11/8/2013. Homecare Association of Arkansas 2013 Fall Conference and Trade Show. Objectives. What is patient engagement?

Transcription

1 Homecare Association of Arkansas 2013 Fall Conference and Trade Show Motivational Interviewing and Patient Activation Paula Suter, BSN, MA Clincal Director Sutter Center for Integrated Care Sutter Health, California Objectives The learner will: Evaluate patient activation as it relates to motivational interviewing Define motivational interviewing (MI) List MI principles that facilitate patient activaton Review MI tools for implementation in practice 2 What is patient engagement? Patient perspective: Actions individuals take to obtain the greatest benefit from the health care services available to them.. Source: K. Carman, et al (2013). Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Affairs 32, No. 2:

2 What is patient engagement? System perspective: A necessary condition for the redesign of the health system The holy grail of health care The next blockbuster drug of the century. Source: K. Carman, et al (2013). Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Affairs 32, No. 2: Patient Engagement and Healthcare Costs Source: Hibbard, J.H., Greene, J., Overton, V. (2013) Patients with lower activation associated with higher costs: delivery systems should know their patients scores Health Affairs 32 (2), Patient Activation and Patient Engagement Low activation Moderate activation High activation Interventions to improve activation Engaged Patient Self-Management Support 6 2

3 The Road to Engagement Wagner s Care Model What Characterizes an Informed, Activated Patient? Informed, Activated Patient They have the information, skills, motivation and confidence necessary to effectively make decisions about their health and manage it. Self-management support as justification for MI adoption The systematic provision of education and supportive interventions to increase patients skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting and problem solving support Source: Institute of Medicine,

4 Provider skills to enhance patient motivation and confidence-building Active listening Assessing skill and confidence Eliciting change talk and supporting change Providing evidence and options for shared decision making conversations Structured goal setting including problem solving 10 What is motivational interviewing (MI)? Communication style to build rapport Not based on one scientific theory Blending of techniques from other theories and interventions Avoids labeling patients Is person-centered 11 What does motivational interviewing do? Can help with developing rapport Used in goal setting to improve self-efficacy and confidence Especially effective for patients that are stuck not making recommended health related behavior changes helps patients explore and resolve ambivalence MI helps activate the patient s own motivations to change Source: Rollnick, Miller, and Butler: Motivational Interviewing in Healthcare

5 Efficacy Effective in 75% of randomized controlled trials MI outperformed traditional advice giving in 75% of these studies Effectiveness was shown even in brief encounters of only 15 minutes Effect was not related to clinician s education background (physician vs. psychologist vs. nurse) Source: S. Rubak, A. Sandboek, T. Lauritzen and B. Christensen Motivational Interviewing: a Systematic Review and Meta-Analysis British Journal of General Practice, April The four basic principles of motivational interviewing Express Empathy Roll with Resistance Develop Discrepancy Support Self efficacy Method Method Method Method Use reflective listening Accept pt s point of view never argue Elicit and reflect change talk Structure mastery experiences 14 Express Empathy What is empathy? Reflects an accurate understanding Assumes the person s perspectives are understandable and valid Seeks to understand the person s feelings and perspectives without judging 5

6 Dr. Polanski s Analogy Prepare the soil Plant the seed Provide sun and water 16 Prepare the soil Plant the seed Provide sun and water 17 Motivational Interviewing Prepare the Soil Open-Ended Questions Affirmations Reflective Listening Summarize 6

7 Open-Ended Questions What are open-ended questions? Require more of a response than a simple yes/no or fill in the blank Often start with words like: How do you feel about What can you tell me about Can you describe for me Some Good Open-ended Questions To Elicit Deeper Understanding What would you like to have happen as a result of our care? What would you like your life to be like 2 months from now? A year from now? What would you like to be able to do, that you can t currently do? Tell me what it is like to have diabetes. Tell me how your life is different as a result of your (disease or condition in plain language). I'd like to give you the best possible care. Can you tell me more about what you would like from my visit today? Affirmations Statement of recognitions of patient s strengths Builds confidence in ability to change Recognize patient s previous efforts to change no matter how big or how small Must be genuine 7

8 Affirmations Examples: I appreciate how hard it must be for you as you deal with this condition. I ve enjoyed talking with you today, and getting to know you. You seem to be a very strong person Reflective Listening: Two Different Types With Two Different Objectives 1. Listening for understanding to make sure you understand their point of view and how they are being affected (empathy) 2. Listening to identify change talk so you can reflect that back (developing discrepancy) The problem with communication is the illusion that it has occurred >-- George Bernard Shaw 8

