Key Tools for Patients Successful Behavior Change for Use in Telephonic Coaching

Transcription

1 Key Tools for Patients Successful Behavior Change for Use in Telephonic Coaching Mary Ann Hodorowicz, RD, MBA, CDE, Certified Endocrinology Coder June 25, 2015

2 Mary Ann Hodorowicz RD, LDN, MBA, CDE, CEC Mary Ann Hodorowicz, RD, LDN, MBA, CDE, CEC, is a licensed registered dietitian and certified diabetes educator and earned her MBA with a focus on marketing. She is also a certified endocrinology coder and owns a private practice specializing in corporate clients in Palos Heights, IL. She is a consultant, professional speaker, trainer, and author for the health, food, and pharmaceutical industries in nutrition, wellness, diabetes, and Medicare and private insurance reimbursement. Her clients include healthcare entities, professional membership associations, pharmacies, medical CEU education and training firms, government agencies, food and pharmaceutical companies, academia, and employer groups. She serves on the Board of Directors of the American Association of Diabetes Educators. Mary Ann Hodorowicz Consulting, LLC hodorowicz@comcast.net

3 LEARNING OBJECTIVES 1. Explain the key differences between compliance counseling and motivational interviewing (MI) counseling. 2. Name the 5 motivational interviewing/adult learning tools reviewed in the presentation to help positively change patient behavior. 3. Explain what the Strike 3 Rule is. 4. Define what S.M.A.R.T. stands for in relation to helping patients create behavior change goals. 5. Name the steps recommended when addressing the patient s barriers to his/her behavior change goals.

4 Key tools in this presentation were selected from the research on motivational interviewing and adult learning principles (see references). MI is a conversational style of working with and/or coaching patients that is designed to increase motivation to change and reduce resistance to changing lifestyle and health behaviors.

5 FIRST, COMPARISON OF KEY DIFFERENCES IN: COMPLIANCE COUNSELING (considered less effective in prompting positive behavior change in outpatient chronic care) vs. MOTIVATIONAL INTERVIEWING (considered more effective) 1,2,3,4

6 COMPLIANCE: Coach Asks Close-Ended Questions: Will you? Could you? Do you? Did you? Have you? MOTIVATIONAL INTERVIEWING: Coach Asks Open-Ended Questions: What? How? Why? Describe? Explain? Tell me about?

7 COMPLIANCE: Coach is sage on the stage Coach selects topics per agenda Coach does most of the talking MOTIVATIONAL INTERVIEWING: Coach is guide on the side Patient selects topics per need Coach does most of the listening

8 REQUEST THAT PATIENT SELECTS TOPIC(S) for each visit Ask patient at each visit: What is your most pressing need or problem that we can work on together today, or the topic you d like to talk about? Consider giving patient list of topics for specific disease intervention to select from See AADE7 Self-Care Behaviors list on next slide Always think patient-centered coaching not agenda-centered or curriculum-centered.

9 Healthy eating Menu planning, label reading, healthy cooking, portion control, dining out, carbohydrate, protein, fat, fiber, sugar, sugar-free foods, omega 3 fats, dietary cholesterol, saturated fat, vitamins, minerals, etc. Being active Simple exercises for everyday life, and why. Reducing risks Monitoring Taking medications Healthy coping Problem solving Risks of complications of uncontrolled diabetes: heart disease, teeth and gum problems, kidney disease, nerve and vision problems, infections, etc. Monitoring of blood glucose, blood pressure, blood cholesterol, other health indicators. How medication works, how to take it, precautions, side effects, how to prevent side effects, etc. Coping with diabetes, adapting to lifestyle changes at work, home, etc. Solving problems with high/low blood sugar, stress, anxiety, traveling, relationships, etc. Ongoing support Diabetes self-care support resources in community.

10 TALK MUCH LESS and prompt patient to talk more Ask open-ended questions to prompt patient to: Answer his own questions Most patients have most of the answers within them, but have the answers buried deep due to fear, anger, busy schedules, denial, etc. Tell his story about the selected topic/need/problem Analyze his need/problem from his own point of view Start thinking about ways to meet his need, fix his own problem, create his own behavior change goals

11 TALK MUCH LESS and prompt patient to talk more Ask open-ended questions to prompt patient to: Review all treatment options to help solve her problem Arrive at treatment option that best fits her I.V.s Issues and Variables related to her own life SAY from her lips to your ears the key core message related to topic selected or to specific behavior change Example: I m pretty sure that my high A1c and my 10 pound weight gain is related to the 6 or more carbohydrate servings that I eat at nearly every meal.

