatment, whether the patient goes to the doctor, how the patient engages in preventative behaviors, diet, or exercise. There is so much decision-making in healthcare, providing countless opportunities to help people make better choices.
While most behavior change models focus on a person’s motivators to changing behavior, Dr. Rubin’s models also focus on the emotions that drive a person's actions. The models are rooted in the idea that feelings are what make a motivator into a true driver for behavior change. The models blend cognitive and emotional approaches to decision making to ensure that a person’s motivators, goals, and feelings are aligned.
My models are based on building trusting relationships, and healthcare payers are not the world's most trusted people. If a payer invests in high-touch, concierge services that build a personal relationship with someone, they earn the right to become a trusted confidant. It gives the payer an opportunity to help individuals change their behaviors.
What's different about my model compared to most other models is that it focuses on the way people feel and the way people get stuck. By being personable and empathetic, you get amazing amounts of information about who a person is from a holistic perspective. You concentrate on finding ways to understand who they are from a perspective of what they need to change within the specific context of their life.
That's why it’s so important to do this in healthcare: the system is so fragmented, it's easy to drop through the cracks. You have an operation, you come home from the hospital, and you get at least five different calls – it's overwhelming. But if you have a trusted guide through that system who can help you lay out the options in such a way where your motivators tie to your goals, and the options become about the pros and cons as they relate to you, your health, your environment, and your feelings, then the likelihood of you succeeding goes up dramatically.
“If you have a trusted guide... to lay out the options so your motivators tie to your goals, your health, your environment, and your feelings, then the likelihood of you succeeding goes up dramatically.”
What are some of the assumptions of these models? What are the keys to encouraging real behavior change?
The assumptions are that people think, people feel, and people behave; that people are people, even when they're your clients for behavior change. You can ask them to do anything you want, but if you don't understand the barriers in their way and what motivates them, then you can't help them think through and sort out what needs to be done.
Another assumption is that relationships require people. It’s important to remember that you can't have a relationship with a script, you can't have a relationship with an assessment, and you can’t have a relationship with an app – at least not yet. We still don't have the artificial intelligence that can look at cues, listen, and use empathic responses to figure out who a person is from a holistic point of view.
“You can ask a person to do anything you want, but if you don’t understand the barriers in their way and what motivates them, then you can’t help them sort out what needs to be done.”
We also must look at emotions. The stronger the emotion, the more clues you want to get about who that person is, and the more clues you want to give about who you are. One thing all my models have in common is empathic listening, also known as reflection of feeling. Carl Rogers argues that mirroring, or reflection of feeling, helps you figure out exactly how you feel. Think about when you talk to somebody and tell them something bad that happened that day, and they say, "Oh, you must be so exhausted." You think, “Exactly.” Think about how close you feel to that person when you get that “Exactly.”
Pager’s Command Center team connects with patients across chat, audio, and video. How do strategies differ across different communication channels when you’re trying to build trusting relationships?
The strategy doesn't necessarily change across different communication channels, but the logistics do.
Good relationships are built on a couple of things. One thing to keep in mind is that the more similar you are to a person, the more likely you are to automatically like them. Another is that you can't build a relationship using a script; you have to be authentic. I train people to help them find their voice rather than teach them a script. It's about considering the goals, and asking a person, “What do you want to say? Where do you want to communicate it? How do you think it was received?” When I first started working with one health plan, they showed me the guide they wanted every care manager and customer service representative to use. And the first thing that it said was to never apologize. I looked at it and thought, "No, that's not human."
With regards to channels, one of the principles that I start with is understanding the effect each channel has on a person. You need to identify the channels a person is best suited for, or the channel they are most likely to use the most often, and work with them there. There is a natural fit between different people and different channels.
“Relationships require people. It’s important to remember that you can’t have a relationship with a script, an assessment, or an app – at least not yet.”
Of course, when communicating, the best thing to do is to offer as many channels as a person utilizes. There are pros and cons of each channel. With the phone, you get more clues: you get to hear what the background sounds like, you get to hear a person’s tone, you get to hear their speed and pacing. When you meet in person, you get even more: you get body language and the visual clues about the way a person holds themselves. On an app, you can get a whole lot, but when someone is really upset, you have to figure out a way to match that. You need to have a strategy to match a person’s emotions and demonstrate that you’re listening via text.
