Motivational Interviewing: Engaging Patients Through Communication

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Catherine M. Mullahy, RN, BS, CRRN, CCM

Michael G. Goldstein, MD

Associate Chief Consultant for Preventive Medicine

Motivational Interviewing:

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Agenda

• Patrice Sminkey, CEO, the Commission ‐ Welcome and Introductions ‐ Overview of Learning Objectives • Catherine M. Mullahy, RN, BS, CRRN, CCM, President of Mullahy & Associates, LLC • Michael G. Goldstein, MD, Associate Chief Consultant for Preventive Medicine, Veteran's Health Administration (VHA), National Center for Health Promotion and Disease Prevention

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Audie

n

ce Notes

• There is no call‐in number for today’s events. Audio is by streaming only. Please use your computer speakers, or you may prefer to use headphones. •Please use the “chat” feature on the lower left‐hand part of your screen to ask questions throughout the presentations. Questions will be addressed as time permits after both speakers have presented. • A recording of today’s session will be posted within one week to the Commission’s website, http://www.ccmcertification.org

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L

earning Objectives Overview

After the presentation, participants will be able to: •Recognize the relevance of communication as an essential component of effective case management; •Describe the basic model of communication and some common methods of communication; •Identify common barriers preventing effective communication and an engaged client; •Explain the conceptual and research background supporting motivational interviewing; •Identify the guiding principles of motivational interviewing, as well as understand the strategies for strengthening commitment to change; and

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Catherine M. Mullahy, RN, BS, CRRN, CCM President, Mullahy & Associates, LLC Motivational Interviewing:

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Associate Chief Consultant for Preventive Medicine

Veteran's Health Administration (VHA) National Center for Health Promotion

and Disease Prevention

Motivational Interviewing:

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Communication, Motivational

Interviewing & Strategies for

Effective Patient Engagement

Catherine M. Mullahy, RN, BS, CRRN, CCM

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Communication

Communication is the response you get from the message you sent regardless of its intent

Assumptions Fatigue

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Case Management

Definition

Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services required to meet the client’s health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost‐effective interventions and outcomes.

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Case Management

Definition

Case management is a collaborative process of planning, facilitation and advocacy for options and services to meet an individual’s holistic needs through communication and available resources to promote quality cost‐effective outcomes.

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Effective Communication

an Ongoing Challenge

• 40% to 80% of the information patients hear in a consultation is lost almost immediately • 78% of patients leave the hospital without understanding their treatment

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Effective Communication

an Ongoing Challenge

•More than 70% of adverse events are caused by breakdowns in communication among caregivers and between caregivers and patients*

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Effective Communication

an Ongoing Challenge

• 23% of nurse time is spent on repetitive patient education • 77% of commercially insured patients would switch hospitals to one that better informs patients about treatment both before and after treatment

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Clinician’s/Case Manager’s Role in

Effective Communication

• Engagement

• Empathy

• Education

• Enlistment

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Patient Engagement!

Satisfied

Loyal

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Elements of Patient Engagement

Passion

Pride

Integrity

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Good CM Communication…

– Assess needs – Establish goals – Create an effective care plan – Collaborate with patients and families, providers, payers & others involved with care – Optimize potential for improved outcomes – Enhance patient satisfaction – Maximize potential for use of available resources

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Poor Communication….

• Stressful environment for patients/families • Confusion • Errors • Anger & frustration • Fragmented care • Unsafe discharges • Transition of care failures • Less than desirable outcomes • Increased costs

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Methods of Communication

– Verbal (spoken) words

– Written words

– Art/Images

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Other Communication Methods

for those cognitively, physically or

developmentally impaired….