12 EXAMPLE: MI Conversation between patient Mark and HCP: Mark: Why does everyone keep telling me that I have to test my blood sugar with this meter? HCP: Why do YOU think they are telling you this? Mark: I really don t know no one explains it to me. HCP: How do you feel about actually using the test results to better control your sugar on a daily basis? Mark: Yeh, I would think about that, if it would help. HCP: If you don t mind, can you share with me your thoughts on how you might use a test result before dinner to better control your after-dinner sugar?

13 TALK MUCH LESS and prompt patient to talk more Adults learn and retain: 20% of what they HEAR 30% of what they SEE 50% of what they SEE and HEAR 70% of what they personally explain or SAY 90% of what they SAY and DO

14 SWEETEST SOUND TO PATIENTS Their own voice SWEETEST WORD TO PATIENTS Their own name SWEETEST TOPICS TO PATIENTS Their own story

15 TALK MUCH LESS and prompt patient to talk more Sign over clock in HCP s counseling office: Why Am I Talking?

16 Polling Question Number 1 Which of these is an open-ended question? Mark, I see that you have had type 2 diabetes for 10 years and own a fairly new blood glucose meter. A. Can you share with me your experiences with using a meter to test your own blood sugar? B. Do you test your blood sugar with your meter?

17 TALK MUCH LESS and prompt patient to talk more Ask open-ended questions to prompt patient to: Persuade SELF to change Avoid you doing the persuading it will backfire! - Patient will dig in and protect and defend exact negative behavior you are trying to change! How to help patient persuade SELF to change: Ask patient B.I.G.G.E.S.T. open-ended questions for change talk - Helps patient find her buried inner strength

18 TALK MUCH LESS and prompt patient to talk more B = How would you BENEFIT if you were to test your blood sugar with a meter 1 or 2 times a day? I = What would IMPROVE or INCREASE in your life? What INCENTIVE would you need to start testing? G = Who else in your life would GAIN if you did test? G = What would you have to GIVE UP to start testing your blood sugar? How would you GAUGE the importance of testing on a 1-10 scale? E = What would you ENJOY about testing your blood sugar? S = Would SOMEONE want to help you test your sugar before and after meals, or fasting in a.m.? T = What would it TAKE to: Get you started with your blood sugar testing? Keep testing on a regular basis? Reduce any barriers you may have to testing your blood sugar?

19 GIVE ADVICE / TELL, BUT only when asked, only when patient cannot say key core message, and only if you first ask permission Consider using the Strike 3 Rule : Ask patient open ended question at least 3 times. If still cannot say key core message, then tell, but first ask permission Remember: most patients have most of the answers within them it s our job to get answers from their lips to our ears (not in reverse!)

20 GIVE ADVICE / TELL, BUT only when asked, only when patient cannot say key core message, and only if you first ask permission Avoid telling patient what her specific treatment will be instead: Lay out all treatment options for patient and Lay out all pro s and con s of each treatment option Give patient opportunity to select best treatment option for her own life s I.V.s her Issues and Variables Patient is to be at center of ALL decision making!

21 USE ADULT LEARNING TOOLS along with MI tools K.I.S.S. interventions / messages: Keep It Simple and Short Examples: Testing blood sugar regularly helps you to make healthier eating and exercise decisions on daily basis High salt intake often increases blood pressure Type 1 diabetes means you don t have any insulin Exercise is great tool to lower high blood cholesterol

22 Polling Question Number 2 Which of these would be the best way to educate a patient on type 1 diabetes? A. Type 1 diabetes is an autoimmune disease that causes beta cell dysfunction and makes you ketoacidosis prone. B. Your body does not make any insulin at all, so you will need to inject insulin into your body with a needle or with an insulin pump.

23 USE ADULT LEARNING TOOLS along with MI tools Avoid the righting reflex (very common among HCPs!): Jumping in to right the problem for the patient Not involving patient in her own problem solving Acting as the expert in the patient s life Summarize back to patient what she has said (focusing on key core messages) about every 10 minutes Ask patient to write down her own correct answers to your open ended questions do allow her to create her own handout!

24 USE ADULT LEARNING TOOLS along with MI tools Ask patient to summarize back to you the info you had to tell her (is usually complicated interventions such as DKA) This gives you opportunity to correct any errors in her summary and this increases learning and retention Remember, every 10 minutes YOU are summarizing what patient said this is summarizing in reverse!

25 USE ADULT LEARNING TOOLS along with MI tools Would you mind giving me a quick summary of what we discussed on how to handle your insulin injections when you are very sick?

