MOTIVATIONAL INTERVIEWING. Assisting With Patient Directed Health Decisions Lisa Becker, MAHS, DPh , NCPS Claremore Comprehensive Indian Health Facility. PATIENT ASSESSMENT TOOLS. To assist in behavior change, providers must first assess patients’: Health care knowledge Concerns Barriers.
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Assisting With Patient Directed Health Decisions
Lisa Becker, MAHS, DPh, NCPS
Claremore Comprehensive Indian Health Facility
To assist in behavior change, providers must first assess patients’:
Health care knowledge
The most recent definition of motivational interviewing (2009) is:
“A collaborative, person-centered form of guiding to elicit and strengthen motivation for change”
The “spirit” of MI is based on three key elements:
Evidence based standards guide self managed care with resulting improved outcomes.
“You are not ready to quit smoking at this time.”
When to use?
When patients are expressing issue resistance
“You are worried that you may not be able to quit without your husband quitting.”
When to use ?
To demonstrate understanding and to address a patient’s core concern
(Active Listening, Safe environment, Support, Information, Rephrase with “feeling”)
“You do not see yourself quitting smoking at this time. What types of things are you willing to do to get your cholesterol down?”
When to use?
To demonstrate understanding and to prevent creating relational resistance
Patient: My doctor says I need to lose weight, take the medicine, quit smoking, and reduce the salt in my diet. I don’t think I need to quit smoking, do you? How about cutting back?
HCP: It sounds like a lot to do. It’s great that you are willing to take your medicine and watch your salt intake. Cutting back on your smoking would be a great first step. Ultimately, quitting smoking would be the healthiest thing to do. What are your thoughts?
“On the one hand, you have an important goal of lowering your blood pressure to prevent stroke and heart attack. On the other hand, your smoking raises your blood pressure and your risks. What are your thoughts?”
When to use?
To create change talk and throw the patient’s system out of kilter without creating more resistance
(Identify core values of patient and if their behavior is consistent with those values)
Patient: I want to lower my blood pressure and reduce my risk of stroke or heart attack.
HCP: On the one hand, taking your medicine as you do really supports your goal of lowering your blood pressure. On the other hand, smoking raises your blood pressure and interferes with your goal.
“I am really glad to hear that you are thinking more about quitting. What has you thinking more about that?”
When to use?
To reinforce both thoughts and actions regarding behavior change
Patient: I don’t think I am ready to walk 4 days a week, but I am willing to try twice a week.
HCP: That sounds like a great start and will really help with your osteoporosis.
Patient: I’ve thought a little more about what you said about quitting smoking.
HCP: Great. Tell me more about what you have been thinking. What’s got you thinking about it?
“A LOOK OVER THE FENCE”
“Encourage change talk, create dissonance”
“MAY I TELL YOU WHAT CONCERNS ME?”
Patient: We’ve all got to die some time. Might as well go out doing something I enjoy.
HCP: You really enjoy smoking and no one can live forever any way.
HCP: May I tell you what concerns me?
Prevent “fixing” or “saving” the patient
Scale TWO concepts: Importance and Confidence
Example: from a 1 to 7 or a 1 to 10 scale
Elicits “Change Talk”
“If I were to hand you an envelope, what would the message have to say inside for you to consider quitting?”
(or whatever change you are discussing)
Explore readiness for change
ASK, INFORM, LISTEN
“Change talk”: communication with the patient in a way that elicits their own reasons for change:
A. Disadvantages of status quo
B. Advantages of change
C. Optimism for change
D. Intention to change
Reflect back your understanding of core concerns and line of reasoning
Ask permission to give information, make suggestions, or clarify
Identify the core concerns
Present a menu of options and determine what the patient wants to work on
Often called micro-counseling skills, OARS is a brief way to remember the basic approach used in MI.
These are core behaviors employed to move the process forward by establishing an alliance and eliciting discussion about change.
Open Ended Questions
The patient needs to make the argument for change—ask the patient what are the benefits of the change?
of the risk/susceptibility involved in not treating the illness or changing a behavior (eg, quitting smoking)
What does the patient understand about the illness and its treatment?
don’t “soften” lab values (blood pressure is 155/110—“It’s a little high”) to “protect the patient”—it backfires
When faced with ambivalence or resistance, EXPLORE, don’t explain