Updated PSM Slides - Combined 28 Nov 2011.ppt Updated PSM Slides - Combined... · 8 What surprised...

Patient Self-Management

Sheraton Wall Centre VancouverNov. 23, 2011

Introductions and Objectives

Liza Kallstrom and Connie Davis

Housekeeping & other issues

What did you hope to accomplish today?

Objectives for the day

Learning on (possibly) two levels - three types of things

� New ideas and skills

� Some to share

� From PSP module

� Some as background information or

additional ideas to try: FYI

� How to present new ideas and skills (learning about learning)

About today

Experiences in Self Management Panel Conversation

Sek Cheung

Shirley Parent

Andre Van Wyk

Leslie Whyte

Christina Southey, Facilitator

What surprised you in the panel conversation?

How does the conversation coincide with your experience?

What additional questions do you have for the panel?

Table Discussion – 15min

What additional questions do you have

for the panelists?

Questions for the Panel

Break and Activity

Stepped Model for Self-

management Support

� Describe a stepped care approach to supporting patient self-

management

� Define health literacy, cultural humility and patient activation

� Demonstrate teach back

� Describe an approach for working across cultures

� Experience a way to TAKE PART in medical visits

� Define minimally disruptive medicine

Objectives for this section

HealthyCommunities and Supportive Family, Friends, andCaregivers

Honorculture

Develop sharedunderstanding

Use Self-management Support Core Techniques:Goal Setting, Action Planning,

Problem solving, Follow-up

Stepped Care for Self-management Support

Provide Advanced Approaches(MI, Case Mgmt, PST, Group Interactions, etc.)

Offer ExpertMethods

Promote activeself-management

Based on the work of the Indian Health Service Improving Patient Care Self-management Support Workgroup and Division of Diabetes Treatment Program with input from the British Columbia Ministry of Health Services Patients as Partners Committee and ImpactBC, 2011.

Self-management relates to the tasks that an individual must

undertake to live well with one or more chronic conditions. These

tasks include gaining confidence to deal with medical management,

role management, and emotional management.

Adams, Greiner, and Corrigan (2004)

What is Self-Management? (definition used in BC)

� Self-management support is defined as the systematic provision

of education and supportive interventions by health care staff to

increase patients’ skills and confidence in managing their health problems, including regular assessment or progress and

problems, goal setting, and problem-solving support.

Adams et. Al. (2004)

What is Self-Management Support? (definition used in BC)

Treatment NNT Time

Antibiotics for H.

pylori ulcers

2 to heal 1 ulcer 1 yr

Statins in people

with previous MI

or known

disease

48 to prevent 1

Statins in people

with risk factors

70-250 to

prevent 1 MI or

stroke

Therapeutics initiative

For the numbers people…

Lifestyle

interventions in

Diabetes

Prevention

Program

7 to prevent 1

person from

developing

diabetes

~3 yrs

Metformin in DPP 14 to prevent 1 ~3 yrs

Nurse-led home

exercise program

for > 80 yo

17 to prevent 1

serious fall

injury

Source: DPP & Robertson, 2001 BMJ

NNT, cont

Patient

Condition

specific skills

information

Condition

specific skills

information

Condition

specific skills

information

Condition

specific skills

information

Condition

specific skills

information

Condition

specific skills

information

Condition

specific skills

information

Condition

specific skills

information

Self-management

education

Honorculture

Offer ExpertMethods

What constitutes our culture?

Four Corners

Traditionalists(born before 1945)

Baby boomers (1945-1961)

Generation X (62-80)

Generation Y (81-2000)

Four Corners – Generations

› What do we say about those from your generation?

› What would you want others to know about people of your

generation?

› How do you think being from this generation impacts your

approach health?

Discussion questions

First Nations, Metis and Inuit

Grandparents or earlier immigrated = third + generation

parents immigrated = second generation

You immigrated = first generation.

Four Corners – Longevity in Canada

› What are some of the things we grow up knowing and

believing?

