1. HLC ACCEPT Training Ohio Valley Sickle Cell Network April 11, 2012

2. Agenda 6:00- 6:10 Welcome and Introductions 6:10-6:15 Plan for Evening’s Activities 6:15- 6:30ACCEPT High Level Overview 6:30-6:45*Asking Open Ended Questions 6:45-7:05*Reflective Listening 7:05-7:15*Identifying Stage of Readiness 7:15-7:25*Importance Ruler 7:25-7:45*Role Play 7:45- 8:00Wrap-up

3. Self-Management Self-management is what people do every day Deciding what to eat, whether to exercise, if and when they will take their medications Everyone self manages; the question is whether or not people make decisions that improve their health Bodenheimer et al. Helping Patients Manage their Chronic Condition California Healthcare Foundation, 2004 www.chcf.org

4. Self-Management Emphasizes the patient’s central role in managing health Bodenheimer et al. Helping Patients Manage their Chronic Condition California Healthcare Foundation, 2004 www.chcf.org

5. Patient Empowerment Knowledge is often not enough to change behavior The additional factors needed are collaborative decision making, and problem solving skills Bodenheimer, PowerPoint presentation, Academic Chronic Care Collaborative. 2005

6. Remember… “If your consultation time is limited you are better off ASKING patients WHY they would want to make a change and HOW they might do it rather than telling them that they SHOULD.” - Rollnick, Miller, Butler 2008

7. ACCEPT is… Behavior change counseling Adapted by CCHMC from motivational interviewing Short (5-30min) intervention designed for office-based settings Goals: – Movement in stage of readiness to change – Positive health behavior change – Better clinical outcomes

8. ACCEPT teaches… The skills of motivational interviewing Anchored by three tools developed at CCHMC – Self-Management Assessment – Stage of Readiness Tool – My Action Plan To promote positive health behavior changes in patients and families.

9. Shifting Your World View In my early professional years, I asked the question: How can I treat or cure or change this person? Now I phrase my question this way: How can I provide a relationship which this person may use for his or her own personal growth?” Carl Rogers Client-Centered Therapy

10. The Spirit of MI Collaboration: – Honors client expertise and perspective Evocation: – Resources and motivation for change lie within the client Autonomy: – Client’s right to self-determination is affirmed and facilitated

11. It’s MI when… 1)The communication style and spirit involve person-centered empathic listening, 2)There is a particular identified target for change that is the topic of conversation AND 3)The interviewer evokes the person’s own goals and values as motivation for change.

12. MI has been demonstrated to be more effective than advice-giving

13. OARS What does this stand for? 13

14. Eliciting Change Talk: OARS O = Open-ended questions A = Affirmations R = Reflective Listening S = Summarization These skills are simple, but not easy. Intuitive but not natural.

15. Affirmations Convey respect & understanding Encourage progress Help patients see themselves more positively Examples: – “You’re courageous to talk about this” – “You’ve accomplished a lot in a short time” – “Sounds like good idea…”

16. Summarization Restates the key parts of the conversation Can help recall and/or focus the conversation in ways it needs to be directed Fosters new ideas, & encourages confidence about moving forward Reflects on ideas in a way that provides support for next steps

17. Stages of Readiness What are these? 17

18. Stages of Readiness not considering change thinking about making change preparing to make a change implementing change sustaining a lifestyle change

19. What if the patient is “holding back”? 19

20. Ambivalence is… A natural tendency of indecision that occurs when someone is thinking about making a behavior change A necessary part of the process of change NOT inherently confrontational Mislabeled as defensiveness or resistance

21. Resistance is … A feeling of opposition or refusal Often just a lack of clarity Created when someone pushes a particular direction or gives advice to someone who is not ready Can become an entrenched position

22. If you can’t tell the difference between ambivalence and resistance, how would you find out?

23. Importance or Confidence Importance “Why change?” Connection with values Understanding and internalizing the benefit of the health behavior change Confidence “How will I change?” Belief that I can: Execute the change Integrate the change into everyday life Overcome barriers

24. ASK… How important do you think it is to (behavior)? What are other people telling you is important? What do you think of that? How confident are you that you can (behavior)? If you were to start (behavior), where would you begin? What are some of the barriers to (behavior)? How would you over come them?

25. READS What does this stand for?

26. READS R = Roll with Resistance E = Express Empathy A = Avoid Argumentation D = Develop Discrepancy S = Support Self-efficacy

27. How do we give information without giving advice? (not a trick question!)

28. Another Important Skill / E-P-E Elicit understanding of patient’s perception Provide request permission & then give information Elicit checking in “How did that sound?” or “What did you think about that?”

29. Where do we go from here? It’s your turn!

30. Open Ended Questions Can’t be answered with a ‘yes’ or ‘no’ Allows the patient/family to know the conversation is about them - and not just the disease Closed ended questions imply the right answer Let the people you are talking with think out loud Answers give a lot of information – about barriers, motivations, influences, and more

31. Reflective Listening A statement – NOT a question Shows that you are listening and that the person’s thoughts and feelings matter to you Moves you closer to a better understanding of the key issues. Lets patient realize that you “get it”, evokes patient’s internal motivation

32. Types of Reflections Content: direct restatement Feeling: making a guess about the feeling behind the statement Meaning: making a guess about the meaning behind the statement Amplified: overstates what the person says Double-sided: captures both sides of the ambivalence

33. Stages of Readiness not considering change thinking about making change preparing to make a change implementing change sustaining a lifestyle change

34. Pre-Contemplation Characteristics: – Not yet ready to make a change – “Ignorance is bliss” or “I am doing just fine” How to facilitate motivation: – Identify medical benefits of change – Acknowledge patients autonomy – Validate patient’s current experience – Discuss change hypothetically

35. Contemplation Characteristics: – Thinking about making a change – “Sitting on the fence” How to facilitate motivation: – Clarify patient’s perceptions – Acknowledge ambivalence – Explore costs and benefits of potential change – Encourage further self-exploration

36. Preparation Characteristics: – Beginning to take steps towards change – “Testing the waters” How to facilitate motivation: – Validate decision for behavior change – Identify potential barriers – Encourage small initial steps

37. Action Characteristics: – Creating a new healthy habit – “I am doing it” How to facilitate motivation: – Build on patient’s success with written Action Plan – Reinforce patient’s change related ideas – Anticipate “slip ups”

38. Maintenance Characteristics: – Sustaining a change over time – “I did it” – “I am successful.” – “I am proud of myself” How to facilitate motivation: – Congratulate patient’s ongoing success – Review progress over time – Reinforce need to ‘stay on track’

39. Personal Action Plan 1. Something you WANT to do 2. Describe HowWhere WhatFrequency When 3. Barriers 4. Plans to overcome barriers 5. Confidence rating (1-10) 6. Follow-Up plan Source: Lorig et al, 2001

40. Now it is your turn! “What would you like to talk about today that may help improve your health?” “Why is this a concern to you?” “How do you think things would be different if this were improved?” “What specific things could you do to improve this aspect of your health?” “That sounds like it would make a big difference to your health! Where could you start to make this change?” “Let’s narrow this down a bit - try to think of something I could take a picture of you doing.” “What might be something that could get in the way of you reaching your goal? How could you work around that?” “How likely do you feel on a scale of 1-10 that you could start on this in the next two weeks?” “When would you like me to touch base with you to see how you are doing?”