26 USE ADULT LEARNING TOOLS along with MI tools Start low & go slow: avoid firehosing patient with too many messages and too much information at one time. Makes patient feel overwhelmed, and then stupid! Ugh!

27 USE ADULT LEARNING TOOLS along with MI tools More on start low and go slow! Do keep key core messages very easy at first visits do kids learn calculus in kindergarten? Later visits more complex simple First few visits

28 TOGETHER WITH PATIENT, create 1 or 2 S.M.A.R.T. behavior change goals S = Sensible (is doable for patient) M = Measurable (amount, what, when) A = Attainable (how do skills training if needed) R = Relevant (meets patient s need or problem) T = Time-based (time period to work on goal)

29 Polling Question Number 3 Which of these is a S.M.A.R.T. behavior goal? A. Decrease the number of cans of regular soda that I drink from 4 to 3 cans a day for the next 2 weeks. B. Cut back on soda.

30 TOGETHER WITH PATIENT, create 1 or 2 S.M.A.R.T. behavior change goals Steps to help patient identify goal barriers and ways to reduce: Ask patient: What her barriers are to each behavior change goal To what extent barriers may effect behavior change To size barriers to prioritize: S, M, L and XL barriers To select L and XL barrier to tackle first To search for ways to reduce or eliminate L and XL Summarize the plan then ask patient to write it down Praise even smallest patient successes at next visits Avoid even slightest criticism of patient s failures

31 QUESTIONS?

32 REFERENCES Ellen R. Glovsky, PhD, RD, LD, Gary Rose, PhD, Motivational Interviewing A Unique Approach to Behavior Change Counseling, Today s Dietitian Vol. 9 No. 5 P. 50, May 2007 Motivational Interviewing, A Taste of Motivational Interviewing Ellen R. Glovsky, PhD, RD, LDN, , Miller WR, Rollnick SR. Motivational Interviewing: Helping People Change, 2nd edition. New York: Guilford Press; 2002 Miller WR, Rollnick SR. Motivational Interviewing, Third Edition: Helping People Change (Applications of Motivational Interviewing),, 3rd edition. New York: Guilford Press; 2013 Rose GS, Rollnick SR, Lane C. What s Your Style? A model for helping practitioners to learn about communication and motivational interviewing. MINUET. 2004;11:2-4 Hersen M, Eisler RM, Miller PM (ed). Progress in Behavior Modification. Belmont, Calif.: Wadsworth; 1994 Marc Steinberg, MD, FAAP, Clinical Perspectives on Motivational Interviewing in Diabetes Care, Diabetes Spectrum, August 2011, vol. 24 no. 3, Rollnick SR, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners. London: Churchill Livingstone; 1999 Nutrition Practice Guideline for Diabetes Mellitus Type 1/Type 2 and Hypertension, and Disorders of Lipid Metabolism Toolkit, Academy of Nutrition and Dietetics; accessed Suzanne E. Mitchell, MD, MS, Motivational Interviewing in the Management of Type 2 Diabetes: An Expert Interview With Faculty and Disclosures, CME Released: 02/07/2012, Medscape Education Diabetes & Endocrinology American Diabetes Association. Standards of Medical Care Diabetes Care Volume 38, Supplement 1, January 2015, Position Statement 2015

33 RESOURCES BY MARY ANN HODOROWICZ Turn Key Materials for AADE DSME Program Accreditation Program Policy & Procedure Manual Consistent with NSDSME (72 pages) Medicare, Medicaid and Private Payer Reimbursement Electronic and Copy-Ready/Modifiable Forms & Handouts Fun 3D Teaching Aids for AADE7 Self-Care Topics Complete Business Plan 3-D DSME/T and Diabetes MNT Teaching Aids How-To-Make Kit Kit of 24 monographs describing how to make Mary Ann s separate 3-D teaching aids plus fun teaching points, evidence-based guidelines and references Money Matters in MNT and DSMT: Increasing Reimbursement Success in All Practice Settings, The Complete Guide, 5th. Edition, 2014 Establishing a Successful MNT Clinic in Any Practice Setting EZ Forms for the Busy RD : 107 total, on CD-r; Modifiable; MS Word Package A: Diabetes and Hyperlipidemia MNT Intervention Forms, 18 Forms Package B: Diabetes and Hyperlipidemia MNT Chart Audit Worksheets: 5 Forms Package C: MNT Surveys, Referrals, Flyer, Screening, Intake, Analysis and Other Business/ Office and Record Keeping Forms: 84 Forms

34 THANK YOU