Motivational Interviewing: Engaging Patients Through Communication
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1 Motivational Interviewing: Engaging Patients Through Communication Catherine M. Mullahy, RN, BS, CRRN, CCM President of Mullahy & Associates, LLC Michael G. Goldstein, MD Associate Chief Consultant for Preventive Medicine Veteran's Health Administration (VHA) National Center for Health Promotion and Disease Prevention 1 Proprietary to CCMC
2 Agenda Patrice Sminkey, CEO, the Commission Welcome and Introductions Overview of Learning Objectives Catherine M. Mullahy, RN, BS, CRRN, CCM, President of Mullahy & Associates, LLC Michael G. Goldstein, MD, Associate Chief Consultant for Preventive Medicine, Veteran's Health Administration (VHA), National Center for Health Promotion and Disease Prevention Question and Answer Session Motivational Interviewing: Engaging Patients Through Communication 2
3 Audience Notes There is no call in number for today s events. Audio is by streaming only. Please use your computer speakers, or you may prefer to use headphones. Please use the chat feature on the lower left hand part of your screen to ask questions throughout the presentations. Questions will be addressed as time permits after both speakers have presented. A recording of today s session will be posted within one week to the Commission s website, Motivational Interviewing: Engaging Patients Through Communication 3
4 Learning Objectives Overview After the presentation, participants will be able to: Recognize the relevance of communication as an essential component of effective case management; Describe the basic model of communication and some common methods of communication; Identify common barriers preventing effective communication and an engaged client; Explain the conceptual and research background supporting motivational interviewing; Identify the guiding principles of motivational interviewing, as well as understand the strategies for strengthening commitment to change; and Discuss strategies that can be utilized to optimize opportunities to engage clients in their care, to include motivational interviewing. Motivational Interviewing: Engaging Patients Through Communication 4
5 Motivational Interviewing: Engaging Patients Through Communication Catherine M. Mullahy, RN, BS, CRRN, CCM President, Mullahy & Associates, LLC Motivational Interviewing: Engaging Patients Through Communication 5
6 Motivational Interviewing: Engaging Patients Through Communication Michael G. Goldstein, MD Associate Chief Consultant for Preventive Medicine Veteran's Health Administration (VHA) National Center for Health Promotion and Disease Prevention Motivational Interviewing: Engaging Patients Through Communication 6
7 Communication, Motivational Interviewing & Strategies for Effective Patient Engagement Catherine M. Mullahy, RN, BS, CRRN, CCM Mullahy Associates LLC 82 Main Street Huntington, NY (631)
8 Communication Copyright 2012, Mullahy and Associates, LLC 8
9 Communication Communication is the response you get from the message you sent regardless of its intent Assumptions Fatigue Distractions HIPAA Copyright 2012, Mullahy and Associates, LLC 9
10 Case Management Definition Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services required to meet the client s health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost effective interventions and outcomes. Copyright 2012, Mullahy and Associates, LLC 10
11 Case Management Definition Case management is a collaborative process of planning, facilitation and advocacy for options and services to meet an individual s holistic needs through communication and available resources to promote quality cost effective outcomes. Copyright 2012, Mullahy and Associates, LLC 11
12 Effective Communication an Ongoing Challenge 40% to 80% of the information patients hear in a consultation is lost almost immediately 78% of patients leave the hospital without understanding their treatment Copyright 2012, Mullahy and Associates, LLC 12
13 Effective Communication an Ongoing Challenge More than 70% of adverse events are caused by breakdowns in communication among caregivers and between caregivers and patients* Copyright 2012, Mullahy and Associates, LLC 13
14 Effective Communication an Ongoing Challenge 23% of nurse time is spent on repetitive patient education 77% of commercially insured patients would switch hospitals to one that better informs patients about treatment both before and after treatment Copyright 2012, Mullahy and Associates, LLC 14
15 Clinician s/case Manager s Role in Effective Communication Engagement Empathy Education Enlistment Copyright 2012, Mullahy and Associates, LLC 15
16 Patient Engagement! Satisfied Loyal Emotionally Attached Copyright 2012, Mullahy and Associates, LLC 16
17 Elements of Patient Engagement Passion Pride Integrity Confidence in an organization Copyright 2012, Mullahy and Associates, LLC 17
18 Good CM Communication Assess needs Establish goals Create an effective care plan Collaborate with patients and families, providers, payers & others involved with care Optimize potential for improved outcomes Enhance patient satisfaction Maximize potential for use of available resources Copyright 2012, Mullahy and Associates, LLC 18
19 Poor Communication. Stressful environment for patients/families Confusion Errors Anger & frustration Fragmented care Unsafe discharges Transition of care failures Less than desirable outcomes Increased costs Copyright 2012, Mullahy and Associates, LLC 19
