Motivational Interviewing, the Asthma Action Plan, and Sharing Decision Making with Patient s Families
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1 Motivational Interviewing, the Asthma Action Plan, and Sharing Decision Making with Patient s Families AAP/KY Chapter Quality Network Learning Session July 17, 2015 Sarah Spurling, Ph.D., HSP Pediatric Psychologist University of Louisville School of Medicine
2 Conflict of Interest No conflicts to report.
3 Asthma Adherence 34-71% for Inhaled Corticosteriods depending on method of measurement (McQuaid, E.L., et al., 2012) Low household income (McQuaid, EL, et al., 2003) Minority status (McQuaid, EL, et al., 2003) 11-17yo have higher mortality than younger children (Akinbami, L, et al., 2006) Adolescents have poorer adherence than younger children beginning around 10yo (Jonasson, G, et al., 1999)
4 Asthma Adherence Asthma knowledge and reasoning about asthma does not improve adherence in adolescents (McQuaid, et al., 2003) Self-management interventions improve outcomes more than educational interventions (Guevara, et al, 2003) but involve >5.5 hrs of direct patient contact (Cabana & Le, 2005)
5 Motivational Interviewing Key Aims: 1. Build intrinsic motivation in patients to adopt health recommendations 2. Resolve ambivalence about behavior change Before providing education! (Miller & Rollnick, 2002)
6 Stages of Change & MI Relapse Precontemplation Phase 1 Increasing motivation Phase 2 Coaching Maintenance Action
7 Foundational Spirit of MI Collaborative Evocative Honoring patient autonomy (Rollnick, Miller, & Butler, 2008)
8 R.U.L.E.s of the Game Resist the Righting Reflex Understand your patient s motivations Listen to your patient Empower your patient
9 Dance, Don t Wrestle Guide Direct Follow
10 Dance, Don t Wrestle Asthma Dialogue without MI v=jts1uvhywkm
11 Using O.A.R.S. to Stay Afloat Open-ended questions Affirmations Reflective Listening Summary Statements
12 Beginning the Consultation (Borrelli, et al., 2007) Set an agenda Discuss a typical day Assess motivation and confidence for change
13 Set the Agenda Asthma Action Plan Provide a menu of options for discussion (essentially your Asthma Action Plan) and let the patient decide where to start the conversation. General Information: Name Emergency contact Phone numbers Physician/healthcare provider Phone numbers Physician signature Date Severity Classification Intermittent Moderate Persistent Mild Persistent Severe Persistent Triggers Colds Smoke Weather Exercise Dust Air Pollution Animals Food Other Green Zone: Doing Well Peak Flow Meter Personal Best = Symptoms Breathing is good No cough or wheeze Can work and play Sleeps well at night Peak Flow Meter More than 80% of personal best or Control Medications: Exercise 1. Premedication (how much and when) 2. Exercise modifi cations Medicine How Much to Take When to Take It Would you like to talk about taking your medication, monitoring asthma symptoms, or avoiding asthma triggers? (Borrelli, et al., 2007) Yellow Zone: Getting Worse Symptoms Some problems breathing Cough, wheeze, or chest tight Problems working or playing Wake at night Peak Flow Meter Between 50% and 80% of personal best or to Red Zone: Medical Alert Symptoms Lots of problems breathing Cannot work or play Getting worse instead of better Medicine is not helping Peak Flow Meter Less than 50% of personal best or to Contact physician if using quick relief more than 2 times per week. Continue control medicines and add: Medicine How Much to Take When to Take It IF your symptoms (and peak flow, if used) return to Green Zone after one hour of the quick-relief treatment, THEN Take quick-relief medication every 4 hours for 1 to 2 days. Change your long-term control medicine by Contact your physician for follow-up care. Ambulance/Emergency Phone Number: Continue control medicines and add: IF your symptoms (and peak flow, if used) DO NOT return to Green Zone after one hour of the quick-relief treatment, THEN Take quick-relief treatment again. Change your long-term control medicine by Call your physician/healthcare provider within hour(s) of modifying your medication routine. Medicine How Much to Take When to Take It Go to the hospital or call for an ambulance if: Still in the red zone after 15 minutes. You have not been able to reach your physician/healthcare provider for help. Call an ambulance immediately if the following danger signs are present: Trouble walking/talking due to shortness of breath. Lips or fi ngernails are blue. Rev_July_2008
14 Discuss a Typical Day What is a typical day like for you, from start to finish, and if you like, tell me about where taking your medication fits into your day. One open-ended questions allows the provider to assess social context and adherence in non-judgmental framework. (Borrelli, et al., 2007)
15 Assess Motivation & Confidence for Change How motivated are you to take your medication? Rate your motivation on a scale of 1-10, where 1 is not at all motivated and 10 is very motivated. Confidence in ability to adhere can also be rated in this way.