› What would you want others to know about being from this

group?

› How do you think being from this group impacts how you

approach health?

Discussion Questions

Eldest

Middle

Youngest

Four Corners – Birth Order

› What are the stories we tell about birth order?

group?

› How do you think being in this birth order impacts how you

approach health?

Suburb

Small town

Rural/Remote

Four Corners - Residence

› What do we say about where people live? What are city

people like? Those who live in the suburbs? Small towns, rural

locations?

group?

› How do you think living where you do impacts on how you

approach health?

� What surprised you about this activity?

� How could you use this in a learning session?

Four Corners - Reflection

� Culture is a way of life of a group of people—the behaviors,

beliefs, values, and symbols that they accept, generally without

thinking about them, and that are passed along by communication

and imitation from one generation to the next.

› New Dictionary

What is culture?

Honour culture

Cultural humility is a lifelong commitment to self-evaluation and self-

critique... and to developing mutually beneficial and non-paternalistic

clinical and advocacy partnerships with communities on behalf of

individuals and defined populations.

› Tervalon & Murray Garcia, 1998

What is cultural humility?

� Maintain control of the interaction

� Have a pre-session

› After introducing yourself to the patient, introduce yourself to the untrained interpreter

› Ask them to interpret everything the pt. says exactly (no “he said” or “she said”)

› Have them position self behind and to the side of the pt.

Tips for using non-professional interpreters

Cross Cultural Health Care program, video available www.xculture.org/

� Speak to the patient, not the interpreter

� Insist that everything be interpreted

› No side conversations

› Understand there may be no exact equivalent in the

language or culture

� Speak in short sentences at moderate pace

› One question at a time

› Avoid jargon

› Avoid slang

Interpreters, cont.

� Check for understanding

� Ask questions about cultural beliefs and traditional treatments

� Stay positive

Your efforts will save you time in the future by avoiding

misunderstandings

Interpreters, cont.

E = Explanation (How do you explain your illness?)

T = Treatment (What treatment have you tried, want

to try?

H = Healers (Have you sought advice from any

healers?)

N = Negotiate options (AND instead of OR)

I = Agreed on interventions

C = Collaboration (with patient, family and healers)

American Association of Medical Colleges, 2005

Model of Effective Cross-Cultural

Communication and Negotiation

� Cultural safety online modules:

http://web2.uvcs.uvic.ca/courses/csafety/mod1/index.htm

� PHSA Indigenous Cultural Competency Training

http://www.culturalcompetency.ca/ (no charge for HA staff)

� Medical Assistants addressing culture videos

http://www.vimeo.com/15822032

Resources

Honorculture

Offer ExpertMethods

Develop Shared Understanding

“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (I.O.M, 2004)

Health Literacy is:

“the ability to access, understand, evaluate and communicate

information as a way to promote, maintain and improve health in a

variety of settings across the life-course” (Rootman and Gordon-El-

Bihbety, 2008)

Health Literacy is:

“The ability of professionals and institutions to communicate effectively so that community members can make informed decisions and take appropriate actions to protect and promote their health.”

adapted from Rootman and Gordon-El-Bihbety, 2008 and Health and Literacy Partnerships, Focus on Basics, World Education, Vol. 9, Issue B, September, 2008.

But there is another important component:

Health Literacy: A Prescription to End Confusion, Institute of Medicine, 2004

� Health literacy emerges when the expectations, preferences and

skills of individuals seeking health information and services meet

the expectations, preferences and skills of those providing

information and services.

Health literacy is a state of being…

How can you help people experience what having low health literacy is like?

I had a pain in my stomach. The doctor did some tests.

He said I had a blgrkrdmr.

I didn’t understand the word he used.

I asked him, “What is a blgrkrdmr?”

He said it was a grtiytuhr of the ptorjfmbtgbba.

I still didn’t understand.

He asked me, “Do you understand?”

