Motivational Interviewing: A Practical Approach Sarah Blust, LMSW, MPH Project manager Primary care development corporation (PCDC)
Learning Objectives • To become familiar with the theory and essence of Motivational Interviewing (MI) • To gain a general understanding of the techniques of MI • To understand how MI techniques can be applied to management of chronic conditions such as diabetes and hypertension
But first… Who’s in the room today? Take off your mute button. Say “here” when I call out a role that applies to you!
Any providers? • MDs, CNMs, NPs, PAs?
How about nurses? • RNs or LPNs?
Social workers? • LMSWs, LCSWs, MSWs
Administrators? • Directors, Program Managers, Office Managers
Thank you! Mute button back on please
Story of MI • Substance Treatment: • Then & Now • 200 Clinical Trials Later • PCMH MI Spirit • The spirit of MI • Guiding Principles: RULE • OARS • Recognizing change talk MI Techniques • Diabetes • Cancer Screening Apply to Practice
The Story of Motivational Interviewing Originally came about as a different approach to substance/alcohol treatment 1970’s - treatment approach was to use counselors who were also in recovery to “confront” clients about their addiction and “make them” change
However, when clients were confronted, their natural instinct was to defend themselves - thereby removing any desire to behave any differently
Enter William Miller, PhD William Miller, PhD Center for Alcoholism, Substance Abuse and Addictions Distinguished Professor of Psychology and Psychiatry Departments of Psychology & Psychiatry at The University of New Mexico
As a student in training, Dr. Miller “accidentally” discovered that other approaches could positively affect the behavior of addicted patients • Listening • Empathy • Over time, these experiences were studied, replicated, modified and enhanced to become the field of Motivational Interviewing
Subsequently, a more common treatment philosophy for addiction is now: Rather then the job of the client/patient to be motivated for change…. It’s our job as health professionals to help people find the motivation for change that’s already there within themselves
Where is the MI field now? • MI has now been in the field for 30 years • More than 200 clinical trials of MI have been published
Positive results for an array of target problems • Cardiovascular rehabilitation • Diabetes management • Dietary change • Hypertension • Illicit drug use • Infection risk reduction • Management of chronic mental disorders • Problem drinking • Smoking • Concomitant mental health & substance abuse disorders
Other advantages Relatively brief Specifiable (but be careful with manuals) Verifiable – is it being delivered properly Generalizable across problem areas Complementary to other treatment methods Learnable by a broad range of providers
Leading to an explosion of MI information Besides the >200 randomized clinical trials… >1000 publications Dozens of books and videotapes 10 Multisite clinical trials Several coding systems for QA MIA-STEP to support MI supervisors Research on MI training
Training for MI Currently, there is no official certification for MI The Motivational Interviewing Network of Trainers (MINT) can be used to train staff Many online resources and trainings exist (see end of presentation) However, in-person supervision or peer support groups is highly recommended as the way to achieve solid MI skills
Direction of healthcare - PCMH In the world of Patient Centered Medical Homes (PCMH) a patient centered counseling approach is also needed MI is not only the right thing to do, it’s become the thing you should do and the thing you will get paid to do
Reimbursement CPT Evaluation and Management codes allow reimbursement for time spent counseling patients. Practices can also be reimbursed by having nurse practitioners or physician assistants provide patient-centered counseling.