How do you go about identifying and connecting emotional motivators?
You listen in two ways.
First, you'll ask questions to elicit those motivators. The best way to do this is a version of the “miracle” question, which is: “if you woke up tomorrow morning and you had lost those 20 pounds, or you had been going to the gym for six months, or you had been taking your medicine as prescribed, what would change? What would you notice first?” You get a person to paint a picture of their positive world. For example, consider a father who has trouble managing his diabetes.
You don’t say, "This person has a kid; that must be the motivator.” Ask them: what about the kid? Do you want to live to see the kid's kid? Do you want to go to their high school graduation? Or dance at their wedding?
It’s about giving them ideas, and helping them sort out their own cognitive dissonance. You ask, “What would that positive outcome look like?”
They might say, “I can picture him graduating college. My work and my money have gone to the right place, and he does really well in school.”
Now, every time I talk about his diabetic diet, I'll say, "We have to get your A1C down so you can see your kid graduate college." And you never separate those two ideas.
Second, even with all that, people don't always act in their best interest. So you lay it out using choice architecture: you identify the pros and cons, attach the motivator to the goal, and remove the barriers.
For healthcare, there are usually about eight or nine barriers to consider, depending on the population. The biggest one is, of course, access. Competing priorities is another – consider the person who can’t go to the gym because they have to pick up their kid from soccer. Cost is also important, for the person who can’t afford their healthcare or they have to make a trade off on another necessity.
It's about working through all those things and helping people sort out their priorities. That’s emotional work, that’s financial work, that’s value-based and cultural work.
“At the end of the day, it is really about improving somebody’s life. It’s about helping them see things in a way that they haven’t before.”
Our clients often ask us the best ways to integrate these strategies into their services. How would you encourage healthcare and insurance organizations who are hesitant to embrace emotions to implement something like this?
There are a few ways to do it. Talking about compliance and using a health plan’s language in a new way is usually the eye-opener. You can’t define context and barriers to health for them, or tell them how to find motivators; it just won’t make sense. But, you can talk to people and say, “Ever try a diet? Tell me what that's like for you.” Think about that person who wants to go to the gym, but they can't because they have to pick up their kid from soccer. How do you negotiate that?
Once you move behavioral change models away from being financial carrots and sticks and instead focus on connecting with people as flawed, complex, messy individuals, you get the highest customer satisfaction scores you've ever seen. You end up having better results – better satisfaction and therefore better compliance, which leads to saving money as well.
And once embraced, how do you design and implement this?
Number one, you need buy-in and executive support. You have to make customer service a valued service and a trusted guide. You need to detox from old-fashioned rules – the ones that say to not say sorry, to use “ma’am” and “sir” – as these can be very off-putting. Understanding your unconscious bias and being culturally aware helps as well. In a health plan, most of the work is changing the customer service experience.
Number two, you need the right staff. If you have staff that are chomping at the bit to talk to people and help people, but you aim for a two-and-a-half minute call time, you're going to have trouble. So you have to prove that not only is this effective but efficient as well. That efficiency can be measured in a lot of ways. For example, we learned from Accolade that a big company who has a quarter of a million employees over five years can save $20 million with better service. You can do a lot of good things with that money.
Is there anything else that we didn't talk about that you would like to share?
At the end of the day, it is really about improving somebody's life. It’s about helping them see things in a way that they haven't before. The key is to listen, not talk – to allow people the dignity of speaking their feelings and to help people identify and understand where the dilemmas are. You lay out every option – and doing nothing is an option too, which a lot of people choose.
This is really a “one size fits none” model. There is tension between population health and approaches like this. To solve that, you must take what the data says about a person or their segment. Then, you bring it down to a segment of one to understand what’s unique about the person.
Then the questions become, do we believe in improving people’s lives and figuring out how to get people to act in their self-interest? If we do, do we have a model for this? What do we have to do to change things? And how do we measure success when we do it?
Interested in learning more? Hear more about how Pager’s solution can help engage members in meaningful behavior change to improve health here.