• Blinking

• Pointing

• Signing

• Braille

• Adaptive devices TDD; telephone, typewriter,

teletypewriter TTY & Other electronic devices

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Critical Aspects of Successful

Communication

– Location – Individual(s) involved – Intent of the message – Desired goal

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Evaluate the Intent, Goals & Individuals

Involved with the

Method

of

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Barriers to Effective Communication

• Socioeconomic Class • Race – Creed – Color • Culture – Ethnicity • Language

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Barriers to Effective Communication

• Physical Appearance • Health Literacy • Linguistic Literacy • Depression • Anxiety • Unrealistic Expectations

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Strategies for Effective Communication

& Effective Engagement

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Techniques & Tools to Engage Patients

Warm greeting Eye contact Plain, non‐medical language Slow down Limit content Repeat key points Graphics http://www.ahrq.gov/qual/literacy/healthliteracttoolkit.pdf

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Training in Communication Techniques

• Motivational Interviewing

• Ask – Tell – Ask

• _{Closing the Loop}

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Engaging Patients…

Making a Difference….

One Patient at a Time!

Thank you!

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Catherine M. Mullahy, RN, BS, CRRN, CCM

82 Main Street, Suite 300

Huntington, NY 11743

[email protected]

www.mullahyassociates.com

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Associate Chief Consultant for Preventive Medicine

Veteran's Health Administration (VHA) National Center for Health Promotion

and Disease Prevention

Motivational Interviewing (MI):

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Motivational Interviewing:

A Method for Engaging, Activating

and Empowering Patients

Michael G. Goldstein, MD Michael G. Goldstein, MD Associate Chief Consultant for Preventive Medicine Associate Chief Consultant for Preventive Medicine National Center for Health Promotion and Disease Prevention, National Center for Health Promotion and Disease Prevention,

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What is Motivational Interviewing?

Definition:

A clinical method of guiding patients to make changes in the interest of their health by

eliciting patients’ own motivation for change

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MI

–

Research Evidence

• Hettema, Steele, and Miller (2005) conducted a systematic meta‐analysis of 72 RCTs: – alcohol abuse (31 studies) – illicit drug abuse (14 studies) – smoking (6 studies) – HIV risk reduction (5 studies) – treatment adherence (5 studies) – diet/exercise (4 studies) – water purification to promote health (4 studies) – gambling (1 study) – intimate relationships (1 study)

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MI

–

Research Evidence

• Significant support for the efficacy of MI across these studies – Large effect immediately following treatment – Effect less, but significant at follow‐ups of about one year – Adding MI to the beginning of treatment led to sustained outcome improvements • Outcomes were better when no manual was used

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Learning Motivational Interviewing

Skills and

Techniques

Principles

Processes

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• Autonomy

– Both implicitly and explicitly recognizing that the patient will exercise choice – Asking permission

• Collaboration

– Non‐authoritarian, partnering style; non‐judgmental

• _Evocation

– Exploring what is important to the patient ‐ their ideas, needs, values and reasons for change

The Spirit of MI

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RULE

• _R

esist the “Righting Reflex” ‐ (Resist Directing)

• U

nderstand your patient’s motivations ‐ (Evoke)

• L

isten to your patient ‐ (with Empathy)

• E

mpower your patient ‐ (Build Confidence)

Some General Principles

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MI is Dancing rather than Wrestling

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Goals/Phases of MI

• Build a

therapeutic alliance

• Elicit and encourage “change talk”

and

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Change Talk: The Ingredients of Change

• Desire: – I wantto stop coming to the hospital over and over • Ability: – I can take better care of my diabetes….I have done it before • Reasons: – Drinking gets me in trouble, makes my blood pressure higher, and makes my family not want to be with me • Need: – I need to take my meds so I can stay healthy and be there for my family • Commitment: – I will make a schedule for my blood sugar checks and plan the meals I eat

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MI Processes

4 Processes ‐ and skills/techniques for each 1. Engaging: listening to understand the dilemma, use of OARS 2. Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, use of information and advice 3. Evoking: selective eliciting, selective responding, selective summaries toward change talk 4. Planning: moving to a change plan and obtaining commitment

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Process I

‐

Engaging

• Goals

– Build a therapeutic relationship

– Understand the patient’s reality

– Understand the patient’s feelings, beliefs, values, concerns (including importance and confidence) – Recognize and affirm strengths, motivation

