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
Ancient Greeks described three basic tools of medicine: The herb The knife The word
Start with a couple of questions
How many of you need to deal with changing patient behavior in your practice?
How successful are you in getting patients to change their behavior?
Health threatening behaviors are the leading cause of premature illness and death in the developed world Goldstein et al AM J Prev Med (2004)
What will we talk about today Brief behavior change theory and importance of counseling style Disclaimers Motivational interviewing General Aspects Brief how to
Patients are faced with many choices
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
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
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
Dealing with non-compliance We try Scare Tactics Badgering Blame Patients Advice Giving
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
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
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
Ambivalence Ambivalence is a normal and defining state of human experience. Most of us are ambivalent about most things most of the time
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
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
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
Advantages of Using MI Improved patient satisfaction Decrease personal frustration with difficult patients (burnout) Lower malpractice risk Better clinical outcomes
MI Outcome Studies by Era 100 80 60 40 20 0 1988-94 1995-99 2000-02 2003-06 Alcohol Drugs Dual Dx Gambling Offenders Eating Dis Adh/Retention Smoking HIV Risk Cardiac Diabetes Psychiatric Health Prom Family Violence Asthma Dental
A Meta-Analysis of Research on Motivational Interviewing Treatment Effectiveness (MARMITE) Hettema and Miller: Annual Review of Clinical Psychology (2005)
Mean Combined Effect Size by Problem Area (N=72 Clinical Trials) MARMITE
Motivational Interviewing Ask permission Listening skills Open ended questions Pt does the talking Provider is curious Provider summarizes with gentle direction
MI is more like dancing
Than a wrestling match
Very Brief How To Guide
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..
Easy things you can start OARS with Elicit Provide -Elicit
OARS Open-ended questions Affirm Reflective listening Summarize Allows us to make sure that we fully understand what the patient means
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?
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).
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?
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?
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
Sentence stems for reflections It sounds like you You mean that You re wondering if So you feel You re feeling You
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
OARS Open-ended questions Affirm Reflective listening Summarize
Advice Giving
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
Elicit-Provide-Elicit
Elicit how the patient feels Step 1
Provide information to the patient Step 2
Elicit again how the patient now feels Step 3
New Challenges Introduced by Technology Dealing with Lies?
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
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
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
OARS Open-ended questions Affirm Reflective listening Summarize Elicit-Provide Elicit
As technology improves, we will still need behavior change counseling to help patients make good choices.