Motivational interviewing a pathway to and a feature of the patient centered medical home
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Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home. Ronald Adler, MD, FAAFP Daniel Mullin, PsyD UMass Medical School STFM Faculty Development Workshop December 5, 2009. The PCMH:.

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Motivational interviewing a pathway to and a feature of the patient centered medical home

Motivational Interviewing:A Pathway to and a Feature of the Patient-Centered Medical Home

Ronald Adler, MD, FAAFP

Daniel Mullin, PsyD

UMass Medical School

STFM Faculty Development Workshop

December 5, 2009


The pcmh

The PCMH:

Is a physician-directed practice providing care that is comprehensive, preventive, coordinated, and centered on the needs of patients (and their families, as appropriate).

Uses HIT, registries and other process innovations to assure high-quality, evidence-based care that is efficient and readily accessible.

Promotes and supports patient self-management and systematically measures its own performance to facilitate continuous quality improvement.


A medical home provides

A Medical Home Provides

Easy access to a PCP,

Who is working with a high-functioning team

And a robust IT system,

To provide comprehensive care to

Activated, informed patients and families.


Easy access to a pcp

Easy Access to a PCP

  • Access

    • Open access scheduling

    • Customized communication

  • Interactions

    • Family-centered

    • Personal attention

    • Relationship is key


High functioning team

High-Functioning Team

Nurse

Care Coordinator

Social Worker

Mental Health Provider

Nutritionist

Pharmacist

(Plus learners: students, residents)


Robust it system

Robust IT System

  • EMR/Electronic Prescribing

  • Decision Support

  • Relevant, up-to-date info available at point-of-care

  • Tracks Data

    • Registry: Process and Outcomes

    • Satisfaction: Patients, Staff and PCPs


Motivational interviewing a pathway to and a feature of the patient centered medical home

  • For individuals, change requires:

  • Motivation – Why to change

  • Information – What to change

  • Ability/Resources/Effort – How to change


Insanity

Insanity

  • “Insanity: Doing the same thing over and over again and expecting different results.” -- Albert Einstein

  • Current state: Provide our patients with information and repeated exhortations – and hope they “get it.”

  • Can we do BETTER?


Is your patient s positive change mia

Is Your Patient’s Positive Change MIA?

  • Motivation

    • Is s/he inspired to make changes?

  • Information

    • Does s/he understand the reasons for change?

  • Ability

    • Does s/he have the resources necessary to create the change?


Facilitating positive change

Facilitating Positive Change

  • Identify your patient’s barriers to change.

  • Tailor your interventions to address these:

  • If Motivation, help inspire them.

  • If Information, educate them.

  • If Ability, provide helpful resources.


Barriers to change

Barriers to Change

  • Each patient faces multiple barriers.

  • Consider the relative contributions of deficits in:

    • Motivation

    • Information

    • Ability

  • Motivation is always a factor, usually the most significant.


Motivation

Motivation

  • Assess:

    • How important is it for you to change right now?

  • Improve/Enhance:

    • Create context: patient’s life goals

    • Review prior efforts, including lessons from successes and failures

    • Recognize your lack of power

    • Acknowledge your lack of power

    • Identify your patient’s strengths

    • Promote your patient’s power


Facts about flossing

Facts about Flossing

  • Flossing removes food debris and plaque.

  • Plaque causes tooth decay and gum disease.

  • Regular flossing can help prevent MI and CVA.


Why don t you floss more

Why don’t you floss more?

  • Do you lack info re: the benefits?

  • Is it difficult to acquire floss?

  • What’s really missing?


Motivational interviewing a pathway to and a feature of the patient centered medical home

There is something in human nature that resists being coerced and told what to do. Ironically, it is acknowledging the other’s right and freedom not to change that sometimes makes change possible.

Rollnick, Miller, and Butler (2008)


The fundamental attribution error

The Fundamental Attribution Error

  • When explaining the behavior of others, we tend to overestimate personal factors and underestimate environmental factors.

  • When explaining our own behavior, we tend to underestimate personal factors and overestimate environmental factors.


Motivational interviewing a pathway to and a feature of the patient centered medical home

When a patient seems unmotivated to change or to take the sound advice of practitioners, it is often assumed that there is something the matter with the patient and that there is not much one can do about it.

