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Presentation on theme: "SARAH BLUST, LMSW, MPH PROJECT MANAGER PRIMARY CARE DEVELOPMENT CORPORATION (PCDC) Motivational Interviewing: A Practical Approach."— Presentation transcript:


2 Learning Objectives To become familiar with the theory and essence of Motivational Interviewing (MI) To gain a general understanding of the techniques of MI To understand how MI techniques can be applied to management of chronic conditions such as diabetes and hypertension

3 But first… Who’s in the room today? Take off your mute button. Say “here” when I call out a role that applies to you!

4 Any health educators in the room?

5 Any providers?  MDs, CNMs, NPs, PAs?

6 How about nurses?  RNs or LPNs?

7 Social workers?  LMSWs, LCSWs, MSWs

8 How about Patient Navigators?

9 Front desk staff?

10 Medical assistants?

11 Administrators?  Directors, Program Managers, Office Managers

12 Did I miss anyone?

13 Thank you! Mute button back on please

14 Motivational Interviewing is an approach all of you can use…

15 Story of MI MI Spirit Substance Treatment: Then & Now 200 Clinical Trials Later PCMH MI Techniques Apply to Practice The spirit of MI Guiding Principles: RULE Diabetes Cancer Screening OARS Recognizing change talk

16 Story of MI

17 The Story of Motivational Interviewing Originally came about as a different approach to substance/alcohol treatment 1970’s - treatment approach was to use counselors who were also in recovery to “confront” clients about their addiction and “make them” change

18 However, when clients were confronted, their natural instinct was to defend themselves - thereby removing any desire to behave any differently

19 Enter William Miller, PhD William Miller, PhD Center for Alcoholism, Substance Abuse and Addictions Distinguished Professor of Psychology and Psychiatry Departments of Psychology & Psychiatry at The University of New Mexico

20  As a student in training, Dr. Miller “accidentally” discovered that other approaches could positively affect the behavior of addicted patients  Listening  Empathy  Over time, these experiences were studied, replicated, modified and enhanced to become the field of Motivational Interviewing

21 Subsequently, a more common treatment philosophy for addiction is now: Rather then the job of the client/patient to be motivated for change…. It’s our job as health professionals to help people find the motivation for change that’s already there within themselves

22 Where is the MI field now? MI has now been in the field for 30 years More than 200 clinical trials of MI have been published

23 Positive results for an array of target problems Cardiovascular rehabilitation Diabetes management Dietary change Hypertension Illicit drug use Infection risk reduction Management of chronic mental disorders Problem drinking Smoking Concomitant mental health & substance abuse disorders

24 Other advantages 1) Relatively brief 2) Specifiable (but be careful with manuals) 3) Verifiable – is it being delivered properly 4) Generalizable across problem areas 5) Complementary to other treatment methods 6) Learnable by a broad range of providers

25 Leading to an explosion of MI information Besides the >200 randomized clinical trials… >1000 publications Dozens of books and videotapes 10 Multisite clinical trials Several coding systems for QA MIA-STEP to support MI supervisors Research on MI training

26 Training for MI Currently, there is no official certification for MI The Motivational Interviewing Network of Trainers (MINT) can be used to train staff Many online resources and trainings exist (see end of presentation) However, in-person supervision or peer support groups is highly recommended as the way to achieve solid MI skills

27 Direction of healthcare - PCMH In the world of Patient Centered Medical Homes (PCMH) a patient centered counseling approach is also needed MI is not only the right thing to do, it’s become the thing you should do and the thing you will get paid to do

28 Reimbursement CPT Evaluation and Management codes allow reimbursement for time spent counseling patients. Practices can also be reimbursed by having nurse practitioners or physician assistants provide patient- centered counseling.