I just said yes. Source: Literacy Partners of Manitoba

Tiny.cc/k5h8d

Health Literacy Video Clip

A Bézier curve is a parametric curve important in computer graphics and related fields. Widely publicized in 1962 by the Frenchengineer Pierre Bézier, who used them to design automobile bodies, the curves were first developed in 1959 by Paul de Casteljau using de Casteljau's algorithm.

In the diagram above, a quartic Bézier curve is constructed using control points P0 through P4. The green line segments join points moving at a constant rate from one control point to the next; the parameter t shows the progress over time. Meanwhile, the blue line segments join points moving in a similar manner along the green segments, and the magenta line segment points along the blue segments. Finally, the black point moves at a constant rate along the magenta line segment, tracing out the final curve in red. The curve is a fourth-degree function of its parameter. t.

Source: Wikipedia, courtesy of Leona Gadsby

I am writing to you at this time to advise you that I have received a referral for your child to have a hearing test. The referral was dated Oct 21, 2010, upon receipt and is being held on the waiting list accordingly.

Doctor Smith has referred your son Bobby to me for a hearing test. I have put him on the waiting list.

Source: Literacy Partners of Manitoba

Letter from a specialist

This is to certify that the surgical procedure known as

____________ (name of operation), the reason why it is considered

necessary, its advantages and possible complications, as well as

possible alternative methods of treatment have been explained to

me by_________(name of Physician or Surgeon), and in light of the

information the anaesthetic deemed advisable, the operation stated

above and also to perform such additional procedures as may be

held to be therapeutically necessary on the basis of findings in the

course of the operation. Any tissues surgically removed may be

disposed of by the surgeon or the hospital in accordance with their

accustomed practice.

Consent Form

I give permission for the surgeon, Dr._________, to operate on me.

During the operation, he/she

� May perform any other surgery that may be necessary

� May use any anaesthetic that may be necessary

� May dispose of any tissue that is cut out

� The following passage simulates what a reader with low general literacy sees on the printed page

� Read the entire passage out loud as a group.

� You have 1 minute to read.

� Hint: The words are written backwards and the first word is “cleaning”

What Is It Like?

GNINAELC – Ot erussa hgih ecnamrofrep,

yllacidoirep naelc eht epat sdaeh dna

natspac revenehw uoy eciton na

noitalumucca fo tsud dna nworb-der edixo

selcitrap. Esu a nottoc baws denetsiom htiw

lyporposi lohocla. Eb erus on lohocla

sehcuot eht rebbur parts, sa ti sdnet ot yrd

dna yllautneve kcarc eht rebbur. Esu a pmad

htolc ro egnops ot naelc eht tenibac. A dlim

paos, ekil gnihsawhsid tnegreted, lliw pleh

evomer esaerg ro lio.

� How do you clean the capstan?

� Reflections on that experience:

So….

55www.hetemeel.com/einsteininform.php

Understanding Instructions

Jargon is everywhere

� Health literacy office practice survey

� Teach Back (video)

� Plain Language check list

� Brown Bag medication review

Health Literacy Tools

The Health Literacy Umbrella

Health Problems & Risks

B e t t e r H e a l t h

Relationships Understanding

Developed by the Health Literacy in Communities Prototype Faculty:

Connie Davis, Kelly McQuillen, Irv Rootman, Leona Gadsby, Lori Walker, Marina Niks, Cheryl Rivard, Shirley Sze, and Angela Hoviswith Joanne Protheroe, July 2009. IMPACT BC.

Partnering

Easy to use survey

Plain Language-Checklist

Literacy Partners of Manitoba

Find anything you give to your patients

Check it out with the “Clear Doc” list

Let’s try it now!

Brown Bag Medication Review

Ohio Patient Safety Institute

• All meds, herbals, traditionals,

• OTC to visit in a bag

• Ask

• How do you take this medication?

• What is it for?

• Check refill dates

• Do you use any aides? (mediset,

blisterpack, etc.)

� After information or instruction has been given, say:

� “Could you tell me back what we just talked about to see if I was

able to make it clear?”

