Effective Engagement: How MI can be used to improve asthma management with patients and their families
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1 Effective Engagement: How MI can be used to improve asthma management with patients and their families Prantik Saha, MD, MPH Assistant Clinical Professor of Pediatrics Columbia University Medical Center Member, Motivational Interviewing Network of Trainers (MINT)
2 Objectives Understand the Stages of Behavior Change and its role in behaviors and adherence to treatment Motivational Interviewing Recognize the spirit or foundation of motivational interviewing (MI) Become acquainted with specific practices and tools used in MI such as OARS, scales, etc.
3 Disclosures I have no conflicts of interest to disclose.
4 Stages of Behavior Change NOT thinking about change Prochaska & Di Clemente: Transtheoretical Model of Behavior Change
5 Stages of Behavior Change NOT thinking about change THINKING about change Prochaska & Di Clemente: Transtheoretical Model of Behavior Change
6 How do we think about or 1. Identifying the behavior contemplate change? 2. Identifying a problem 3. Desiring a Change 4. Feeling confident/capable to change 5. Moving on to Preparation, Action, etc.
7 Value of Stage of Change Models Reminds us that Rome wasn t built in a day You ve done a good day s work if you can help someone go from not thinking about change to really thinking about it. Knowing where patients are stuck may help you narrow down the likely barriers. MOST IMPORTANTLY: They can serve as a framework for empathy.
8 The Spirit of MI Acceptance (autonomy & empathy) Ambivalence is normal When it comes to behavior change the patient is the expert If given a choice, greater propensity of behavior change Nonjudgmental acceptance facilitates change Collaboration being an equal partner Evocation eliciting patient s perspective as well as change talk Compassion in MI, you re not tricking the patient Bulk of evidence shows that in general MI works better than unsolicited persuasion
9 With that spirit, how do we do MI? Where is the patient? What s their perspective? Empathy/You can use the Stages of Change What are the specific micro-skills I need? Person Centered Guiding Skills (OARS) Giving Information (includes suggestions, voicing your concerns, etc.) Rolling with resistance What is my overarching goal? Paying attention to, reflecting, eliciting, and reinforcing change talk: the reasons, desire, ability, need, etc. for behavior change
10 Change Talk Consists of the patient s expression of their own desires, ability, reasons, and need for behavior change. This is in contrast to sustain talk, which is the patient s expression of their own desires, reasons and need to stay the same, and includes the inability to change.
11 New Concepts in MI Engaging Focusing Evoking Planning
12 Clarifying & Redefining Resistance Resistance: is elicited when we try to push patients farther than they are ready to go and when patients have not been given sufficient opportunity to direct their actions. New terminology regarding resistance: Discord: interpersonal conflict between provider and patient Sustain talk: client statements which favor the status quo
13 Directing Guiding Following
14 MI-inconsistent behaviors Direct confrontation Unsolicited advice, recommendations prior to any indication that patient is willing to hear it Asserting authority, tell them what they must do Not empathically listening or collaborating Persuading, arguing, lecturing Not respecting autonomy or honoring their choice
15 Case presentation You are seeing a 4 year old boy with poorly controlled asthma in clinic. He has been admitted three times in the past 6 months for acute exacerbations. During your interview with the mother, a pack of cigarettes falls from her coat. She quickly states that she does not smoke around her son.
16 SO Where is our patient (mother)? (hint: do we really know at this point? What questions would you ask?)
17 Affirmation: That s great that you trying to keep the smoke away from your son. Exploring more of the story with evocative, open ended questions How is everything going? How are things going with your child s asthma? Tell me more about your smoking What are the things that you like about smoking? How do you feel about your smoking?
18 You get more history The mother says she has been feeling very stressed recently, especially with her child s recent hospitalizations. She has been smoking since she was a teenager (she is in her mid-20 s) and she says that smoking relaxes her. She does think that quitting would help her child s asthma, and several people have told her that she should stop smoking in the interest of her child s health. When asked about quitting, she frowns and says she has tried to quit smoking several times in the past without success.
19 So, again, where is she? Stuck at the level of capability/confidence
20 What would you say to the mother now?
21 Affirmation I am impressed that you have been trying to quit despite all the stress you are going through Reflection On the one hand, smoking helps you to deal with the stress in your life, and on the other hand, you also wish you could quit in the interest of your child s health
22 Importance Scale How important is it for you right now to change? On a scale of 1-10, what number would you give yourself? 0.10 Not at all Important Extremely important Patient says 9 That s great it sounds like this is a high priority for you.
23 Confidence Scale If you did decide to change, how confident are you that you will be able to? On a scale of 1-10, what number would you give yourself? 0.10 Not at all confident Extremely confident Patient says 4 OK - it seems somewhere in the middle. Why is it a 4 and not a 1? What would make you go from 4 to let s say, 6 or 7?
24 Summary It is common to feel discouraged about quitting smoking, which can be a very difficult thing to do. You ve been able to quit in the past, you re concerned about it affecting your child s health, and right now you re not sure what to do. What would be most helpful for you right now?
