Transcript Title

Motivational Interviewing: Helping
People to Change When They Aren’t
Sure They Want To or Can.
OCHI 2014 Fall Forum
October 2014
Rebeka Radcliff, MSW
F. Daniel Duffy, MD, MACP
Learning Objectives
• Use motivational interviewing methods to
– Help patients voice ambivalence about adherence
– Make their own arguments for self-care
• Guide patients through the stages of change
using MI when it may be useful
– Use Importance/Confidence and Readiness Ruler
to elicit change talk
– Use Decisional Balance to amplify ambivalence
– Use reflective statements (OARS) to elicit intrinsic
motivation and guide behavior change
Care Management Goals
• Guiding and encouraging patient self-care
• Accessing support and resources,
• Solving problems that Interfere with
adherence to treatment plan and achieving
health and life goals
MI was designed to elicit internal
motivation to help people stop addictive
behavior – works for other behaviors.
Cycle of Behavior Change
Precontemplation
Precontemplation
Relapse
Relapse
Maintenance
Maintenance
New
New Habit
Habit
Contemplation
Contemplation
Determination
Determination
Action
Action
F. D. Duffy
July 19, 2013
Specific Guidance for Stage of Change
Feedback, Advice, Empathy &
Self-Assessment
Guide Internal Motivation
Readiness Ruler
Decisional Balance
Reflective Listening: OARS
Elicit Change Talk
Specific target and time
Specific actions
Who/What will help
Problems & solutions
Interview Style and Skill
50
45
40
35
30
Telling
25
Asking
20
Listening
15
10
5
0
Directing
Guiding
Following
Barbara Walker p21 Rollineck, Miller, Buttler Motivational Interviewing in Health Care 2008 Gillford
Press
Motivational Interview Methods
ASK
TELL
LISTEN
Permission
May we talk about…?
Open Question
What do you know about…?
Closed Question
How much do you smoke?
Inform
Diabetes causes blindness.
Give Feedback
Your tests show…
Advise
Exercise will benefit you.
Appreciate
You are very courageous
Reflect
You want to change, but…
Summarize
Let’s see if I got it…
Motivational Interview Methods
ASK
TELL
LISTEN
Permission
May we talk about…?
Open Question
What do you know about…?
Closed Question
How much do you smoke?
Inform
Diabetes causes blindness.
Give Feedback
Your tests show…
Advise
Exercise will benefit you.
Appreciate
You are very courageous
Reflect
You want to change, but…
Summarize
Let’s see if I got it…
O
A
R
S
High Risk patient referred to Care Management to improve adherence to
self-care for diabetes and asthma and reduce ED use and missed medical
home appointments.
SCENARIO #1
Rosa/Ross Carver
• High-Risk patient with asthma, obesity, type-2 diabetes
• Cancels appointments, takes meds erratically, uses the
ED for routine care
• Diabetes education completed, metformin and
glipizide., last A1C was 9.7, no blood sugar log, BMI is
31%; she has gained 25 pounds.
• Has asthma treatment plan, stopped smoking, lives
with smoker, likes to use the rescue inhaler.
• Manufacturing job, on spouse’s health insurance, 20%
deductible, $25 PCP co-pay. and $100 ED/UC co-pay.
• Referral for Care Management to improve adherence,
reduce ED use, improve quality of life and reduce risk
of CVD and Respiratory Failure.
#1 Guide Pre-contemplation to
Contemplation
• First Visit – Phone Call?
• Clarify and simplify the current behavior
• Clarify readiness to change
– Acceptance of health problem and its treatment
– Importance of changing behavior to patient
– Confidence patient can change behavior
Importance – Confidence Ruler
How Important is it for you to be more active in your care?
Not At All Convinced
0
1
Totally Convinced
2
3
4
5
6
7
8
9
10
How confident are you that you will become more active in your care?
Not At All Confident
0
1
Totally Confident
2
3
4
5
6
7
8
9
Why “4”? Why not “6”?
What would it take to move from a “5” to an “8”?
Importance/Confidence Score Stage of Change
0-2 on either
Pre-Contemplation
3-7 on either or both
Contemplation
< 7 on either
Not motivated to change
8-10 on Conviction
Determination
9-10 on Confidence
Action or Maintenance
10
Role Play #1
Care Manager – Determine Readiness
to change – use rulers
Patient – Participate
Observer – Count MI Methods used
Observer Debriefing Conversation
•
•
•
•
Ask the care manager what went well?
Ask the patient what went well?
Reflect your observations on what went well?
Ask care manager what he/she might do
differently next time?
• Ask the patient what might work better from
his/her perspective?
• Reflect your observations on what you might do
differently
• Give feedback on the count of MI methods used.
Same patient, explores ambivalence between strategy of proactive selfcare and reactive rescue care. Elicit patient’s argument and internal
motivation to change.
SCENARIO #2
#2 Contemplation to Action
• Amplify ambivalence about changing behavior
– Good/not-so-good outcomes from current
behavior
– Good/not-so-good outcomes from new behavior
• Elicit enough discomfort to tip balance from
internal debate to action
• Make patient argue for change, roll with
resistance
Decisional Balance
Keep Doing
What I’m Doing
Reasons To Change
What are GOOD things
about your care now?
What are NOT-SO-GOOD
things about your care
now?
Become More
Active in Self-Care
Reasons Not To Change
What are NOT-SO-GOOD
things that might happen
if you become more
active in your care?
What are some GOOD
things that might happen
if you become more
active in your care?
Role Play #2
Care Manager – Determine Readiness
to take action
Patient – Participate
Observer – Count MI Methods used
Same patient is ready to take action in improving self-care.
SCENARIO #3
Listen for Change Talk
I want to
I should
I can
I must
I will
I am doing
Treatment
Adherence
Plan
Rollineck, Miller, Buttler Motivational Interviewing in Health Care 2008p-41 Gillford Press
#3: Determination to Action
• Spontaneous change talk
• Action Plan
– What will you achieve by when?
– What will you do to achieve your objective?
– Who or what will help?
– What problems might arise? Solution?
– Rehearse plan
Role Play #3
Care Manager – Determine Readiness
for Action– elicit change talk and plan
Patient – Participate
Observer – Count MI Methods used
Did We Reach Our Objectives?
• Use motivational interviewing methods to
– Help patient voice ambivalence
– Make their own arguments to take action
• Guide patient through the cycle of change
– Use Importance/Confidence and Readiness Ruler
to elicit change talk
– Use Decisional Balance to amplify ambivalence
– Use reflective statements to elicit intrinsic
motivation and guide to taking action