� “After you leave this appointment a family member or friend might

ask you what happened today. What are you going to tell them

about what you are going to do?”

� If teaching a skill, use “Show me.”

� “Show me how you are going to do this at home so I know if I was

clear.”

Try Teach Back

American Medical Association

Try using Teach-Back now

� Turn to someone seated next to

� Tell them how to get from your house to the post office

� Ask them a teach-back question

(can you tell me…so I know if I was clear)

� Repeat as needed

Reflections on Teach-Back

67Ley, Communicating with patients: Improving Communication, Satisfaction and Compliance. NYL Croom Helm, 1988,

Diabetic patients data for Past Two Years, courtesy of Dr James Hii

Literacy BC Health Literacy resources

www.literacybc.ca/PLRC/health_literacy.php

Simply

Putwww.cdc.gov/healthliteracy/pdf/Simply_Put.pdf

Health Literacy Missouri

www.healthliteracymissouri.org

Healthy Roads Media (examples of documents)

http://www.healthyroadsmedia.org/index.htm

Google:

Health Literacy Listserv

Plain Language Thesaurus (CDC)

Health Literacy Resources

Honorculture

Offer ExpertMethods

Promote Active Self-management

� Patient activation: a person’s ability to manage their health and

health care (Hibbard & Cunningham, 2008)

� Patient engagement: actions individuals take to obtain the

greatest benefit from the health care services available to them

(Center for Advancing Health, 2010)

Definitions

� Video of Dr Vic Montori, Mayo Clinic

http://www.youtube.com/watch?v=flcRKdoaiVk

Minimally Disruptive Medicine

Personalizing care

Activation

Accepting role

Gaining knowledge and skills

Using skills to manage health

Use skills under stressHibbard, Hlth Serv Rsch, 2004

Professionals match what they do to

activation level

Accepting role: peer interactions, stories, linking behavior to health status, analogies, skills to understand the patient (open-ended questions, reflections, summaries, listening)

Gaining knowledge and skills: clear language

information, programs, training, action plansabout current behavior

Using skills to manage health: goal setting, action planning, problem solving, follow-up new behaviors. Motivational support!

Use skills under stress:Problem-solving

Prepare

keep track

report

Repeat

Take Action

Take PART

Chronic Disease Self-Management Program, Stanford University

Thoughts about patient activation and the PSM module?

Honorculture

Offer ExpertMethods

Patient-self management support:

Core Techniques

� Demonstrate making an action plan

� Experience problem solving

� Consider how to work into daily practice

1. Individual-centered

2. Collaborative

3. Respects right of not changing

4. SMART

5. Commitment statement

6. Behavioral menu

7. Measure confidence

8. Follow-up

9. Occurs in every interaction

9 Core Principles & the Evidence Base

Action planning is individual-centered, i.e. what the person wants,

not what he/she is told to do.

“Spirit” of Motivational Interviewing: Evocation

Core Principle #1

Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, Guilford Press, 2002

• Work in pairs, not with your boss or supervisor

• Speaker: Think of something you are considering, something you

are thinking about changing in your life but definitely haven’t

decided. It might be something you think will be good for you or

that you should do. Something you feel comfortable sharing. Tell

this to your partner.

Persuasion

Partner: your task is to try as hard as you can to convince the

speaker to make the change they are considering. Do these five

things:

1. Explain why they should make the change

2. Give at least three specific benefits that would result from

making the change

3. Tell the person how they should make the change

4. Emphasize how important it is for them to make the change.

This might include the negative consequences of not doing it.

5. Tell the person to do it.

Persuasion, cont.

Debrief

What did the speaker feel or think while

their partner was talking to them?

• Work with one other person

• Not with your boss or supervisor

• One will be the speaker and the other

will be the listener

– If time permits, you can reverse

roles.

– Subject: something you are

ambivalent about

A Taste of MI

• TOPIC: something about yourself that you

– Want to change

– Need to change

– Should or ought to change

– Have been thinking about changing

• But you haven’t changed yet

– i.e., something that you are ambivalent about

The speaker

• Listen carefully with a goal of understanding the dilemma

• Give no advice

• Ask these four open-ended questions:

– Why would you want to make this change?

