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Using Motivational Interviewing to Improve Health Outcomes Among Older Adults

Using Motivational Interviewing to Improve Health Outcomes Among Older Adults. March 7, 2018. Lee Ellenberg , Massachusetts Screening, Brief Intervention and Referral to Treatment Training & Technical Assistance, Boston Medical Center

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Using Motivational Interviewing to Improve Health Outcomes Among Older Adults

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  1. Using Motivational Interviewing to Improve Health Outcomes Among Older Adults March 7, 2018 • Lee Ellenberg, Massachusetts Screening, Brief Intervention and Referral to Treatment Training & Technical Assistance, Boston Medical Center • Jennifer Raymond, Massachusetts Healthy Living Center of Excellence, Elder Services of the Merrimack Valley • Dianne Davis, Partners in Care Foundation

  2. Unhealthy Alcohol Use in Older Adults; Using Motivational Interviewing to Improve Health Outcomes Lee Ellenberg, LICSW Training Manager

  3. MASBIRT Training & Technical Assistance (TTA) (www.masbirt.org) Supported by MA DPH: Bureau of Substance Abuse Services (BSAS) to build statewide SBIRT awareness and capacity to • implement and integrate SBIRT into diverse settings and organizations, • and promote clinician SBIRT skills and competency. www.maclearinghouse.com

  4. Alcohol and Aging Bodies • Increased sensitivity • Lowered tolerance • Slowed metabolism • Effects experienced more quickly and for longer time Lower amounts = bigger effect

  5. What Is SBIRT ? Screening, Brief Intervention, Referral to Treatment UNIVERSAL Screen using validated tool to identify substance use In past year Referral for those who need assessment / add’l. services Positive Screens: Brief Negotiated Interview

  6. Historical Perspective Of SBIRT In Healthcare Problem No Problem • 1 in 6 patients talk with their doctor, nurse or other health professional about their drinking • 1CDC Vital Signs. National Center for Chronic Disease Prevention and Health Promotion. January 2014.

  7. Addiction:Historical Perspective Problem No Problem http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf

  8. Addiction:HistoricalPerspective New concept Risky use SUD Proble Low risk use or no use http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf

  9. Addiction:HistoricalPerspective New concept Risky use Unhealthy use SUD Proble • Risky use: • For alcohol— • Men < 65: >4 drinks/occasion or >14 drinks/wk • Women & >65: >3 drinks/occasion or >7 drinks/wk • For drugs*— ANY use Low risk use or no use http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf

  10. National Institute on Alcohol Abuse and Alcoholism (NIAAA) Lower Risk Drinking Guidelines ALCOHOL • People with medical conditions and people on medications should speak with their doctor about alcohol use. • DRUGS: Any illicit drug use or any prescription drug misuse is considered unhealthy

  11. What’s a Drink?

  12. What’s a Drink?

  13. What’s a Drink? The Full Bottle Wine Glass. Lifetime Guarantee Although it holds up to 750ml, the glass allows users to assure that they, in all honesty, had only one glass of wine.

  14. Validated Alcohol Questions Sensitivity/Specificity: 82%/79% • Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation of a single-question alcohol screening test. J Gen Intern Med 2009; 24(7):783-8

  15. Screening Instruments • Short Michigan Alcohol Screening Test-Geriatric Version (SMAST-G) • Health Screening Survey (quantity/frequency and CAGE AID questions embedded in a general health survey) • CAGE AID (Cut down, Annoyed by others, feel Guilty, need Eye opener) • AUDIT, DAST10

  16. Validated Single Item Drug Question Sensitivity/Specificity: 100%/74% • Smith P.C., Schmidt S.M., Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med 2010; 170(13):1155-60.

  17. What IsSBIRT? Screening, Brief Intervention, Referral to Treatment UNIVERSAL Screen using validated tool to identify substance use In past year Referral for those who need assessment / add’l. services Positive Screens: Brief Intervention

  18. Activity: Reflection Think about a difficult change that you had to make in your life. CONSIDER: • How long did it take you to move from considering that change to actually taking action? • Did you go back and forth about whether or not to make the change? • Why was it difficult to make the change?

  19. The Perceived Journey of CHANGE…

  20. The Perceived Journey of CHANGE…

  21. The Perceived Journey of CHANGE…

  22. A Definition of Motivational Interviewing Motivational Interviewing: A collaborative, goal-orientedstyle 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 anatmosphere of acceptance and compassion. - Stephen Rollnick and William R. Miller, Sheffield, UK Oct 2011

  23. Change is a Process Ambivalence is a normal part of the change process. :-| Change happens by resolving ambivalence.

  24. Principle: Ambivalence is Normal To The Change ProcessStrategy: Ask the Pros & Cons To Help Resolve Ambivalence What do you like about drinking? It makes me feel good. It makes me feel relaxed. And what do you like less about drinking? I’m tired of feeling awful the next day and I don’t want to lose my apartment.

  25. Strategy (cont’d): Asking the Pros & Cons Helps Resolve Ambivalence Then, reflect back the ambivalence: So on the one hand, drinking makes you feel relaxed and AND at the same time it causes you to feel hung over the next day and jeopardizes your housing.

