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October 2012 Webinar• Motivational Interviewing• Self-Management Support
PDSA Sharing• NCQA Requirements, Resources
Motivational InterviewingComplimentary Technique to Use with 5 A’s
Not everyone seems to benefit from our treatment?• Data and knowledge are important…• But may not be enough.• Need to translate to Behavior Change!
Motivational Interviewing• A directive patient-centered counseling
style for increasing INTRINSIC motivation by helping the patient explore and resolve ambivalence
• Avoid the “Blame game” – a patient’s resistance does not equal noncompliance
• Initially developed for use in the alcohol and drug abuse field
Ambivalence• Can you imagine yourself saying or
thinking this:• “Perhaps I should exercise more. I’m a
little concerned about it, but I don’t think I’ll do anything today.”
Ambivalence• Ambivalence is a normal and defining
state of human experience• Most of us are ambivalent about most
things most of the time• Motivational Interviewing is the practice
of disentangling competing and often obscured motives
Some Basic Assumptions• Patients talk themselves into changing.• Patients don’t change just because we want
them to change.• Patients rarely change just because we tell
them to change.• The process of changing may be accelerated
by practitioners—but it might also be inhibited.
Advantages of Using MI• Improved patient satisfaction• Decrease personal frustration with difficult
patients (burnout)• Better clinical outcomes
A Meta-Analysis of Research on Motivational Interviewing Treatment Effectiveness (MARMITE)Hettema and Miller: Hettema and Miller: Annual Review of Clinical PsychologyAnnual Review of Clinical Psychology (2005)(2005)
Mean Combined Effect Size by Problem Area (N=72 Clinical Trials)
MARMITE
Motivational Interviewing• Ask permission• Listening skills:
• Open ended questions• Patient does the talking• Provider is ‘curious’• Provider summarizes with gentle direction
Establishing Rapport• Acknowledge setting• Change gears from H&P
“Now that this is out of the way, can we take a few minutes to talk about other things that are affecting your diabetes?”
Start with OARS• Open-ended
questions• Affirm• Reflective
listening • Summarize
Allows us to make sure we fully understand what the patient means.
O. Open-ended questions• Closed question: Do you always take your
insulin?• Open ended question: Tell me a little about
how it’s going with taking your insulin?• Or if you strongly suspect adherence issues:
• Many people find it challenging to take their insulin daily. How is it going for you?
A. Affirm• Finding something positive about the
patient’s behavior • Making that finding verbally explicit• Appreciation vs. approval (“You” vs. “I”)• Genuineness is critical• What if I can’t find anything positive about
my patient?
R. Reflect• Demonstrates a desire for mutual
understanding• Good follow up to open-ended question• Being selective as we hold up a mirror for
the people we work with
Sentence stems for reflections• It sounds like you…• You mean that…• You’re wondering if…• So you feel… You’re feeling…• You…
S. Summarize• Indicates attentiveness on the part of the
interviewer (“Let me make sure I’m getting this…”)
• Allows patient statements to be clarified, consolidated, and reinforced
• Builds discrepancy and provides direction
Sentence stems for reflections• It sounds like you…• You mean that…• You’re wondering if…• So you feel… You’re feeling…• You…
Start with OARS• Open-ended
questions• Affirm• Reflective
listening • Summarize
.
TRY IT?MAYBE EVEN TAPE YOURSELF WITH PERMISSION
To Learn More• Motivational Interviewing in Health
Care• By Rollnick, Miller, and Butler published
by Guilford Press (2008)• Available at Amazon and elsewhere
• MotivationalInterviewing.org
Conclusion: Improving Outcomes
• Education is necessary, but not sufficient.• Need to work with patients to help with
behavior change.• People don’t change just because we tell them
to.• Counseling style is key.• Ask the patient and use open-ended questions.
PDSA SharingWhat self-management support have you been testing?