– How might you go about it, in order to succeed?

– What are the three best reasons for you to do it?

– On a scale from 0-10, how important would you say it is for you to make this change?

• Why is it a ___ and not a zero?

The listener

Debrief

What did the speaker feel or think while

their partner was talking to them?

Action planning is collaborative.

“Spirit” of Motivational Interviewing: Partnership

Core Principle #2

Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, Guilford Press, 2002;

Heisler et al, JGIM, 2002

After the plan has been formulated, the clinician/coach elicits a final

“commitment statement.”

Strength of the commitment statement predicts success on action

Core Principle #3

Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, Guilford Press, 2002

Action Planning is “SMART”: Specific, Measurable, Achievable,

Relevant and Timed

Core Principle #4

Based on the work of Locke (1968) and Locke & Latham (1990,

2002); Bodenheimer, 2009

After the plan has been formulated, the clinician/coach elicits a final

“commitment statement.”

Strength of the commitment statement predicts success on action

Core Principle #5

(Aharonovich, 2008; Amrhein, 2003)

Offer a behavioral menu when needed or requested

“Spirit” of Motivational Interviewing: Autonomy

Core Principle #6

Rollnick, Miller & Butler, 2008. Motivational Interviewing in Health Care

“Here are the things we have talked about. Which one is most important to work on right now?”

Behavioral Menu

Smoking

Avoidingtriggers

Exercise

Taking meds

(write others

Adapted from Stott et al, Family Practice 1995; Rollnick et al, 1999, 2010

There are many things people do to improve their health. Here are some things you might want to talk to your health care team about.

�Consider the items in circles and add other concerns in the blank circles.

Monitoringyour health Taking medications

Eating habitsMood

Smoking

Activity

Avoidinghealth

problems

MeaningfulActivities

Confidence levels are evaluated and problem-solving utilized for confidence levels less than 7.

Higher self-efficacy is associated with healthier behaviors and better outcomes.

Core Principle #7

(Bandura, 1983; Lorig et al, Med Care 2001; Bodenheimer review, CHCF 2005; Bodenheimer, Pt

Ed Couns 2009.)

People’s beliefs about their capabilities to perform specific behaviors and their ability to exercise influence over events that affect their lives. Self-efficacy beliefs determine how people feel, think, motivate themselves and behave.

» Albert Bandura

Self-efficacy

Action planning includes arranging follow-up or other accountability.

Core Principle #8

(Resnicow, 2002; multiple condition specific studies)

Action planning is considered in all chronic, planned, or preventive

visits.

Non-physician staff are 9 times more likely to engage in goal-setting

than clinical staff. Technology (such as howsyourhealth.org) is

an option.

Core Principle #9

(Bodenheimer, 2009)

Other possibilities to demonstrate the principles?

Brief Action Planning (B.A.P.)

““““Is there anything you would like to do for your health In the next week or two?””””

““““How confident (on a scale from 0 to 10) do you feel about carrying out your plan?””””

““““When would you like to check in with me to review how you are doing with your plan?””””

Steven Cole, et. al.

SMART Behavioral Contracting Elicitation of Commitment Statement

If Confidence >7

Brief Action Planning (B.A.P.)

““““Is there anything you would like to do for your health In the next week or two?””””

““““How confident (on a scale from 0 to 10) do you feel about carrying out your plan?””””

““““When would you like to check in with me to review how you are doing with your plan?””””

Steven Cole, et. al.

SMART Behavioral Contracting Elicitation of Commitment Statement

If Confidence <7, problem solve barriers

Behavioral

1. Identify the problem.

2. List all possible solutions.

3. Pick one.

4. Try it for 2 weeks.

5. If it doesn't’t work, try another.

6. If that doesn't’t work, find a resource for ideas.

7. If that doesn't’t work, accept that the problem may not be solvable now.

Problem solving

Source: Lorig et al, 2001

Ways to teach problem-solving

� When?

