INTEGRATING MOTIVATIONAL INTERVIEWING INTO THE MEDICAL APPOINTMENT

Transcription

1 INTEGRATING MOTIVATIONAL INTERVIEWING INTO THE MEDICAL APPOINTMENT MELODY COLE, MS, RDN, CD, CDE A MEMBER OF THE MOTIVATIONAL INTERVIEWING NETWORK OF TRAINERS DISCLOSURE None 1

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3 OBJECTIVES Compare the traditional advice giving approach with the Motivational Interviewing (MI) approach Practice Agenda Mapping to focus the medical appointment Utilize Two Key Questions to draw out Change Talk Examine resources for future development of MI skills 3

4 CHRONIC DISEASE As of 2012, about half of all adults 117 million people had one or more chronic health conditions. One of four adults had two or more chronic health conditions. In 2013, Chronic health problems such as cardiovascular disease, diabetes, obesity, cancer and kidney disease accounted for more than 75% of the nation's $2.7 trillion in annual spending for medical care, according to the CDC. WARD BW, SCHILLER JS, GOODMAN RA. MULTIPLE CHRONIC CONDITIONS AMONG US ADULTS: A 2012 UPDATE. PREV CHRONIC DIS. 2014;11: DOI: THE CHALLENGE A primary care physician with a panel of 2500 average patients would spend: 7.4 hours per day to deliver all recommended preventive care 10.6 hours per day to deliver all recommended chronic care services YARNALL ET AL. AM J PUBLIC HEALTH 2003;93: ; OSTBYE ET AL. ANNALS OF FAM MED 2005;3:

5 THE TRADITIONAL APPROACH DEMONSTRATION 2 Volunteers 1 to identify a behavior that you are ambivalent about changing 1 to write on the white board WHAT WE ARE TRAINED TO DO: Assess the condition Determine what the patient needs to do Instruct or give information 5

6 PERSUASION TECHNIQUES Agree the patient should make the change Explain why change is important Direct/Tell the person what to do Reassure patient that change is possible Disagree if person argues against change Offer lots of advice and interrupt often Warn of the consequences of not changing MILLER AND ROLLNICK 2013 IT S NOT ABOUT THE NAIL 6

7 RIGHTING REFLEX Built in desire to set things right Identified by words such as: You Should. You Must You Need to. It s important that you. THE RIGHTING REFLEX 7

8 WORST CASE SCENARIO Clinician argues for change while the patient argues against it. By simply reducing discord, we increase the odds of a good clinical outcome. MILLER AND ROLLNICK 2013 DEFINITION OF MI A collaborative conversation style for strengthening a person s own motivation and commitment to change MILLER AND ROLLNICK

9 EVIDENCE FOR MI Martins et. al. 37 total articles reviewed, with 33 articles specifically on diet, exercise and diabetes Overall MI outperformed traditional advice giving in 77% of the studies reviewed. Individuals with Diabetes: Lowered blood glucose Increased PA Decreased weight Engaged in dietary changes Increased self efficacy Increased sense of control over diabetes EVIDENCE FOR MI Systematic review of randomized controlled trials 48 studies, 9,618 participants Concluded that medical providers can use MI to help patients exercise more, lose weight, lower blood pressure and lower cholesterol. If medical providers can build relationships and evoke change talk an expected 10 to 15% improvement can be seen across a wide variety of behaviors and medical outcomes. 9

10 MOTIVATIONAL INTERVIEWING CHANGE TALK Engage OARS Focus TARGET BEHAVIOR Evoke DARNCAT Plan SMART GOALS MI SPIRIT Partnership Acceptance Compassion Evocation THE SPIRIT & STYLE OF MI Partnership Compassion MI Spirit Acceptance Evocation 10

11 ACTIVE LISTENING THE MI PROCESS Plan Evoke Focus Engage Active Listening, OARS MI SPIRIT & STYLE 11

12 BEGINNING MICRO SKILLS: OARS Open Questions or Statements Affirmations Reflective Listening Summaries THE MI PROCESS Plan Evoke Focus Target Behavior Engage Active Listening, OARS MI SPIRIT & STYLE 12