20 Methods of Communication Verbal (spoken) words Written words Art/Images Non verbal Copyright 2012, Mullahy and Associates, LLC 20
21 Methods of Communication Copyright 2012, Mullahy and Associates, LLC 21
22 Other Communication Methods for those cognitively, physically or developmentally impaired. Blinking Pointing Signing Braille Adaptive devices TDD; telephone, typewriter, teletypewriter TTY & Other electronic devices Copyright 2012, Mullahy and Associates, LLC 22
23 What kind of communication is best??? Copyright 2012, Mullahy and Associates, LLC 23
24 Critical Aspects of Successful Communication Location Individual(s) involved Intent of the message Desired goal Copyright 2012, Mullahy and Associates, LLC 24
25 Evaluate the Intent, Goals & Individuals Involved with the Method of Communication to be used. Copyright 2012, Mullahy and Associates, LLC 25
26 Barriers to Effective Communication Socioeconomic Class Race Creed Color Culture Ethnicity Language Gender & Sexual Orientation Copyright 2012, Mullahy and Associates, LLC 26
27 Barriers to Effective Communication Physical Appearance Health Literacy Linguistic Literacy Depression Anxiety Unrealistic Expectations Copyright 2012, Mullahy and Associates, LLC 27
28 Strategies for Effective Communication & Effective Engagement Copyright 2012, Mullahy and Associates, LLC 28
29 Techniques & Tools to Engage Patients Warm greeting Eye contact Plain, non medical language Slow down Limit content Repeat key points Graphics Copyright 2012, Mullahy and Associates, LLC 29
30 Training in Communication Techniques Motivational Interviewing Ask Tell Ask Closing the Loop Teach Back Copyright 2012, Mullahy and Associates, LLC 30
31 Engaging Patients Making a Difference. One Patient at a Time! Thank you! Copyright 2012, Mullahy and Associates, LLC 31
32 Catherine M. Mullahy, RN, BS, CRRN, CCM 82 Main Street, Suite 300 Huntington, NY Copyright 2012, Mullahy and Associates, LLC 32
33 Motivational Interviewing (MI): Engaging Patients Through Communication Michael G. Goldstein, MD Associate Chief Consultant for Preventive Medicine Veteran's Health Administration (VHA) National Center for Health Promotion and Disease Prevention Motivational Interviewing: Engaging Patients Through Communication 33
34 Motivational Interviewing: A Method for Engaging, Activating and Empowering Patients Michael G. Goldstein, MD Associate Chief Consultant for Preventive Medicine National Center for Health Promotion and Disease Prevention, Veterans Health Administration 34
35 What is Motivational Interviewing? Definition: A clinical method of guiding patients to make changes in the interest of their health by eliciting patients own motivation for change (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008) VETERANS HEALTH ADMINISTRATION 35
36 MI Research Evidence Hettema, Steele, and Miller (2005) conducted a systematic meta analysis of 72 RCTs: alcohol abuse (31 studies) illicit drug abuse (14 studies) smoking (6 studies) HIV risk reduction (5 studies) treatment adherence (5 studies) diet/exercise (4 studies) water purification to promote health (4 studies) gambling (1 study) intimate relationships (1 study) eating disorders (1 study) VETERANS HEALTH ADMINISTRATION (Hettema, J., et al., Annu Rev Clin Psychol, 1, , 2005) 36
37 MI Research Evidence Significant support for the efficacy of MI across these studies Large effect immediately following treatment Effect less, but significant at follow ups of about one year Adding MI to the beginning of treatment led to sustained outcome improvements Outcomes were better when no manual was used VETERANS HEALTH ADMINISTRATION 37
38 Learning Motivational Interviewing Skills and Techniques Processes Principles VETERANS HEALTH ADMINISTRATION Spirit 38
39 The Spirit of MI Autonomy Both implicitly and explicitly recognizing that the patient will exercise choice Asking permission Collaboration Non authoritarian, partnering style; non judgmental Evocation Exploring what is important to the patient their ideas, needs, values and reasons for change Viewing patients as the experts Patient speaks more than clinician VETERANS HEALTH ADMINISTRATION 39
40 Some General Principles RULE Resist the Righting Reflex (Resist Directing) Understand your patient s motivations (Evoke) Listen to your patient (with Empathy) Empower your patient (Build Confidence) VETERANS HEALTH ADMINISTRATION 40
41 MI is Dancing rather than Wrestling VETERANS HEALTH ADMINISTRATION 41
42 Goals/Phases of MI Build a therapeutic alliance Elicit and encourage change talk and strengthen commitment to change VETERANS HEALTH ADMINISTRATION 42
43 Change Talk: The Ingredients of Change Desire: I want to stop coming to the hospital over and over Ability: I can take better care of my diabetes.i have done it before Reasons: Drinking gets me in trouble, makes my blood pressure higher, and makes my family not want to be with me Need: I need to take my meds so I can stay healthy and be there for my family Commitment: I will make a schedule for my blood sugar checks and plan the meals I eat VETERANS HEALTH ADMINISTRATION 43
44 MI Processes 4 Processes and skills/techniques for each 1. Engaging: listening to understand the dilemma, use of OARS 2. Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, use of information and advice 3. Evoking: selective eliciting, selective responding, selective summaries toward change talk 4. Planning: moving to a change plan and obtaining commitment When is it MI? Processes 1, 2, and 3 are necessary for it to be MI VETERANS HEALTH ADMINISTRATION 44