› They ask for information

› You ask permission to give it

� How?

› Ask what they already know

› Fill in any gaps or gently correct misunderstandings

› Concentrate on key messages

› Use Teach-Back

Tips for Giving Information

courtesy of Bill Miller, 2010

� When?

› They ask for information

› You ask permission to give it

› You qualify your advice to emphasize autonomy

� How?

› Offer several suggestions instead of one

› End with a question about something they have thought of on

their own

› Emphasize it’s their choice

Tips for Giving Advice

courtesy of Bill Miller, 2010

Pre-visit

preparation

Question 1: “Is there anything …?”

Behavioral

SMART action plan

Commitment statement

Question 2: “How confident

are you…?”

Problem solving

Question 3: “When can we

follow-up...?”

Documentation

Follow-up

Fitting this into office flow

Artinian et al, Circulation 2010

Regular contact over time better than 1x intervention

Builds trusting relationship

If happens often in early stages of change, can decrease frequency as behavior more secure.

� Try a wide variety of methods, whichever patient prefers (in

person, phone, email)

� Make sure follow-up happens, patient trust can be destroyed by

missed follow-up

� Use outreach and community opportunities

� Can be done by self or with a family member

Tips for Follow-up/Accountability

� Healthy and don’t need a plan

� Not ready? Let them know you are ready when they are

� No ideas? Behavioral menu

� Ready? Make a plan

� Resistant? Use more advanced skills

Question 1: Is there anything...

� and 50% of the time, you ask Question 1 = 10 patients/day

� Of those

› 25% will not be ready or not need help or are healthy (2 pts.)

› 25% will easily make a plan

› 25% will need a behavioral menu

› 25% will need advanced skills

So, if you have 20 patients/day in clinic

� About 70% will follow through

� In a study of goal setting in office practice (half safety net, half

private practice), of 274 patients

› 83% made a plan

› 3 wks later, 86% remembered the plan

› Of those, 66% did at least part of the plan• Handley, 2006

Of those who make a plan...

Thoughts about teaching B.A.P.

Feedback sandwich

� What they liked about what they DID

� Your statement about what you liked that they DID

� What they thought could have gone better

� Your statements about what could have gone better

› keep it simple

� End with a positive comment

Feedback sandwich

Honorculture

Offer ExpertMethods

Advanced Approaches

� Define motivational interviewing

� Describe the spirit of motivational interviewing

� Recognize change talk

� Demonstrate using complex reflections

Advanced Approaches

Motivational Interviewing

Has anyone taken a trip lately?

What MI is like?

It’s all about change!

• Change talk is any client speech that favors

movement in the direction of change

• Clinicians can learn to elicit more change talk from clients

• More change talk is linked to better outcomes

• Remember---DARN CATS

Change Talk

DESIRE to change (want, like, wish…)

ABILITY to change (can, could…)

REASONS to change (if…then)

NEED to change (need, have to, got to)

Preparatory Change Talk: DARN

COMMITMENT to change (intend, decide, promise…)

ACTIVATION (willing, ready, preparing…)

TAKING STEPS to change (started, tried…)

Mobilizing Change Talk: CATS

The MI hill

Pre-contemplation

Action

� When you hear sustain talk, do nothing.

� When you hear preparatory talk, drum

� When you hear mobilizing change talk, clap

Drumming for Change Talk

Reflections on Drumming for Change

Break and Activity

� Elaborate “Tell me more…”

� Affirm “You are the kind of person

who…”

� Reflect - simple or complex*

� Summarize “Let me see if I have this

right…”

*more on next slides

Responding to Change Talk: All EARS

� Stays close to the

speaker’s words

› repetition

› rephrase

Simple Reflections

Complex Reflections

Makes a guess

� Paraphrase and then continue

the paragraph

� Reflect feeling, metaphor

� Amplified reflection

� Double-sided reflection

� Speaker: Something you may not know about me

is … (a quality, trait or characteristic, not

something concrete!)