29 NCQA’s PCMH 2011 Standards PCMH 3: Plan and Manage Care (17 points) The practice systematically identifies individual patients and plans, manages and coordinates their care, based on their condition and needs and on evidence-based guidelines (4 points) Element C: Care Management 1. Conducts pre-visit preparations 2. Collaborates with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each relevant visit 3. Gives the patient/family a written plan of care 4. Assesses and addresses barriers when the patient has not met treatment goals 5. Gives the patient/family a clinical summary at each relevant visit 6. Identifies patients/families who might benefit from additional care management support 7. Follows up with patients/families who have not kept important appointments

30 NCQA’s PCMH 2011 Standards PCMH 4: Provide Self-Care Support and Community Resources (9 points) The practice acts to improve patients' ability to manage their health by providing a self care plan, tools, educational resources and on-going support. (6 points) 1. Provides educational resources or refers at least 50 percent of patients/families to educational resources to assist in self management 2. Uses an EHR to identify patient-specific education resources and provide them to more than 10 percent of patients, if appropriate 3. Develops and documents self-management plans and goals in collaboration with at least 50 percent of patients/families 4. Documents self-management abilities for at least 50 percent of patients/families 5. Provides self-management tools to record self-care results for at least 50 percent of patients/families 6. Counsels at least 50 percent of patients/families to adopt healthy behaviors

31 PCMH 4: Factor 4 Patients and families who feel they can manage their condition, learn needed self-care skills or adhere to treatment goals will have greater success. Practices may use motivational interviewing to assess patient readiness to change and self-management abilities, including questionnaires and self-assessment forms. The purpose of assessing self-management abilities is that the practice can adjust self-management plans to fit patient/family capabilities and resources.


33 Spirit of MI

34 Eight Stages in Learning MI 1) The Spirit of MI 2) OARS 3) Recognizing change talk 4) Eliciting and strengthening change talk 5) Rolling with resistance 6) Developing a change plan 7) Consolidating client commitment 8) Engaging MI with other methods

35 Some Definitions Motivational interviewing (MI) is a clinical method for helping people to resolve ambivalence about change by evoking intrinsic motivation and commitment. A skillful, clinical style for eliciting from patients their own motivations for making behavior change in the interest of their own health

36 The Spirit of MI - Collaborative Collaborative Approach  Clinician is not “above” the patient, telling them what to do  Conversation is more equal, in which joint decision-making occurs

37 The Spirit of MI - Evocative “Often healthcare involves giving patients what they lack…MI instead seeks to evoke from patients that which they already have”. (Rollnick, Miller & Butler, 2008)  MI seeks to understand the patient’s perspective by evoking their own good reasons and arguments for change

38 The Spirit of MI – Honoring Patient Autonomy “There is something in human nature that resists being coerced and told what to do. Ironically, it is acknowledging the other’s right and freedom not to change that sometimes makes change possible.” (Rollnick, Miller & Butler, 2008) o Clinicians may inform, advise, even warn but ultimately it is the patient who decides what to do. o Honoring this can help facilitate change.


40 Four Guiding Principles RULE  Resist – the righting reflex  Understand – the patient’s own motivations  Listen – with empathy  Empower – the patient

41 Motivational Interviewing in Practice How NOT to Do Motivational Interviewing

42 R: Resist the Righting Reflex People who enter the helping professions often want to set things right and prevent harm Can lead to a “correcting” of a person who is off course Natural human tendency to resist persuasion

43 R: Resist the Righting Reflex “We tend to believe what we hear ourselves say. The more patients verbalize the disadvantages of change, the more committed they are to sustaining the status quo” (Rollnick, Miller & Butler, 2008)

44 U: Understand Your Patient’s Motivations It is your patient’s own reasons for change, not yours, that are the most likely to trigger behavior change Best use of your consultation time - ask patients why they would want to make a change and how they might do it – rather than telling them that they should

45 L: Listen to your Patient “A practitioner who is listening, even if it is just for a minute, has no other agenda than to understand the other person’s perspective and experience” (Rollnick, Miller & Butler, 2008) Good listening is actually a complex clinical skill When done right, it can make the patient feel they have had more time with you then they actually have AND save time

46 E: Empower Your Patient “A patient who is active in the consultation, thinking aloud about the why and how of change, is more likely to do something about this afterward.” (Rollnick, Miller & Butler, 2008)


48 Techniques

49 OARS Four communication techniques engender MI spirit:  Open-ended questions  Affirmations  Reflective listening  Summary statements (OARS).