25 Giving Information (includes suggestions and concerns) Provide information when asked Ask for permission before giving Elicit-Provide-Elicit (or E-P-E) Mode If you re interested, I ve seen some patients quit who ve done X, Y, or Z, (after giving suggestions): What do you think of these options?
26 Let s say you get this history instead The mother, who is 35 years old, smokes with her girlfriends who come and visit her in her apartment. She feels a sense of community with them, and smoking is a shared pastime they enjoy. The mother does not think her child s asthma has worsened because of her smoking I ve been smoking since he was born and his asthma wasn t this bad before When asked about quitting, she says Yes, I m sure it would be better for my health, but so would moving out of New York City!
27 SO Where is she? Not an issue with confidence as much as importance, right? So, now how would you approach this patient and mother?
28 Reflecting and empathizing with the pros and cons ; highlighting discrepancy Smoking is an important part of your social world, and at the same time you re also concerned about its effects upon your health. Roll with resistance Yes, it does seem that you ve been smoking for quite some time and your child s asthma has only recently been flaring up. Yes, New York City can certainly be hazardous to your health! Key question (advantages of change) If you did quit smoking, what would your life look like? What would be the positive things you might see in your life? Key questions (disadvantages of not changing) What do you think will happen if you don t change anything?
29 Giving information For you there are a lot of reasons why your son s asthma is acting up, and smoking doesn t seem like it s playing a big role. I d like to share some information with you, if that s OK. It s an interesting thing, even in these situations, I find that smoking in the home does seem to make asthma worse, even when you are not smoking around the child. What do you think of that? Empathize/Elicit Provide - Elicit Can use Importance Scales as well
30 Case Presentation #2 You are seeing a 7 year old girl with poorly controlled asthma in your clinic. She has been coughing several times a week at nighttime, interfering with her sleep. In addition she has required two oral steroid courses this year, missed several school days, and has taken several trips to the ED. The mother is concerned and would like some treatment. You prescribe an inhaled corticosteroid for twice daily use to be continued even when her symptoms resolve.
31 Case Presentation #2 (con t) Four weeks later, during a follow-up visit, the mother tells you that she stopped the inhaled steroid medication because her child s symptoms resolved. How would you proceed at this point?
32 Clarifying the patients perspective! What do you remember about the instructions for the medication prescribed for your daughter s cough? Do you have any concerns about the medication? Are there people you know who have taken steroids for asthma? Tell me what you feel [or know] about steroids
33 You get more history The mother does remember that she was instructed to continue the medication even after her child s cough resolved, but she stopped giving the medication because she doesn t like giving medications to her daughter. When asked why, she simply repeats herself I just don t like it!
34 All right what s going on here?
35 Sustain Talk? Discord? From the motivational interviewing perspective, both sustain talk and discord are elicited when we try to push patients farther than they are ready to go. Discord also occurs when clients have not been given sufficient opportunity to direct their actions and have simply been given instructions from their providers.
36 What approach should we take now? Empathizing with the client It sounds like many of us have been telling you what you should do and we re not listening to what you would like to do for your child EMPOWER the client (honoring autonomy) You know, it s up to you what you would like to do with your daughter s medication after all, you are her mother.
37 Sometimes people have concerns about steroids Sometimes people have concerns about giving medicines when there child is fine Other issues: There may be various cultural influences (in the broadest sense) that might affect the viewpoint of the patient/family. Health literacy is another factor to consider
38
39 MI and evidence Systematic reviews and meta-analyses have shown some beneficial effect of MI interviewing techniques compared to traditional advice giving in various contexts outside of the addictions, such as with diet, exercise and adherence to medications. Some reviews have even shown statistically significant change in direct measures such as blood pressure, cholesterol, and body mass index (Rubal, Sandbaek, et al. Motivational Interviewing: A Systematic Review and Meta- Analysis. British Journal of General Practice 2005; 55: ).
40 Effect measure n Estimate of effect P-value (95% CI) Body mass index (0.33 to 1.11) HbA1c (%GHb) (-0.16 to 1.01) Total blood cholesterol (mmol/l) Systolic blood pressure (mmhg) Number of cigarettes/day Blood alcohol content (mg%) Standard ethanol content (units) (0.20 to 0.34) (0.23 to 8.99) (-0.25 to 2.88) (46.80 to 99.04) (13.73 to 15.55)
41 Recent Studies Halterman JS, et al. Randomized controlled trial to improve care for urban children with asthma: results of the School-Based Asthma Therapy trial. Arch Pediatr Adolesc Med Mar;165(3): Lai DT et al. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev Jan 20;(1):CD Lavoie KL, et al. Efficacy of brief motivational interviewing to improve adherence to inhaled corticosteroids among adult asthmatics: results from a randomized controlled pilot feasibility trial. Patient Prefer Adherence Nov 10;8:
42 Resources Change Talk app from AAP for iphones, ipads and Android devices - free Kaiser Permanente Health Education modules also free ml
43 THANK YOU!! Questions?
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