Motivational Interviewing: A Pathway to and a Feature of the Patient-Centered Medical Home Ronald Adler, MD, FAAFP Daniel Mullin, PsyD UMass Medical School STFM Faculty Development Workshop December 5, 2009

The PCMH: Is a physician-directed practice providing care that is comprehensive, preventive, coordinated, and centered on the needs of patients (and their families, as appropriate). Uses HIT, registries and other process innovations to assure high-quality, evidence- based care that is efficient and readily accessible. Promotes and supports patient self-management and systematically measures its own performance to facilitate continuous quality improvement.

A Medical Home Provides Easy access to a PCP, Who is working with a high-functioning team And a robust IT system, To provide comprehensive care to Activated, informed patients and families.

Easy Access to a PCP Access –Open access scheduling –Customized communication Interactions –Family-centered –Personal attention –Relationship is key

High-Functioning Team Nurse Care Coordinator Social Worker Mental Health Provider Nutritionist Pharmacist (Plus learners: students, residents)

Robust IT System EMR/Electronic Prescribing Decision Support Relevant, up-to-date info available at point-of-care Tracks Data –Registry: Process and Outcomes –Satisfaction: Patients, Staff and PCPs

For individuals, change requires: Motivation – Why to change Information – What to change Ability/Resources/Effort – How to change

Insanity “Insanity: Doing the same thing over and over again and expecting different results.” -- Albert Einstein Current state: Provide our patients with information and repeated exhortations – and hope they “get it.” Can we do BETTER?

Is Your Patient’s Positive Change MIA? M otivation –Is s/he inspired to make changes? I nformation –Does s/he understand the reasons for change? A bility –Does s/he have the resources necessary to create the change?

Facilitating Positive Change Identify your patient’s barriers to change. Tailor your interventions to address these: If Motivation, help inspire them. If Information, educate them. If Ability, provide helpful resources.

Barriers to Change Each patient faces multiple barriers. Consider the relative contributions of deficits in: –Motivation –Information –Ability Motivation is always a factor, usually the most significant.

Motivation Assess: –How important is it for you to change right now? Improve/Enhance: –Create context: patient’s life goals –Review prior efforts, including lessons from successes and failures –Recognize your lack of power –Acknowledge your lack of power –Identify your patient’s strengths –Promote your patient’s power

Facts about Flossing Flossing removes food debris and plaque. Plaque causes tooth decay and gum disease. Regular flossing can help prevent MI and CVA.

Why don’t you floss more? Do you lack info re: the benefits? Is it difficult to acquire floss? What’s really missing?

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, and Butler (2008)

The Fundamental Attribution Error When explaining the behavior of others, we tend to overestimate personal factors and underestimate environmental factors. When explaining our own behavior, we tend to underestimate personal factors and overestimate environmental factors.

When a patient seems unmotivated to change or to take the sound advice of practitioners, it is often assumed that there is something the matter with the patient and that there is not much one can do about it. Rollnick, Miller, and Butler (2008)

These assumptions are usually false. Motivation for change is actually quite malleable and is particularly formed in the context of relationships. Rollnick, Miller, and Butler (2008)

Motivational Interviewing is a patient-centered, goal-oriented method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

Four Principles of MI R esist Righting Reflex U nderstand and explore patient’s motivations L isten with empathy E mpower patient, encouraging hope and optimism

Resist Righting Reflex Tolerate incorrect information that is irrelevant or useful. Ask permission before educating or informing.

Understand and Explore Patient’s Motivations Explore the patient’s values; what are the functional limitations that result from their illness? What has motivated them to make changes in the past? What do others in the patient’s life say about their behavior and how does this impact their motivation?

Listen With Empathy What is the difference between empathy and sympathy? Empathy is the cognitive process of understanding another person’s emotions. Unfortunately, many people react negatively to the assertion “I understand how you feel.”

Empower Patient, Encourage Hope and Optimism Create the expectation of success. Give positive attention to any change the patient makes. Offer to give examples of other successes you have witnessed. Set realistic goals to increase chances of success.

Ambivalence … is characterized by conflicting thoughts and feelings for and against change. People often think: First of reasons to change, Then of reasons not to change. … Then they stop thinking of change

Resolving Ambivalence Change follows the exploration and resolution of ambivalence. Providers are successful when patients talk themselves into change.

Thinking About The Costs and Benefits of Change What specific behavior change are you considering? _______________________ STAY THE SAMEMAKE SOME IMPROVEMENT BENEFITSI like:I will like: COSTSI don’t like:I won’t like: Create some ideas and reflections for each of the four boxes above. This will help clarify your thoughts about what you want to do next. Welch, G., Rose, G., & Ernst, D. (2006)

Listening for Change Talk We tend to believe what we hear ourselves say. The more patients verbalize the disadvantages of change, the more committed they become to sustaining the status quo.

0|0| 1|1| 2|2| 3|3| 4|4| 5|5| 6|6| 7|7| 8|8| 9|9| 10 | On a scale of 0 to 10, how IMPORTANT is it for you right now to change? On a scale of 0 to 10, how CONFIDENT are you that you could make this change? 0|0| 1|1| 2|2| 3|3| 4|4| 5|5| 6|6| 7|7| 8|8| 9|9| 10 |

Becoming a Medical Home Requires meaningful transformation All personnel in your practice must engage Change is difficult –Especially for busy health care providers –ESPECIALLY for doctors

For individuals, change is very difficult. For organizations, the complexities and challenges associated with change increase -- dramatically with the size of the organization.

Aha! Moment Techniques to support and facilitate behavior change in patients, may be useful when helping your colleagues achieve behavior change in the work environment. Just as for chronic illness to be managed effectively, the patient must actively participate in the process, so must the entire health care team participate in change processes.

An Illustrative Vignette Resident presents a woman with DM-2 whose A1C had gone from 7.0 to 9.5 over 6 months. I ask "To what extent do you think she understands diabetes?“ Resident replies "I explained it to her: she has to take her medicine, eat a better diet,..."

Exercise Does the resident understand that it is important to explore the patient’s perspective? Does the resident have confidence that she can be successful in exploring the patient’s perspective? Is the resident ambivalent about exploring the patient’s perspective? How can you help the resident adopt this patient’s perspective?

An Illustrative Vignette Resident presents a woman with DM-2 whose A1C had gone from 7.0 to 9.5 over 6 months. I ask "To what extent do you think she understands diabetes?“ Resident replies "I explained it to her: she has to take her medicine, eat a better diet,..." I reply "I didn't ask if YOU understand diabetes. How can we help HER do better?“