50 OARS has been shown to increase patient collaboration and satisfaction, treatment adherence, and patient-physician working alliance Underlying OARS is empathy – the ability to understand the patient's thoughts, feelings, and struggles from their point of view. Empathy is a strong predictor of treatment outcome

51 OARS: Open-ended questions Open-ended questions cannot be answered with a yes or no. They produce less biased data because they allow patients to “tell their story.” Open-ended questions elicit important information that otherwise might not be asked. Closed-ended questions often damage rapport, decrease empathic connections, and paradoxically end up taking more time.

52 Example Closed “Did you take your medicine last night?” Open “Tell me what it’s like for you fitting medicine into your day.”

53 OARS: Affirmations Affirmations are statements of appreciation, which are important for building and maintaining rapport. Efforts to make changes are acknowledged, no matter how large or small “I am impressed by your maintaining a weekly schedule during the allergy injection build-up phase”


55 OARS: Reflective Listening Involves taking a guess at what the patient means and reflecting it back, restating their thoughts or feelings in a slightly different way

56 Helps to ensure understanding of the patient's perspective, emphasizes his or her positive statements about change, and diffuses resistance.  Resistance occurs most often when patients experience a perceived loss of freedom or choice. Reflective responses move the interaction away from a power struggle and toward change.

57 Example “How was your day?” “So what I hear you saying is…” “Did I get that right?”

58 Reflective Listening – Breast cancer screening Table I. Types of reflections 1. RepeatingPatientPatient Navigator Use to diffuse resistance.“I don't want to have a mammogram.”“You don’t want to have a mammogram.” 2. RephrasingPatientHCP Slightly alter what the patient says to provide the patient with a different point of view. “I want to have a mammogram but last time I did it, it hurt too much.” “Having a mammogram is important to you.” 3. Empathic reflectionPatientHCP Provide understanding for the patient's situation.“You've probably never had to deal with anything like this.”“It's hard to imagine how I could possibly understand.” 4. ReframingPatientHCP Help the patient think about his or her situation differently. “I keep trying to schedule a mammogram, but I don’t have the time because of the kids and my job.” “You are persistent, even when things are really difficult. Getting a mammogram is important to you.”

59 Reflective Listening – Colon Cancer Screening 5. Feeling reflectionPatientHCP Reflect the emotional undertones of the conversation. “I know that not taking medication is bad for my asthma.”“You're worried about your asthma getting worse.” 6. Amplified reflectionPatientHCP Reflect what the client has said in an exaggerated way. This encourages the client to argue less and can elicit the other side of the client's ambivalence. “My mom is totally exaggerating my symptoms. My asthma isn't that bad.” “There's no reason to be concerned about your asthma.” (said without sarcasm) 7. Double-sided reflectionPatientHCP Acknowledge both sides of the patient's ambivalence. “Taking medications just takes away my freedom. It's such a hassle.” “On the one hand, you find that medication takes away your freedom. On the other hand, you said that your asthma symptoms limit your freedom by preventing you from doing things you enjoy. What do you make of this?” 5. Feeling reflectionPatientHCP Reflect the emotional undertones of the conversation. “I know that not getting a colon screen is a bad idea. “You're worried that you might be at risk for colon cancer.” 6. Amplified reflectionPatientHCP Reflect what the client has said in an exaggerated way. This encourages the client to argue less and can elicit the other side of the client's ambivalence. “I think the statistics on colon cancer are totally overrated. I don’t think I need to do this.” “There's no reason to be worried about colon cancer.” (said without sarcasm) 7. Double-sided reflectionPatientHCP Acknowledge both sides of the patient's ambivalence. “My dad had colon cancer. But it’s such a hassle to go through the screening.” “On the one hand, you sound like you are worried about colon cancer because your father had it. On the other hand, you think it’s too much trouble to get a colon screen. What do you make of this?” Table I. Types of reflections

60 OARS: Summary Statements Longer than reflections Used to transition to another topic Highlights both sides of a patient's ambivalence, or provide recap at strategic points to ensure continued understanding. “You have several reasons for wanting to take your asthma medication consistently; you say that your mom will stop nagging you about it and you will be able to play basketball more consistently. On the other hand, you say they are a hassle to take, and that they taste bad. Is that about right?”