� Listener: give a simple reflection

� Speaker: respond with a Yes or No

� Listener: give a complex reflection

� Speaker: respond naturally to the reflection

� Observers: coach the listener as needed

Forming Reflections

What is going on here?

• Partnership (formerly Collaboration)Provider and client equal

• EvocationIdeas for change come from the client

• Acceptance (formerly Respect for Autonomy)Client has the right to change or not

• CompassionActing for the other person’s welfare

*Clinician’s global MI Spirit adherence ratings strongly predict patient outcomes

The Spirit of Motivating People for

Change

Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, Guilford Press, 2002; Miller & Rollnick, MINT, 2011

a person-centered counseling method for addressing the common problem of ambivalence about change.

-Miller, 2010

What is Motivational Interviewing?

1991 2002 2012

• MI books in 19 languages

• 11 books on MI published

• >200 outcome trials, 10 multisite trials

• meta-analyses & Cochrane review

• >800 publications, doubling every 3 years

• >1200 trainers in at least 38 languages

• State- and nation- level implementation

• used in substance use, corrections, human

resources, education, health…

Current Status

Courtesy of Wm. Miller

The Interaction Sequence

1. Engaging

2. Focusing

3. Evoking

4. Planning

Courtesy of Wm. Miller

� Awareness

� Exposure training

� Skills acquisition

� Experience and coaching/feedback

� Training experience and coaching/feedback

� Motivational Interviewing Network of Trainers

About training in MI

• Books:

– Motivational Interviewing in Health Care. Rollnick, Miller and

Butler, 2009, Guildford Press.

– Motivational Interviewing, Miller & Rollnick, 3 ed. due in 2012

• www.motivationalinterviewing.org

• www.cmirti.org

Selected Resources

Key messages about MI for physicians

Next Steps

(you may wish to move into RST specific groups for this discussion)

� What are your next steps with the GMV/HL/PSM module?

� Which of the activities/resources used today will you try?

� What additional support do you need?

Table discussion – 20 min

� One person from each RST please share:

› One this your can give the group moving forward?

› One thing you would like to receive to help you move forward

Gives and Gets

Evaluation

Updated PSM Slides - Combined 28 Nov 2011.ppt Updated PSM Slides - Combined... · 8 What surprised...

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PSM & NEW MEDIA

Proportional directional spool valve type PSL, PSM, and ... · PSM UNF 4 PSM 5 PSM UNF 4 PSM 5L Flow pattern symbols (see also sect. 3.1.4) Coding Port P and R conf. ISO 228/1 (BSPP)

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Power Saving Mode (PSM) in UEs - Cisco · Power Saving Mode (PSM) in UEs ThisfeaturedescribesthePowerSavingMode(PSM)supportontheMMEinthefollowingsections: • FeatureSummaryandRevisionHistory,page1

PSM Briefing

PSM Interchange 2014: Bejon Misra, PSM India

Manual Teg Psm

PSM Manual

PSM Win Software for - Noptel · PSM Win Software for PSM-200 / PSM-R Page 3/16 1 Setting up the software When you setup the PSM-software from the file PSM_1_5_2_1.msi (or later versions),

PSM Dashboard

SQL/PSM. Persistent, Stored Modules ANSI/ISO 1996: SQL/PSM (or PSM or PSM-96) –also part of SQL:2003 Write procedures /functions and store them in the

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Psm Compliance

ME910C1/NE910C1/ML865C1 PSM Application Note · 2019-03-08 · ME910C1/NE910C1/ML865C1 PSM Application Note . 80529NT11643A Rev. 1 Page 10 of 23 2019 -03 04. 3. PSM DESCRIPTION PSM

InformIT Power System Monitoring PSM 510, PSM …...PSM 510, PSM 511 PSM 530, PSM 550 Technical Data 1MRB520375-Ben Page 1 Issued: July 2003 Changed since: May 2003 Data subject to