Behavior Change Counseling to Improve Adherence to New Diabetes Technology

Transcription

1 Behavior Change Counseling to Improve Adherence to New Diabetes Technology Reinventing Diabetes Care for the 21st Century Robert A. Gabbay, M.D., Ph.D. Executive Director, Penn State Institute for Diabetes and Obes Professor of Medicine Penn State College of Medicine

2 Ancient Greeks described three basic tools of medicine: The herb The knife The word

3 Start with a couple of questions

4 How many of you need to deal with changing patient behavior in your practice?

5 How successful are you in getting patients to change their behavior?

6 Health threatening behaviors are the leading cause of premature illness and death in the developed world Goldstein et al AM J Prev Med (2004)

7 What will we talk about today Brief behavior change theory and importance of counseling style Disclaimers Motivational interviewing General Aspects Brief how to

8 Patients are faced with many choices

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10 Not everyone seems to benefit from continuous glucose monitoring? Data and knowledge are important But may not be enough Need to translate to Behavior Change

11 What determines positive change in self-care behavior Clinician counseling style!!!! (Rost et al., 1991; Glasgow et al., 1999; Anderson & Funnell, 2000; Doherty et al., 2000).,and many many other studies

12 Our Traditional Style: Directive Expert Advice Giving Promotes Passive uninvolved patient Lack of fit between clinician agenda and pt agenda Look how well it works! Two components Information exchange Persuasion Can lead to resistance

13 Dealing with non-compliance We try Scare Tactics Badgering Blame Patients Advice Giving

14 Patient Centered Approach Goals and agenda negotiated Patient values are examined Outcomes are superior! Greenfield et al., 1988; Kaplan et al., 1989; Greenfield et al., 1988; Uhlmann et al., 1988; Roter & Hall, 1989; Golin et al., 1996 and many many more

15 Motivational Interviewing A directive client (patient)-centered counseling style for increasing INTRINSIC motivation by helping the patient explore and resolve ambivalence (Miller and Rollnick, 2001) Avoid the Blame game a patient s resistance does not equal noncompliance Initially developed for use in the alcohol and drug abuse field

16 Ambivalence Can you imagine yourself saying or thinking this: Perhaps I should do something about this, I m a little concerned but I don t think I ll do anything about it yet And besides, it s not that bad. I m happy enough for the moment one day maybe

17 Ambivalence Ambivalence is a normal and defining state of human experience. Most of us are ambivalent about most things most of the time

18 Ambivalence Complex motivational forces are often represented in simple speech. I really should check my blood sugars more often but I just don t have the time MI is the practice of disentangling competing and often obscured motives

19 Some basic assumptions Patients talk themselves into changing Patients don t change just because we want them to change Patients rarely change just because we tell them to change The process of changing may be accelerated by practitioners but it might also be inhibited

20 More basic assumptions Practitioners who understand the effects of ambivalence in their patient are more likely to influence behaviors It s the patient that has to do the changing and that s often hard work What we do and how we do it makes all the difference

21 Advantages of Using MI Improved patient satisfaction Decrease personal frustration with difficult patients (burnout) Lower malpractice risk Better clinical outcomes

22 MI Outcome Studies by Era Alcohol Drugs Dual Dx Gambling Offenders Eating Dis Adh/Retention Smoking HIV Risk Cardiac Diabetes Psychiatric Health Prom Family Violence Asthma Dental

23 A Meta-Analysis of Research on Motivational Interviewing Treatment Effectiveness (MARMITE) Hettema and Miller: Annual Review of Clinical Psychology (2005)

24 Mean Combined Effect Size by Problem Area (N=72 Clinical Trials) MARMITE

25 Motivational Interviewing Ask permission Listening skills Open ended questions Pt does the talking Provider is curious Provider summarizes with gentle direction

26 MI is more like dancing

27 Than a wrestling match

28 Very Brief How To Guide

29 Establishing Rapport Acknowledge setting Change gears from H&P -now that this is out of the way, can we take a few min to talk about other things that are affecting your diabetes..

30 Easy things you can start OARS with Elicit Provide -Elicit

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32 OARS Open-ended questions Affirm Reflective listening Summarize Allows us to make sure that we fully understand what the patient means

33 Open-ended questions Closed questions- do you always count carbs when you take your pump boluses? Open ended question: tell me a little about how it s going with counting carbs when your take boluses? Or if you strongly suspect adherence issues: Many people find it challenging to count carbs daily- how is it going tor you?

34 Asking Good Questions Good question: A question for which the answer is change talk. (It draws out the reasons and intentions for change.) Not-so-good question: A question for which the answer is resistance (commitment to the way things are).

35 Good question or not? How do you think it might be helpful if you counted carbs? Why don t you check your blood sugars? What do you think is the value of looking at your BG trends How can you put your life at risk by not taking your insulin boluses? Don t you know you must check your blood sugar 4 x a day?

36 A. Affirm Finding something positive about patient s behavior Making that finding verbally explicit Appreciation vs. approval ( You vs. I ) Genuineness is critical What if I can t find anything positive about my patient?

37 R. Reflect Demonstrates a desire for mutual understanding Good follow up to open-ended question Being selective as we hold up a mirror for the people we work with

38 Sentence stems for reflections It sounds like you You mean that You re wondering if So you feel You re feeling You

39 S. Summarize Indicates attentiveness on part of interviewer ( Let me make sure I m getting this ) Allows pt statements to be clarified, consolidated, & reinforced Builds discrepancy, provides direction

40 OARS Open-ended questions Affirm Reflective listening Summarize

41 Advice Giving

42 GIVE ADVICE SPARINGLY I ve learned that it is best to give advice in only two circumstances; when it is requested and when it is a life-threatening situation. --Andy Rooney

43 Elicit-Provide-Elicit

44 Elicit how the patient feels Step 1

45 Provide information to the patient Step 2

46 Elicit again how the patient now feels Step 3

47 New Challenges Introduced by Technology Dealing with Lies?

48 Some Guidelines Do Not be Accusatory or Judgmental Present the facts Act curious- help me understand Normalize problems with adherence Again try to use OARS

49 Where do we go from here? Learning more Books, videos Training sessions Medical School curriculum DYNAMIC (Diabetes Nurse case Management And Motivational Interviewing for Change) Try aspects now? Consider taping yourself

50 Reference Health Behavior Change: A Guide for Practitioners By Rollnick, Mason, and Butler published by Churchill, Livingstone (1999) Available at Amazon and elsewhere MotivationalInterviewing.org

51 OARS Open-ended questions Affirm Reflective listening Summarize Elicit-Provide Elicit

52 As technology improves, we will still need behavior change counseling to help patients make good choices.