16 Midconsultation Strategies Use the lower-higher exercise Explore the costs and benefits of change Provide medical advice and feedback Advise your patient to change using RAISE Ask evocative questions
17 Lower-Higher Why not a lower number? (helps elicit positive statements about change) What would it take for you to get to a 9 or 10? (helps identify barriers and facilitators of adherence) Same can be done for confidence levels.
18 Costs & Benefits of Change What are some of the not so good things about taking your medication? What are some of the good things about taking your medication? Encourage detailed answers. Finish with a summary statement.
19 Provide Medical Advice & Feedback Elicit-Provide-Elicit (Shared decision making) Elicit: What connection, if any, do you see between taking your medication and your asthma? Provide: ASK permission to provide education Would you like to know more information about how medication can help your asthma? What usually happens to some of my patients who take their medication Elicit: What was their interpretation? I wonder if we could talk briefly about whether or not this may apply to you. What do you make of this information? Can then incorporate test results, health care utilization, etc.
20 Advise Your Patient to Change Use R.A.I.S.E. 1. Relationship with patient 2. Advice to change (use the Asthma Action Plan) 3. I statements 4. Support of patient autonomy 5. Empathy As your doctor, I (I statement) think the best thing you can do for your asthma right now is to take your medication every day (advice). I am not going to pressure you to do that; the decision to take your medication is completely up to you (support autonomy). I know that these decisions can sometimes be difficulty (empathy).
21 Ask Evocative Questions Evoking Optimistic Statement about Adherence If you were to take your medication consistently, what might be the best results you can imagine? What worries you most about your asthma? How does asthma stop you from doing the things you want to do?
22 Ending the Consultation Summarize and ask what, if anything, the patient will do next and negotiate attainable goals if motivation is present. Asthma Dialogue with MI watch?v=lvxa64immiy
23 Appropriateness for Adolescents MI promotes personal control and autonomous decision-making for change overlapping with the developmental task of adolescence MI doesn t assume health is the most important factor motivating the adolescent but rather acknowledges and incorporates other motivators within the unique context of the teen s life. (Riekert, et al., 2011)
24 Tick, tick, tick Studies have shown MINIMAL time differences between delivery of patient-centered counseling and delivery of standard approaches typically, no more than 2 MINUTES! (Weston & Brown, 2003) One study of PCPs found that MI for smoking cessation took an average of 9.69 minutes. (Butler, et al., 1999)
25 Motivational Interviewing Resources 2 nd Edition 3rd Edition
26 Motivational Interviewing Resources motivationalinterviewing.org
27 References McQuaid, EL, Everhart, RS, Seifer, R, Kopel, SJ, Mitchell, DK, Klein, RB, Esteban, CA, Fritz, GK, & Canino, G. (2012). Medication adherence among Latino and Non-Latino White children with asthma. Pediatrics, 129(6), e1404-e1410. McQuaid, EL, Kopel, SJ, Klein, RB, Fritz, GK. (2003). Medication adherence in pediatric asthma: reasoning, responsibility, and behavior. Journal of Pediatric Psychology, 28, Akinbami, L. (2006). The state of childhood asthma, United States, Adv Data 2006: Jonasson, G, Carlsen, KH, Sodal, A, Jonasson, C, & Mowinckel, P. (1999). Patient compliance in a clinical trial with inhaled budesonide in children with mild asthma. Eur Respir J, 14, Guevara, JP, Wolf, FM, Grum, CM, & Clark, NM. (2003). Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ, 326, Cabana, MD, Le, TT. (2005). Challenges in asthma patient education. J Allergy Clin Immunol, 115, Miller, W, Rollnick, S. (2002). Motivational interviewing: preparing people for change, 2 nd Edition. New York: Guildford Press. Rollnick, S, Miller, WR, & Butler, CC. (2008). Motivational Interviewing in health care: Helping patients change behavior. New York: Guilford Press. Borrelli, B., Riekert, KA, Weinstein, A, & Rathier, L. (2007). Brief motivational interviewing as a clinical stragety to promote asthma medication adherence. J Allergy Clin Immunol, 120, Riekert, KA, Borrelli, B, Bilderback, A, Rand, CS. (2011). The development of a Motivational Interviewing intervention to promote medication adherence among inner-city, African-American adolescents with asthma. Patient Educ Couns, 82, Weston, W, Brown, J. (2003) Challenges in learning and teaching the patient-centered clinical method. In: Patient-centered care: Patient-Centered medicine transorming the clinic method. 2 nd Ed. Oxon: Radcliffe Medical Press. Butler, C, Rollnick, S, Cohen, D, Bachmann, I, Stott, N. (1999). Motivational consulting versus brief advice for smokers in general practice: A randomized trial. Br J Gen Pract, 49,
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