62 Recognizing Change Talk Change talk is any client speech that favors movement in the direction of change Previously called “self-motivational statements” (Miller and Rollnick, 1991) Change talk is by definition linked to a particular behavior change target

63 DARN – 4 examples of Change Talk Desire to change I wish, I want, I would like Ability to change I can, I could Reasons to change If…..then Need to change Need to, have to, got to

64 Motivational Interviewing in Practice The Effective Physician


66 Apply to Practice

67 Staff need not apply the entire arsenal of MI techniques during a single visit but rather chose the strategies that fit best with their own style and with patient readiness to change.

68 Focus: Asthma/COPD Successful asthma management requires an array of patient behaviors. National asthma guidelines (National Asthma Education and Prevention Program) 1 suggest that individuals with persistent asthma: 1  take 1 or more daily controller medications  use rescue medication as needed for symptoms  monitor lung function with peak flow monitors  need to avoid asthma triggers.

69 Adherence rates for inhaled corticosteroids (ICSs) range from 44% to 72%. Only 8% to 13% of patients taking ICSs continue to fill their prescriptions 1 year after the initial prescription. Non-adherence is associated with increased asthma symptoms, frequent emergency department visits, hospitalizations, and need for oral steroids.

70 However… Increasing asthma knowledge through education yields little improvement in patient adherence or asthma outcomes.

71 Self-management approaches (i.e. identifying barriers to adherence, self-monitoring medication use, goal setting, and problem solving) have done better:  fewer urgent care visits,  short-term improvements in adherence  higher asthma management self-efficacy  improved quality of life  reduced asthma symptoms

72 However… Limitation of both educational and self-management approaches – assumes that patients are already motivated to accept treatment recommendations. Making this assumption prematurely can actually create resistance in patient

73 Need for a medication adherence approach that:  Targets both those who are ready and those who are not ready to change.

74 Particularly relevant for asthma medication, about which patients might falsely self-report adherence. 3 3 Creating a nonjudgmental atmosphere enhances the likelihood of accurate self-report. 30 30

75 Studies have found that patients with asthma or COPD desire greater participation in decision making about their treatment. However, patients might be hesitant to voice their agendas without being prompted. 49 49

76 Where to Begin Set the agenda - collaboratively

77 Begin by providing a “menu” of options for discussion and let the patient decide where to start the conversation. “ Would you like to talk about taking your medication, monitoring asthma symptoms, or avoiding asthma triggers? What are you most concerned about?”. 50 50

78 Next - Discuss a typical day Ask a single open-ended question inquiring about the patient's typical day  This allows you to assess the patient's social context and adherence in a nonjudgmental framework

79 Instead of asking, “How many times did you take your medication this week?,” which can lead to face- saving answers, you can ask, “What is a typical day like for you, from start to finish, and, if you like, tell me about where taking your medication fits into your day.”

80 Next, assess motivation and confidence for change For example, you can ask, “How motivated are you to take your medication? Rate your motivation on a scale of 1-10, where ‘1’ is not at all motivated and ‘10’ is very motivated.” Confidence in the patient's ability to adhere can also be rated.

81 Option - Use the lower-higher exercise After motivation is assessed as outlined above, you can ask: “Why not a lower number?”  This nonjudgmental approach helps to elicit positive statements about change, which have been shown to be associated with better treatment outcomes. 37, 57 37 57

82 After the patient provides several reasons, you can ask, “What would it take for you to get to a 9 or a 10?”  This approach helps to identify barriers and facilitators of adherence. The same exercise can also be done with confidence levels.