45 Process I Engaging Goals Build a therapeutic relationship Understand the patient s reality Understand the patient s feelings, beliefs, values, concerns (including importance and confidence) Recognize and affirm strengths, motivation Accept without judgment what you have learned VETERANS HEALTH ADMINISTRATION 45
46 Process I Engaging: OARS Open ended questions: understanding the patient s perspective and motivation, agenda setting, eliciting change talk Affirmation: recognizing patient s efforts and strengths Reflection: sharing and deepening understanding, eliciting more, selectively reinforcing change talk Summary: understanding, eliciting more, reinforcing change talk VETERANS HEALTH ADMINISTRATION 46
47 Open Ended Questions Examples What are you currently doing that helps you to manage your diabetes? Tell me more about your interest in staying healthy. What worries you the most about your heart condition? How important is it to address your drinking? What do you think would help you to improve your functioning? What would you like to do to optimize your health? VETERANS HEALTH ADMINISTRATION 47
48 Reflective Listening Effortful use of listening to seek, clarify and deepen understanding Hypothesis testing Creates awareness of gaps in understanding (for both speaker and listener) VETERANS HEALTH ADMINISTRATION 48
49 Reflective Listening: A Primary Skill Reflect: Words simple reflection Deeper meaning, feelings, values complex Summary Wait for listener to correct, clarify, continue. Statements, not questions; voice goes down Takes hard work and practice VETERANS HEALTH ADMINISTRATION 49
50 Example: Struggles with Smoking I know I need to quit smoking. It s just really hard to do; I ve tried many times before. I just get really stressed and find myself eating up a storm! My health is really important, and I m not getting any younger. You hear so much about smoking causing lung cancer and heart disease and I certainly don t want that! What can I do? VETERANS HEALTH ADMINISTRATION 50
51 Example: Levels of Reflection You are aware of the serious health risks that smoking can cause and you don t want that to happen to you. You are worried about what will happen if you don t quit smoking and you are concerned about how to manage stress if you do. Trying to quit has been challenging and frustrating and you would like to find a way to quit for good. You sound interested in finding a way to quit that will work for you. VETERANS HEALTH ADMINISTRATION 51
52 Affirmations Appreciation of patient attributes, effort, perseverance, showing up All patients need confidence (self efficacy) you can support self efficacy by recognizing personal strengths, resources and successes Must be personal and genuine VETERANS HEALTH ADMINISTRATION 52
53 Summaries Special form of reflective listening Structure: Indicate you re about to summarize Series of reflections Be selective and concise May use to shift direction or ask a key question about change VETERANS HEALTH ADMINISTRATION 53
54 54
55 Summaries Summaries 0ffer a Bouquet So, you mentioned several reasons for working on healthy eating and meal planning, including being able to reduce the number of meds you are taking for your diabetes. You also want to gain better control over your diabetes and want to avoid the complications that your mother had. You are frustrated by pervious attempts to work on your weight, but you have had some success in the past. I would like to help you develop a plan that will work for you. VETERANS HEALTH ADMINISTRATION 55
56 Process I Engaging (Review) Goals Build a therapeutic relationship Understand the patient s reality Understand the patient s feelings, beliefs, values, concerns (including importance and confidence) Recognize and affirm strengths, motivation Accept without judgment what you have learned VETERANS HEALTH ADMINISTRATION 56
57 Process I Engaging: OARS (Review) Open ended questions Affirmations Reflections Summaries VETERANS HEALTH ADMINISTRATION 57
58 Summary Motivational Interviewing a clinical method of guiding; eliciting veterans own motivation for change Spirit: collaborative, evocative, support autonomy Principles: RULE resist directing; understand patients motivation; listen with empathy; empower Processes: Engaging, Focusing, Evoking, Planning Core Skills: OARS Key outcome: engaged activated, motivated, empowered and confident patients VETERANS HEALTH ADMINISTRATION
59 Learning Motivational Interviewing Skills and Techniques Processes Principles VETERANS HEALTH ADMINISTRATION Spirit 59
60 Learning MI How will you know how you re doing? Patient is doing most of the talking Patients are making a lot of change talk statements Resistance is minimized Patients are doing most of the work toward change VETERANS HEALTH ADMINISTRATION 60
61 Contact Information National Center for Health Promotion and Disease Prevention Office of Patient Care Services, Veterans Health Administration Michael G. Goldstein, MD Associate Chief Consultant for Preventive Medicine 3022 Croasdaile Drive, Suite 200, Durham, NC (919) , ext VETERANS HEALTH ADMINISTRATION
62 Thank you! Question and Answer Session Commission for Case Manager Certification Commerce Parkway, Suite C Mount Laurel, NJ Corporate: ccmchq@ccmcertification.org 62 Proprietary to CCMC
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