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Process I

‐

Engaging: OARS

• Open‐ended questions: understanding the patient’s perspective and motivation, agenda setting, eliciting change talk • Affirmation: recognizing patient’s efforts and strengths • Reflection: sharing and deepening understanding, eliciting more, selectively reinforcing change talk • Summary: understanding, eliciting more, reinforcing change talk

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Open Ended Questions

‐

Examples

“What are you currently doing that helps you to manage your diabetes?” “Tell me more about your interest in staying healthy.” “What worries you the most about your heart condition?” “How important is it to address your drinking?” “What do you think would help you to improve your functioning?” “What would you like to do to optimize your health?”

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Reflective Listening

• Effortful use of listening to seek, clarify and deepen understanding • Hypothesis testing • Creates awareness of gaps in understanding (for both speaker and listener)

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Reflective Listening: A Primary Skill

• Reflect:

– Words – “simple” reflection

– Deeper meaning, feelings, values – “complex”

– Summary

• Wait for listener to correct, clarify, continue….

• Statements, not questions; voice goes down

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Example: Struggles with Smoking

“I know I need to quit smoking. It’s just really hard to do; I’ve tried many times before. I just get really stressed and find myself eating up a storm! My health is really important, and I’m not getting any younger. You hear so much about smoking causing lung cancer and heart disease and I certainly don’t want that! What can I do?”

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Example: Levels of Reflection

• “You are aware of the serious health risks that

smoking can cause and you don’t want that to happen to you.”

• “You are worried about what will happen if you

don’t quit smoking and you are concerned about how to manage stress if you do.”

• “Trying to quit has been challenging and

frustrating and you would like to find a way to quit for good.”

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Affirmations

• Appreciation of patient attributes, effort, perseverance, showing up

• All patients need confidence (self‐efficacy) – you can support self‐efficacy by recognizing personal strengths, resources and successes

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Summaries

• Special form of reflective listening • Structure: – Indicate you’re about to summarize – Series of reflections ‐ Be selective and concise • May use to shift direction or ask a key question about change

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Summaries

Summaries ‐ 0ffer a Bouquet ‐ “So, you mentioned several reasons for working on healthy eating and meal planning, including being able to reduce the number of meds you are taking for your diabetes. You also want to gain better control over your diabetes and want to avoid the complications that your mother had. You are frustrated by pervious attempts to work on your weight, but you have had some success in the past. I would like to help you develop a plan that will work

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Process I

‐

Engaging (Review)

• Goals

– Build a therapeutic relationship

– Understand the patient’s reality

– Understand the patient’s feelings, beliefs, values, concerns (including importance and confidence) – Recognize and affirm strengths, motivation

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Process I

‐

Engaging: OARS (Review)

• Open‐ended

questions

• Affirmations

• _Reflections

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Summary

• Motivational Interviewing ‐ a clinical method of guiding; eliciting veterans’ own motivation for change • Spirit: collaborative, evocative, support autonomy • Principles: RULE ‐ resist directing; understand patients’ motivation; listen with empathy; empower • Processes: Engaging, Focusing, Evoking, Planning • Core Skills: OARS • Key outcome: engaged activated, motivated, empowered and confident patients

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Learning Motivational Interviewing

Skills and

Techniques

Principles

Processes

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Learning MI

• How will you know how you’re doing? • Patient is doing most of the talking • Patients are making a lot of change talk statements • Resistance is minimized • Patients are doing most of the work toward change

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National Center for Health Promotion and Disease Prevention Office of Patient Care Services, Veterans Health Administration Michael G. Goldstein, MD Associate Chief Consultant for Preventive Medicine 3022 Croasdaile Drive, Suite 200, Durham, NC 27705 (919) 383‐7874, ext. 240 [email protected] www.prevention.va.gov

Contact Information

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Thank you!

Commission for Case Manager Certification 15000 Commerce Parkway, Suite C Mount Laurel, NJ 08054 Corporate: 1‐856‐380‐6836 Email: [email protected] www.ccmcertification.org