83 Then, explore the pros and cons of change This helps patients to: (1) see both sides of their ambivalence simultaneously (2) realize that you are interested in both sides of their ambivalence and not only the “pro-change” side (3) articulate and think more deeply about their reasons for adherence and non-adherence.

84 For example, you might start with the “not so good things” about taking medication to convey a nonjudgmental posture. You can then ask, "what about the other side; what are some ‘good’ things about taking your medication?”

85 Next, provide medical advice and feedback In MI health information is shared in a manner that increases the likelihood that the patient hears, understands, and accepts the information.  Clear and understandable language  Reflections that convey empathy and the patient's concerns.

86 MI uses the elicit-provide-elicit process to give patients feedback about their health. 24 24 This approach, also called shared decision making, has received empiric support across a variety of studies, 58, 60, 61 including studies in asthma. 62 58 60 61 62

87 Even deeper, advise the patient to change In MI, advice is given after a relationship has been established and the patient's perspective on the situation has been sufficiently explored.

88 For example, you can say, “As your doctor, I think the best thing you can do for your asthma right now is to take your medication every day (‘advice’). I am not going to pressure you to do that; the decision to take your medication is completely up to you (‘support autonomy’). I know that these decisions can sometimes be difficult (‘empathy’).”

89 Ask those evocative questions There are several key questions you can ask to evoke optimistic statements about adherence from patients:  “If you were to take your medication consistently, what might be the best results you can imagine?”  “What worries you most about your asthma?”  “How does asthma stop you from doing the things you want to do?”

90 Ending the consultation…

91 The MI consultation ends with a summary and a query about what the patient would like to do next, if anything, about managing his or her asthma. Attainable goals are negotiated if the patient is sufficiently motivated.

92 Motivational Interviewing in Practice Applying MI to Primary Care eature=related

93 Thank you! Questions? Sarah Blust, LMSW, MPH Project Manager, PCDC 212-437-3955

94 Last, but not least, a survey Please complete as soon as possible!

95 Resources - Web

96 Resources - Books Books: Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (2006) Developed as part of the NIDA Clinical Trials Network, this document provides a complete model for developing staff competency in Motivational Interviewing. Motivational Interviewing in Health Care; Helping Patients Change Behavior. Stephen Rollnick, William R. Miller, and Christopher C. Butler Building Motivational Interviewing Skills; A Practitioner Workbook. David B. Rosengren

97 Resources - Videos Motivational Interviewing Training Video: A Tool for Learners (Hettema, 2009) The 3 DVD set contains over 4 hours of educational material, including: Interactive lessons on the background, principles, and core skills of motivational interviewing. 12 clinical vignettes demonstrating motivational interviewing. Clinical analyses of each vignette. Vignette and interview with Dr. William Miller. Appropriate for a variety of audiences, including:  Physicians and other medical professionals.  Mental health workers.  Probation officers or criminal justice employees  Students or trainees. Covers a range of problem areas, including:  Alcohol and drug use  Smoking  Anxiety disorders  Treatment engagement  Medication compliance  Diabetes  Cholesterol  Diet and exercise  Prenatal behavior  Infectious disease

98 Resources - Videos Motivational Interviewing: Professional Training Series, (Miller and Rollnick, 1998) This series of two DVDs, produced at the University of New Mexico, is intended to be used as a resource in professional training, offering six hours of clear explanation and practical modeling of component skills. Because it is helpful to see how a method is practiced in various contexts, the tapes include clinical demonstrations of the skills of motivational interviewing, showing ten different therapists working with 12 clients who bring a variety of problems. Major sections include: A. Introduction to Motivational Interviewing B. Opening Strategies C. Handling Resistance D. Feedback and Information Exchange E. Motivational Interviewing in Medical Settings F. Phase 2: Moving Toward Action