9 Listening by Reflecting and Summarizing Ensures that your patient is your teacher Provides proof that you are listening and that you understand Reflection is not repeating, it is restating with an attempt at understanding, using different words Examples of Reflective Listening It sounds like you feel... It seems as if... What I hear you saying is... I get a sense that... It feels as though... Help me to understand. On the one hand you... and on the other hand... Summaries Pulls together what has transpired thus far during the conversation Can be used strategically Clinician can select what information should be included or emphasized and what can be minimized or left out Additional information can also be incorporated into summary e.g., past conversations 9

10 Prepare the soil Plant the seed Provide sun and water 28 Ambivalence puts the patient in a rut! The Tell Tale Sign Yes, but 10

11 Ambivalence is Normal Ambivalence makes change possible It is the precursor to positive behavior change Against Change Toward Change Arguments against change Arguments in support of change Push debate out of consciousness Beware: we can negatively effect ambivalence Studies show that patient resistance can lead to confrontational behaviors in the clinician Pushing against resistance by arguing your point tends to amplify the negative part of the equation Patient resistance is a predictor of poor patient outcomes Against Change Toward change 32 Rolling with resistance Don t lecture Acknowledge & validate how difficult it is to change life long behaviors Back off ask open ended questions, don t pressure or preach Clarify decision is the patient s Making the effort to understand the causes of each patient's non-adherent behavior helps tailor an approach to removing obstacles 33 11

12 Developing Discrepancy: Lets Hear From The Patient One of the biggest differences between MI communication and other techniques is that the patient is the one who verbalizes the need for change rather than the clinician. The more the patient thinks about and talks about change, the more likely they will take action. Developing discrepancy Difference between the person s core values and life goals and their health behavior Difference between the person is now and where he/she would like to be in the future Cognitive dissonance is necessary for change to occur 35 Reflective Listening: Two Different Types With Two Different Objectives 1. Listening for understanding to make sure you understand their point of view and how they are being affected (empathy) 2. Listening to identify change talk so you can reflect that back (developing discrepancy) 12

13 One Simple Method To Elicit Change Talk & Develop Discrepancy Pros and Cons Tool Tool: Pros and Cons Ask the patient the pros and cons of making a behavior change Allows the patient to weigh these pros and cons of a behavior change Allows the patient to come face to face with their uncertainty regarding specific behavior changes Decision Balance to Elicit Change Talk Facilitates exploration of ambivalence Quitting Smoking Pros Cons Taste improves No way to deal with stress Easier to breath May gain weight Reduced respiratory infections Will feel like a failure if I relapse Feel healthy More money 13

14 Concluding the Conversation Pros and Cons Conclude by asking some key questions: Where does that leave you now? What would you like to do now? It sounds like things can t stay the same, what can you do? Provides patient with an invitation to take it step further.to be in the driver s seat Confidence- help it grow Prepare the soil Plant the seed Provide sun and water 41 Supporting self-efficacy through goal setting Identify where the patient wants to go long term goal Provide options for how to get there tie your clinical goals to the patient goals The patient selects the option that they wish to pursue Set a short term goal as step one- make it a baby step 42 14

15 Provide options and tie to long-term goal These are some things you can do to help you with your long term goal. What would you like to work on in the next few weeks? Diabetes Self Management Taking My Medicine to Control My Blood Sugar Exercise Eating Healthy Monitoring My Blood Sugar Stop Smoking Foot & Skin Care Regular Exercise 43 Writing short-term achievable goals I will smoke 10 cigarettes a day instead of 12 I will keep a log of how many I smoke a day My confidence level is at a 7 Relevant This will help me have more energy to work in my shop I will do this for one week Source: CDC 44 Goal setting/action planning Make sure goal is achievable and realistic Work with the patient to visualize taking first step toward the goal Visualizing actions assists with identifying barriers and obstacles Discuss ways to minimize barriers and have the patient come up with solutions this is problem solving A plan should be written down 45 15

16 Behavior Change Is HARD! Plan for barriers Make sure goal is achievable and realistic Use confidence ruler Ask patient what may throw them off track Discuss ways to minimize barriers Have the pt come up ideas too - this is problem solving Goal setting plan should be written down and posted in home 47 Create a cascade of successes Work to promote a cascade of successes : Achievement of one goal creating and achieving additional new goals Creating a cascade of successes empowers patient to continue making behavior changes 48 16

17 Assessing Confidence with Stanford Tool MI Requires Behavior Change on Your Part As Well What baby-step can you take tomorrow? Open-ended questions Refective listening Pros and Cons tool Provide options Action plans 50 MI Reference Cards 51 17

18 The Sutter Center for Integrated Care Contact Information: Paula Suter s address: suterp@sutterhealth.org 52 18