NCQA’s PCMH 2011 Standards PCMH 3: Plan and Manage Care (17 points) The practice systematically identifies individual patients and plans, manages and coordinates their care, based on their condition and needs and on evidence-based guidelines (4 points) Element C: Care Management 1. Conducts pre-visit preparations 2. Collaborates with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each relevant visit 3. Gives the patient/family a written plan of care 4. Assesses and addresses barriers when the patient has not met treatment goals 5. Gives the patient/family a clinical summary at each relevant visit 6. Identifies patients/families who might benefit from additional care management support 7. Follows up with patients/families who have not kept important appointments
NCQA’s PCMH 2011 Standards PCMH 4: Provide Self-Care Support and Community Resources (9 points) The practice acts to improve patients' ability to manage their health by providing a self care plan, tools, educational resources and on-going support. (6 points) 1. Provides educational resources or refers at least 50 percent of patients/families to educational resources to assist in self management 2. Uses an EHR to identify patient-specific education resources and provide them to more than 10 percent of patients, if appropriate 3. Develops and documents self-management plans and goals in collaboration with at least 50 percent of patients/families 4. Documents self-management abilities for at least 50 percent of patients/families 5. Provides self-management tools to record self-care results for at least 50 percent of patients/families 6. Counsels at least 50 percent of patients/families to adopt healthy behaviors
PCMH 4: Factor 4 Patients and families who feel they can manage their condition, learn needed self-care skills or adhere to treatment goals will have greater success. Practices may use motivational interviewing to assess patient readiness to change and self-management abilities, including questionnaires and self-assessment forms. The purpose of assessing self-management abilities is that the practice can adjust self-management plans to fit patient/family capabilities and resources.
Eight Stages in Learning MI 1) The Spirit of MI 2) OARS 3) Recognizing change talk 4) Eliciting and strengthening change talk 5) Rolling with resistance 6) Developing a change plan 7) Consolidating client commitment 8) Engaging MI with other methods
Some Definitions Motivational interviewing (MI) is a clinical method for helping people to resolve ambivalence about change by evoking intrinsic motivation and commitment. A skillful, clinical style for eliciting from patients their own motivations for making behavior change in the interest of their own health
The Spirit of MI - Collaborative Collaborative Approach • Clinician is not “above” the patient, telling them what to do • Conversation is more equal, in which joint decision-making occurs
The Spirit of MI - Evocative “Often healthcare involves giving patients what they lack…MI instead seeks to evoke from patients that which they already have”. (Rollnick, Miller & Butler, 2008) • MI seeks to understand the patient’s perspective by evoking their own good reasons and arguments for change
The Spirit of MI – Honoring Patient Autonomy “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 & Butler, 2008) • Clinicians may inform, advise, even warn but ultimately it is the patient who decides what to do. • Honoring this can help facilitate change.
Four Guiding Principles • RULE • Resist – the righting reflex • Understand – the patient’s own motivations • Listen – with empathy • Empower – the patient
Motivational Interviewing in Practice How NOT to Do Motivational Interviewing http://www.youtube.com/watch?v=kN7T-cmb_l0
R: Resist the Righting Reflex People who enter the helping professions often want to set things right and prevent harm Can lead to a “correcting” of a person who is off course Natural human tendency to resist persuasion
R: Resist the Righting Reflex “We tend to believe what we hear ourselves say. The more patients verbalize the disadvantages of change, the more committed they are to sustaining the status quo” (Rollnick, Miller & Butler, 2008)
U: Understand Your Patient’s Motivations It is your patient’s own reasons for change, not yours, that are the most likely to trigger behavior change Best use of your consultation time - ask patients why they would want to make a change and how they might do it – rather than telling them that they should
L: Listen to your Patient “A practitioner who is listening, even if it is just for a minute, has no other agenda than to understand the other person’s perspective and experience” (Rollnick, Miller & Butler, 2008) Good listening is actually a complex clinical skill When done right, it can make the patient feel they have had more time with you then they actually have AND save time
E: Empower Your Patient “A patient who is active in the consultation, thinking aloud about the why and how of change, is more likely to do something about this afterward.” (Rollnick, Miller & Butler, 2008)
OARS • Four communication techniques engender MI spirit: • Open-ended questions • Affirmations • Reflective listening • Summary statements (OARS).
OARS has been shown to increase patient collaboration and satisfaction, treatment adherence, and patient-physician working alliance Underlying OARS is empathy– the ability to understand the patient's thoughts, feelings, and struggles from their point of view. Empathy is a strong predictor of treatment outcome