13 FOCUSING: FINDING THE DIRECTION An ongoing process of seeking and maintaining direction We find the focus from three sources: 1. Individual 2. Setting 3. Clinical Expertise FOCUSING: AGENDA MAPPING FOR DIABETES Healthy Eating Monitoring Medication Activity 13

14 FOCUSING ACTIVITY FOCUSING: AGENDA MAPPING IN THE MOMENT Stress/ healthy coping Education Refresher Eating Out Blood Pressure Insulin Sodium A1c 14

15 THE MI PROCESS Plan Evoke Importance & Confidence Focus Target Behavior Engage Active Listening, OARS MI SPIRIT & STYLE WHAT DO WE KNOW ABOUT CHANGE TALK? Predicts behavior change Suppressed by confrontation Enhanced by listening Highly responsive to clinician style 15

16 PREPARATORY CHANGE TALK: FOUR KINDS DESIRE to change (I want, I wish, I like..) ABILITY to change (I can, I could..) REASONS to change (if.. then) NEED to change (I need, I have to, I ve got to..) COMMITMENT TALK: C- Commitment A- Activation T- Taking Steps 16

17 TWO KEY QUESTIONS THAT EVOKE CHANGE TALK 1. What are some of your reasons for wanting to make a change? Evokes Importance 2. What do you think you might do? Evokes Confidence BRIEF MI CONVERSATION REAL PLAY ACTIVITY In Dyads; Person 1: Identify a behavior that you are ambivalent about changing. Person 2 : Ask the following questions, reflecting after each question. 1. What are some of your reasons for wanting to make a change? Reflect 2. What do you think you will do? Reflect 17

18 ELICIT-PROVIDE-ELICIT An MI consistent way to share information Elicit: What do you already know or would like to know about? Provide: Share the information in a manageable chunk. Elicit: After sharing the information ask: What are your thoughts on what I just shared with you? OR What does this mean for you? OR What part of this, if any, might you use to make a change? KEY POINTS MI is a collaborative conversation style for strengthening a person s own motivation and commitment to change When a clinician uses a persuasive style and argues for change with a person who is ambivalent, it naturally brings out the person s opposite arguments The MI Process is Engaging, Focusing, Evoking and Planning The MI spirit and style of Partnership, Acceptance, Compassion and Evocation (PACE) is the foundation of MI 18

19 KEY POINTS Beginning micro skills for MI are Open Questions, Affirming, Reflective Listening and Summaries (OARS) Agenda mapping is a way to focus the conversation and identify a target behavior Using evocative questions to draw out Change Talk is the heart of MI A respectful way of sharing information is to use the Elicit-Provide- Elicit approach SUMMARY OF MI TOOLS TO INTEGRATE INTO THE MEDICAL APPOINTMENT 1. Resist the Righting Reflex 2. Active Listening 3. Agenda Mapping 4. Two Question MI Approach 5. Elicit-Provide-Elicit 19

20 WHAT TOOLS WILL YOU TAKE WITH YOU TO YOUR PRACTICE? RESOURCES FOR FURTHER TRAINING Motivational Interviewing Network of Trainers website Click access online version Link to British Medical Journal 20

21 REFERENCES AND RESOURCES Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: a 2012 update. Prev Chronic Dis. 2014;11: DOI: Lundal, B., Moleni, Teena, Burke, Brian L., Butters, Robert, Tollefson, Derrik, Butler, Christopher, Rollnick, Stephen (2013). A systematic review and meta-analysis of randomized controlled trials. Patient Education and Counseling, Martins, Renata K., and Daniel W. McNeil. Review of Motivational Interviewing in promoting health behaviors. Clinical Psychology Review 29 (2009): Miller, W. R. & Rollnick, S. (2013) Motivational Interviewing: Helping People Change (3 rd edition). New York: The Guilford Press. Rosengren, David B. (2009) Building Motivational Interviewing Skills: A Practitioner Workbook. New York: The Guilford Press. It s not about the nail. The righting reflex. 21