99 References 1) National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Institutes of Health; 1997;Publication no. 97-4051 2) Sherman J, Patel P, Hutson A, Chesrown S, Hendeles L. Adherence to oral montelukast and inhaled fluticasone in children with persistent asthma. Pharmacotherapy. 2001;21:1464–1467 3) Krishnan JA, Riekert KA, McCoy JV, Stewart DY, Schmidt S, Chanmugam A, et al. Corticosteroid use after hospital discharge among high-risk adults with asthma. Am J Respir Crit Care Med. 2004;170:1281–1285 4) McQuaid EL, Kopel SJ, Klein RB, Fritz GK. Medication adherence in pediatric asthma: reasoning, responsibility, and behavior. J Pediatr Psychol. 2003;28:323–333 5) Bender B, Wamboldt FS, O'Connor SL, Rand C, Szefler S, Milgrom H, et al. Measurement of children's asthma medication adherence by self report, mother report, canister weight, and Doser CT. Ann Allergy Asthma Immunol. 2000;85:416–421 6) Apter AJ, Reisine ST, Affleck G, Barrows E, ZuWallack RL. Adherence with twice-daily dosing of inhaled steroids. Socioeconomic and health-belief differences. Am J Respir Crit Care Med. 1998;157:1810–1817 7) Apter AJ, Boston RC, George M, Norfleet AL, Tenhave T, Coyne JC, et al. Modifiable barriers to adherence to inhaled steroids among adults with asthma: it's not just black and white. J Allergy Clin Immunol. 2003;111:1219–1226 8) Bender BG, Pedan A, Varasteh LT. Adherence and persistence with fluticasone propionate/salmeterol combination therapy. J Allergy Clin Immunol. 2006;118:899–904 9) Marceau C, Lemiere C, Berbiche D, Perreault S, Blais L. Persistence, adherence, and effectiveness of combination therapy among adult patients with asthma. J Allergy Clin Immunol. 2006;118:574–581 10) Bauman LJ, Wright E, Leickly FE, Crain E, Kruszon-Moran D, Wade SL, et al. Relationship of adherence to pediatric asthma

100 References 11) Williams LK, Pladevall M, Xi H, Peterson EL, Joseph C, Lafata JE, et al. Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma. J Allergy Clin Immunol. 2004;114:1288–1293 12) Hing E, Cherry DK, Woodwell DA. National ambulatory medical care survey: 2004 summary. Adv Data. 2006;374:1–33 13) Ho J, Bender BG, Gavin LA, O'Connor SL, Wamboldt MZ, Wamboldt FS. Relations among asthma knowledge, treatment adherence, and outcome. J Allergy Clin Immunol. 2003;111:498–502 14) Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003;326:1308–1309 15) Walders N, Kercsmar C, Schluchter M, Redline S, Kirchner HL, Drotar D. An interdisciplinary intervention for undertreated pediatric asthma. Chest. 2006;129:292–299 16) Smith JR, Mildenhall S, Noble MJ, Shepstone L, Koutantji M, Mugford M, et al. The Coping with Asthma Study: a randomised controlled trial of a home based, nurse led psychoeducational intervention for adults at risk of adverse asthma outcomes. Thorax. 2005;60:1003–1011 17) Put C, van den Bergh O, Lemaigre V, Demedts M, Verleden G. Evaluation of an individualised asthma programme directed at behavioural change. Eur Respir J. 2003;21:109–115 18) Cicutto L, Murphy S, Coutts D, O'Rourke J, Lang G, Chapman C, et al. Breaking the access barrier: evaluating an asthma centers' efforts to provide education to children with asthma in schools. Chest. 2005;128:1928–1935 19) Magar Y, Vervloet D, Steenhouwer F, Smaga S, Mechin H, Rocca Serra JP, et al. Assessment of a therapeutic education programme for asthma patients: “un souffle nouveau”. Patient Educ Counseling. 2005;58:41–46 20) Cabana MD, Le TT. Challenges in asthma patient education. J Allergy Clin Immunol. 2005;115:1225– 1227


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