When is Your Patient Ready, Willing, and Able to Change? Joseph (Joe) Nelson M.A., L.P.,CST

Transcription

1 When is Your Patient Ready, Willing, and Able to Change? Joseph (Joe) Nelson M.A., L.P.,CST

2 Who are you? And who is your patient? Beliefs about medical relationship? Emotions about Hypertension? History with Hypertension? Experience with Hypertension? Communication skills? Goals? Feelings toward each other?

3 Barriers to good disease management Low level of confidence or motivation Poor understanding of the process of change Depression It s not worthwhile It s not achievable Environmental barriers

4 What to Do?

5 If Nothing is Worthwhile Depression appears associated with hypertension

6 Depression Medical focus often misses the diagnoses Attribution of misbehavior to noncompliant patient Uncertainty of how to help Fear to ask

7 The Two Question Assessment Have you been bothered often by feeling down, depressed, or hopeless? Have you often had little interest or pleasure in doing things?

8 Integration of Depression and Hypertension Treatment Bogner, devries, Annals of Family Medicine, 10/31/2008 Comparisons of integrated treatment and usual treatment indicated: Improvement in BP Improvement in Depression scores Improved adherence in taking both medicines

9 Environmental Barriers Stress Daily Demands Limited Finances Poor or no insurance Socio-cultural influences

10 Almost no one is unmotivated to live a long and healthy life.

11 But for Some

12 How Change Doesn t Happen Diagnose the problem Identify the solution Apply the solution Change is permanent

13 How Change Really Seems to Happen There is not a problem There might be a problem There is a problem There is not a problem OK there is a problem Is there a solution? Maybe Do I like the solution?

14 How Change Seems to Happen I don t like the solution much Are there alternatives so I don t have to give up my old behavior And on.. and on.. and on.

15 Motivational Interviewing Improves Adherence in Hypertensive African Americans Gbenga Ogedegbe, and William Chaplin, et.al. American Journal of Hypertension Vol 21 number 10, October 2008 Improved adherence by 14% over UC Modest improvement in BP, but not statistically significant

16 Stages of Change James Prochaska et. al. Transthoretical Model of Change Readiness for Change

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18 Thinking Stages Pre-contemplation Contemplation

19 Transition stage Preparation From chaos To coordination

20 Movement and change Action Maintenance

21 Pre-contemplation Nothing is wrong so why would I change

22 Pre-contemplation Professional Style Usually Directive Give the facts Give them research Give clear basic information Appreciate the difficulty of change, it takes time, even if it makes sense

23 Two Informing Strategies Chunk - Check Chunk Elicit Provide - Elicit

24 Pre-contemplation Patient is unlikely to change in the next six months Many change abruptly Dramatic relief and return to former state = discouraged 40% of the population is in this stage

25 Maybe I will and Maybe I won t Contemplation

26 Contemplation Professional Styles Following and Guiding Ambivalence Listen actively Appreciate their conflict Encourage their discomfort It must be difficult to try new treatments when you re not sure you need to change

27 Contemplation Patient is considering change in the next three to six months 40% of the population is in this stage.

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29 The Spirit of Motivational Interviewing Collaborative Evocative Honoring of patient autonomy

30 Principles of R.U.L.E. Resist the righting reflex Understand their motivation Listen actively Empower them to take action

31 Styles of MI Following Directing Guiding

32 Skills of MI Asking Listening Informing

33 Following Asking Listening Informing

34 Directing Asking Listening Informing

35 Guiding Asking Listening Informing

36 Active Listening Open ended questions Patient focused Reflective listening Self Awareness Responding

37 Prochaska s research indicates If someone moves one stage they double the likelihood they will take action Therefore, help them to shift thinking or behavior Gradual movement is better than rejection

38 Explore Ambivalence Decisional balance sheet Pros Cons Values Barriers

39 Questions to help examine ambivalence On a scale of 1 to 10 where are you in terms of your interest in making this change? What has helped you get to a 4? What prevents you from being higher than a four? Rollnick 1999

40 Confidence in making change On a scale of 1 10 how confident are you that you can make this change What has helped you to get to a 3? What prevents you from being higher than a 3? Rollnick 1999

41 Let s get busy Preparation

42 Preparation What is their intention? Make sure they understand how to use the treatment Do they know what to expect? Have support available

43 D.A.R.N. Desire Ability Reason Need

44 D.A.R.N. Change Talk Desire - They want to Ability They can see themselves doing it Reason They know why they are considering change- the benefits Need They recognize the risks if they don t

45 Preparation The patient is likely to take action in the next one to three months Beware perpetual intenders

46 I am ready to do it Action

47 Commitment to Action Help them develop a plan the steps Specific Clear Start date What is success?

48 Action In the process of change Less than 10% of the population

49 Action for Action Anticipate recycling Stay in touch Use medical measures to show them the success of behavior change Caution! Don t use medical measures as the GOAL. Work with behavior.

50 Maintenance Patient has been doing it for three or more months Less than 5 % of patient populations are in this stage Beware of recycling

51 Timing is everything What is the patient ready for? Match your activities with their stage Know your style preference Remember R.U.L.E. Respect the spirit of MI Watch your judgments

52 What To Do?

53 What to do? Engage the patient Lead, follow, and join your patient Listen, Listen, Listen actively Stay in the present Take responsibility for yourself Help the patient be responsible When in doubt - support

54 MI is About Presence Joining Supporting Feeling better about what you are doing

55 Suggested Readings Prochaska James O, et al Changing for Good, Avon Books; 1994 Rollnick S, et al, Motivational Interviewing in Health Care; Guilford Press 2008 Polonsky WH. Diabetes Burnout: What To Do When You Can t Take It Anymore, Washington, DC: ADA; Rollnick S, et al. Health Behavior Change. New York: Churchill Livingstone; 1999.

56 Suggested Readings Major Developments in Behavioral Diabetes Research Journal of Consulting and Clinical Psychology Cox, Gonder-Frederick; 1992 Motivational Readiness for Change American Journal of Health Behavior Bock, Marcus, Rossi, Redding; 1998

57 Suggested Readings A Stages of Change Approach to Helping Patients Change Behavior American Family Physician Zimmerman, Olsen, Bosworth; 2000