Rollnick, Miller, and Butler (2008)


Motivational interviewing a pathway to and a feature of the patient centered medical home

  • These assumptions are usually false.

  • Motivation for change is actually quite malleable and is particularly formed in the context of relationships.

    Rollnick, Miller, and Butler (2008)


Motivational interviewing

Motivational Interviewing

is

a patient-centered, goal-oriented method of communication

for enhancing intrinsic motivation to change

by exploring and resolving ambivalence.


Four principles of mi

Four Principles of MI

Resist Righting Reflex

Understand and explore patient’s motivations

Listen with empathy

Empower patient, encouraging hope and optimism


Resist righting reflex

Resist Righting Reflex

  • Tolerate incorrect information that is irrelevant or useful.

  • Ask permission before educating or informing.


Understand and explore patient s motivations

Understand and Explore Patient’s Motivations

  • Explore the patient’s values; what are the functional limitations that result from their illness?

  • What has motivated them to make changes in the past?

  • What do others in the patient’s life say about their behavior and how does this impact their motivation?


Listen with empathy

Listen With Empathy

  • What is the difference between empathy and sympathy?

    Empathy is the cognitive process of understanding another person’s emotions.

  • Unfortunately, many people react negatively to the assertion “I understand how you feel.”


Empower patient encourage hope and optimism

Empower Patient,Encourage Hope and Optimism

  • Create the expectation of success.

  • Give positive attention to any change the patient makes.

  • Offer to give examples of other successes you have witnessed.

  • Set realistic goals to increase chances of success.


Ambivalence

Ambivalence

  • … is characterized by conflicting thoughts and feelings for and against change.

    People often think:

  • First of reasons to change,

  • Then of reasons not to change.

  • … Then they stop thinking of change


Resolving ambivalence

Resolving Ambivalence

  • Change follows the exploration and resolution of ambivalence.

  • Providers are successful when patients talk themselves into change.


Motivational interviewing a pathway to and a feature of the patient centered medical home

Welch, G., Rose, G., & Ernst, D. (2006)


Listening for change talk

Listening for Change Talk

  • We tend to believe what we hear ourselves say.

  • The more patients verbalize the disadvantages of change, the more committed they become to sustaining the status quo.


Motivational interviewing a pathway to and a feature of the patient centered medical home

On a scale of 0 to 10, how IMPORTANT is it for you right

now to change?

On a scale of 0 to 10, how CONFIDENT are you that you

could make this change?

0

|

0

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1

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1

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2

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2

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3

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3

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4

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4

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5

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5

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6

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6

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7

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10

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Becoming a medical home

Becoming a Medical Home

  • Requires meaningful transformation

  • All personnel in your practice must engage

  • Change is difficult

    • Especially for busy health care providers

    • ESPECIALLY for doctors


Motivational interviewing a pathway to and a feature of the patient centered medical home

  • For individuals, change is very difficult.

  • For organizations, the complexities and challenges associated with change increase -- dramatically with the size of the organization.


Aha moment

Aha! Moment

  • Techniques to support and facilitate behavior change in patients, may be useful when helping your colleagues achieve behavior change in the work environment.

  • Just as for chronic illness to be managed effectively, the patient must actively participate in the process, so must the entire health care team participate in change processes.


An illustrative vignette

An Illustrative Vignette

  • Resident presents a woman with DM-2 whose A1C had gone from 7.0 to 9.5 over 6 months.

  • I ask "To what extent do you think she understands diabetes?“

  • Resident replies "I explained it to her: she has to take her medicine, eat a better diet, ..."


Exercise

Exercise

  • Does the resident understand that it is important to explore the patient’s perspective?

  • Does the resident have confidence that she can be successful in exploring the patient’s perspective?

  • Is the resident ambivalent about exploring the patient’s perspective?

  • How can you help the resident adopt this patient’s perspective?


An illustrative vignette1

An Illustrative Vignette

  • Resident presents a woman with DM-2 whose A1C had gone from 7.0 to 9.5 over 6 months.

  • I ask "To what extent do you think she understands diabetes?“

  • Resident replies "I explained it to her: she has to take her medicine, eat a better diet, ..."

  • I reply "I didn't ask if YOU understand diabetes. How can we help HER do better?“


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