  26. Four (4) Principles of MI:Collaboration, Evocation, Autonomy and Empathy • Collaborate/ Be a Partner:(vs. confront) with the pt. • Develop a partnership in which the patient’s expertise, perspectives, and input are central to the consultation • Recognize the person is the expert. • Foster and encourage power sharing in the interaction

  27. Principle: Collaboration“Resistance is an Interpersonal Process”

  28. Principle: Collaboration“Resistance is an Interpersonal Process”

  29. Principle: Collaboration“Resistance is an Interpersonal Process”

  30. Four (4) Principles of MI:Collaboration, Evocation, Autonomy and Empathy 2. Evoke / Draw Out (vs impose)thepatient’s ideas about change; Change is within the patient – to be discovered.

  31. Motivational Interviewing Basic When people can voice their own reasons for change, they are more likely to make the change.

  32. Principle: EvocationStrategy: Ask Open Ended Questions To Enhance Motivation To Change Open-Ended Questions Keep A Conversation GoingThe Patient THINKS about the answering, instead of answering reflexively. - “Do you think you have a problem with alcohol?

  33. Principle: EvocationStrategy: Ask Open Ended Questions To Enhance Motivation To Change Open-Ended Questions Keep A Conversation GoingThe Patient THINKS about the answering, instead of answering reflexively. - “Have you been taking your meds?” • - “Have you been checking your sugar?” - “Do you think you have a problem with alcohol? - “Are you interested in finding out about the exercise program?

  34. Principle: Evoke The Patient’s Reasons For Change Strategy: Use the Readiness Scale to Enhance Motivation To Change Given what we have been discussing, on a scale from 1-10, how ready are you to make a change regarding your use of opiates? Why did you choose that # and not a lower one? If zero: What would need to happen for you to consider making a change?

  35. Four (4) Principles of MI:Collaboration, Evocation, Autonomyand Empathy Four (4) Prinicipals of MI: Collaboration, Evocation, Autonomy and Empathy • Emphasize theautonomyof the client vs. being authoritative • Not to be confused with approval or disapproval. • Respecting the patient’s right to make informed choices facilitates change. • Emphasize patient control and choice.

  36. Principle: The Pt. is the Active Decision MakerStrategy: Ask Permission Before Making Recommendations or Suggestions • Is it OK if I ask you some questions about your use? • Is it OK if I give you some ideas of what other people do to manage their diabetes without medication?

  37. Strategy : When Giving Feedback & Advice: Explore-Offer-Explore Ask permission: Is it OK if we discuss your drinking / the results of the survey you completed?Explore: What do you know about how alcohol affects your health? How do you see your use of alcohol? Offer:Drinking at your level can increase blood pressure.I recommend not drinking more than 14 drinks/week.Explore: What do you think about that? What might you do?

  38. Principle: EmpathyStrategy #6: Use Reflections To Communicate Understanding 4. Practice empathy or compassion in the process. • Empathy for the experience of others • Belief and commitment to act in the best interests of the patient

  39. 4 Strategies TO HELP DECREASE RESISTANCE TO CHANGE • Don’t try to convince them they have a problem. • Don’t argue about the benefits of change. • Don’t tell them how they should change. • Don’t warn them of the consequences of not changing.

  40. MI Resources Motivational Interviewing in Healthcare: Helping Patients Change Behavior Rollnick, S., Miller, W., Butler, C. 2008. Motivational Interviewing; Helping People Change William Miller, Stephen Rollnick. 2013. 3rd edition. Websites: www.MotivationalInterviewing.org www.NIAAA.gov (SBIRT) www.SAMHSA.gov (SBIRT) www.MASBIRT.org

  41. THANK YOU

  42. Person Activation, Motivational Interviewing, and Evidence-Based Program Success

  43. Overview of the HLCE Vision: Transforming the healthcare delivery system, so that medical systems, community- based social services, and older adult collaborate to achieve better health outcomes and better healthcare, both at sustainable costs. • Key Features: • * Statewide Disease Management Coalition with website and universal license • * Seven (7) regional collaboratives • * Centralized referral, technical assistance, learning, and quality assurance • * Multi-program, multi-venue, across the lifespan approach • * Diversification of funding for sustainability • *EBP integration in medical home, ACO and other shared settings

  44. Total Program Participants January 1 – December 31, 2017 7037 Participants 596 Workshops

  45. One Key to Recruitment Success An Understanding of Person Activation and Motivational Interviewing

  46. Person Activation Staff and Volunteers responsible for recruitment receive training in “person activation”. Person Activation means having the information, motivation and behavioral skills necessary to self- manage, chronic illness, collaborate with health care providers, and access appropriate care

  47. Why Patient Activation Matters • Improved adherence to medications • Increased likelihood to eat healthier and engage in physical activity • Decreased likelihood of ED usage and readmissions post discharge • Increase engagement with clinicians J Gen Intern Med. 2012 May; 27(5): 520–526

  48. Levels of Activation Insignia Health (2016)

  49. Where are your clients and patients? Insignia Health (2016)

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