TCPI Motivational Interviewing Series Part 3 of 3 June 7, 2018 Hosted by: Margaret M. Menna, MBA Senior Training & Education Specialist Rhode Island Quality Institute
Motivational Interviewing in the Clinical Environment: A1c Control and Lowering BMI Presenters: Beth Bennett, NCTTP, CTTS-M, NBC-HWC Clinical Director Tobacco Cessation Services of RI CODAC Behavioral Healthcare JoEllen Golberg, RN, BSN, CCM Senior Clinical Practice Advisor Rhode Island Quality Institute 2018
Quality Measures Preventative Care and Screening: Body Mass Index ( BMI) and Follow-Up Plan (NQF 0421) Diabetes: Hemoglobin A1c Poor Control (NQF 0059) BMI s relation to A1c Control 3
Today s Objectives Review MI spirit and skills in greater depth Put MI into practice for helping patients with A1c control and lowering BMI Introduce two new brief intervention skills Select one Motivational Skill you are committed to using in your clinical practice today! 4
Definition of Motivational Interviewing Motivational Interviewing is a collaborative, goaloriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person s own reasons for change within an atmosphere of acceptance and compassion. Stephen Rollnick and William R. Miller, Sheffield, UK Oct 2011 5
Motivational Interviewing: Spirit Collaboration come alongside, honor client s wisdom, they are the expert on their life Evocation elicit vs impart Autonomy ability to chose, empowerment Compassion empathy, understanding their competent world view 6
RULE of MI Resist the righting reflex Understand Motivation Listen Empower the client 7
Structure: What the Heck are We Doing Here? ENGAGE: EXPRESS EMPATHY FOCUS: EVOKE: (radical acceptance, rapport, compassion) HEIGHTEN AMBIVALENCE (allows them to be heard and believed) (clarifies the two sides of an identified change) DEVELOP DISCREPANCY (increases importance, creates subtle discomfort).change TALK PLANNING: EMPOWERMENT (Supports self-efficacy and confidence, autonomy) 8
Skills and Strategies: OARS O: open-ended questions have more than a yes/no, or one word answer A: affirmations notice their strength/courage listen for values/dreams R: reflections are empathic and help build safety use more reflections than questions S: summaries use during transitions & end of the conversation selectively highlight content 9
Change Talk: DARN-CAT Desire I want to get my blood sugar under control. Ability I can make some better food choices. Reason My doctor say I ll have to start insulin if I keep up this way. Need Carrying this extra weight is making it hard to get up the stairs. Commitment I will see what Planet Fitness costs. Activation Today, I am going to talk to my partner after work about buying less junk food. Taking Steps On my break I walked around the block. 10
Elicit Provide - Elicit 1. ELICIT client s ideas, needs 2. Ask PERMISSION to share information 3. PROVIDE relevant advice, information or a menu 4. ELICIT client s reactions & commitment to taking the next step 11
Responding to Change Talk E: Elaborating - Ask for more detail Ask what s next? Ask, What might you do? A: Affirming Comment positively on the person s change talk R: Reflecting Verbalize what you understand the other person to have said. S: Summarizing Collect bouquets of the person s change talk 12
Eliciting Change Talk SKILL: Double-sided Reflection A double-sided reflection is powerful because it contrasts the patient s own pros and the cons of making a change. The format is simple On one hand AND on the other hand Ex. On one hand you enjoy doughnuts and candy and on the other hand you are pretty shocked about the 8lb. weight gain since you were here last month. Note that the reasons for change are at the end so the patient focuses on them. 13
Eliciting Change Talk SKILL: Importance Scale Using a two-part scaling question elicits change talk very quickly and is perfect for very brief interventions. Part One: On a scale of 0-10, where 0 is GOAL is not important at all and 10 is that GOAL is very important what number are you now? Clinician: On a scale of 0-10, where 0 is losing 20lbs. is not important at all and 10 is that losing that weight is VERY important to you what number are you now? Patient: I guess I m a 6. 14
Eliciting Change Talk SKILL: Importance Scale Part Two: Why aren t you a LOWER number? Clinician: Ok, you re a 6. Why aren t you a 2? Patient: Well, I am trying to get more exercise and I ve backed down to two Cokes a day. I used to drink at least 4. And I m drinking water at my desk at work Patients expect you to ask why they aren t a HIGHER number. Your question surprises them and helps them notice and build upon existing successes. 15
Planning Am I evoking rather than prescribing a plan? Am I asking permission to give information or advice? Does this feel like a collaborative partnership? Am I maintaining a sense of quiet curiosity about what kind of support will work best for this person? Given what we ve just discussed, what MIGHT be a reasonable next step? 16
Demonstrations: Conversation with and without MI skills 17
Questions? 18
Leaving in Action Consider which of the MI skills would help you in your practice, starting today. Contact your RIQI- TCPI Practice Facilitator for further assistance in understand National Quality Measures CODAC Behavioral Healthcare offers individualized Motivational Interviewing trainings at your practice. If you or someone you know is in need of information, support or treatment because of substance use please call 401-461-5056. WWW. CODACINC.ORG 19
Resources for Learning MI Thinking Outside the Pillbox- -Medication Adherence as a Priority for Health Care Reform https://www.nejm.org/doi/full/10.1056/nejmp1002305 Motivational interviewing for adherence: post-training attitudes and perceptions of physicians who treat asthma patients https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5407448/ Motivational Interviewing Network of Trainers http://www.motivationalinterviewing.org/ Motivational Interviewing (hosted by the Mid-Atlantic Addiction Technology Transfer Center http://www.motivationalinterview.org/ UMass Center for Integrated Primary Care: Certificate of Intensive Training in MI http://www.umassmed.edu/cipc/ Health Education & Training Institute (HETI) http://www.hetimaine.org/ Motivational Interviewing in Health Care (Rollnick, Miller, Butler) https://www.guilford.com/books/motivational-interviewing-in-health-care/rollnick- Butler/9781593856120/reviews Miller- 20
Contacts Beth Bennett, NCTTP, CTTS-M, NBC-HWC Clinical Director Tobacco Cessation Services of RI CODAC Behavioral Healthcare CODAC Behavioral Healthcare bbennet@codacinc.org Margaret Mottola Menna, MBA Training & Education Specialist Rhode Island Quality Institute mmenna@riqi.org 21
Thank you! 22