How’s it been going for you?Share your PDSAs!• Goal-setting forms• Goal-setting process• Staff training• Provider role• Patient reception• Data capture
NCQA Self-Care RequirementsIncluding Numerous Resources to Assist You
NCQA: Self-Care Support • Element A: Support Self-Care Processes
• Must pass element!• 6 Factors: First 2 factors require provision of
educational resources for patients• Factor 3: Develops and documents self-
management plans and goals in collaboration with at least 50% of patients/families.• NCQA expects written self-care (action) plans.• Critical factor!
Self-Management Resources• “Helping Patients Manage Their Chronic Conditions,” California
Healthcare Foundationhttp://www.chcf.org/~/
media/MEDIA%20LIBRARY%20Files/PDF/H/PDF%20HelpingPatientsManageTheirChronicConditions.pdf
• “Facilitating Behavior Change,” American Society on Aging, American Society of Consultant Pharmacists Foundation
http://www.adultmeducation.com/downloads/Adult_Med_Facilitating.pdf• Patient Assessment of Chronic Illness Care, MacColl Institute at
Group Healthhttp://www.improvingchroniccare.org/downloads/2004pacic.doc.pdf• Community Health Center, Inc.
http://www.diabetesinitiative.org/programs/DICHC.html
NCQA: Self-Care Support • Factor 4: Documents self-management abilities for
at least 50% of patients/families.• NCQA suggests using motivational interviewing or
forms to assess patient readiness to change.
Patient Assessment Resources• A few “readiness to change” assessment tools:
• http://aom3.americaonthemove.org/~/media/B62B030924954B2A95AC74436519BD2C.ashx
• http://www.adultmeducation.com/downloads/Readiness-to-Change_INSTR.pdf
• http://www.ama-assn.org/ama1/pub/upload/mm/433/patientreadiness.pdf
• http://www.lsuhospitals.org/cmo/hcet/docs/obesityclinical/Patient_Readiness.pdf
• http://www.nationalobesityforum.org.uk/index.php/lifestyle/adults_/obesity-care-pathway/219-patient-motivation-readiness-to-change.html
More Assessment Resources• Summary of Diabetes Self-Care Activitieshttp://care.diabetesjournals.org/content/23/7/943.full.pdf• Morisky Medication Adherence Questionnairehttp://media.mycme.com/documents/30/11-
136_case_3_table_2_rev_7413.pdf• Patient Health Questionnaire (PHQ-9) and PHQ-2 (depression)http://steppingup.washington.edu/keys/documents/phq-9.pdfhttp://www.cqaimh.org/pdf/tool_phq2.pdf• Case-finding and Health Assessment Tool (CHAT)http://www.bpac.org.nz/magazine/2009/adultdep/
appendices.asp#appendix9
NCQA: Self-Care Support • Factor 5: Provides self-management tools to
record self-care results for at least 50% of patients/families.• Need to give patients forms (or other tools) to collect
health information at home. • Blood pressures• Blood sugars• Weight
• Along with instructions and information about home monitoring. • How to do it• How/when to provide the data to the practice• How to titrate medicines based on data being collected
Patient Reporting Resources• American Diabetes Association online tracking
system: http://www.diabetes.org/living-with-diabetes/treatment-and-care/247.html?loc=contentpage-promo-247
• University of Wisconsin Diabetes Self-Management Tools: http://www.uwhealth.org/living-with-diabetes/self-management-and-tracking-tools/10397
• University of Pittsburgh Diabetes Self-Management Assessment Report Tool (D-SMART): http://knowledgetranslation.ca/sysrev/articles/project21/RefID931-Charron-Prochownik-20090620001517.pdf
NCQA: Self-Care Support • Factor 6: Counsels at least 50% of patients/
families to adopt healthy behaviors.• NCQA suggests evidence-based counseling like
motivational interviewing or coaching.• What are you doing about tobacco cessation
counseling?• What resources or assistance do you provide?• How are you capturing this counseling for your data
reports?• Meaningful Use requirement too!
What else do you need?What can you share?Share freely… steal shamelessly!
Upcoming Webinars…..
Because of the approaching holiday season, we have scheduled our next webinars for:
November 15 December 20
Both webinars will be held from 12-1pm
Please be in touch!• South Central – Sharon Adams
814-344-2222, [email protected]• North West – Patty Stubber
814-217-6029, [email protected]