Motivational Interviewing: Engaging Patients Through Communication

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

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

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, http://www.ccmcertification.org Motivational Interviewing: Engaging Patients Through Communication 3

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

Motivational Interviewing: Engaging Patients Through Communication Catherine M. Mullahy, RN, BS, CRRN, CCM President, Mullahy & Associates, LLC Motivational Interviewing: Engaging Patients Through Communication 5

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

Communication, Motivational Interviewing & Strategies for Effective Patient Engagement Catherine M. Mullahy, RN, BS, CRRN, CCM Mullahy Associates LLC 82 Main Street Huntington, NY 11743 (631) 673 0406 www.mullahyassociates.com

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

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

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

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

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

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

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

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

Techniques & Tools to Engage Patients Warm greeting Eye contact Plain, non medical language Slow down Limit content Repeat key points Graphics http://www.ahrq.gov/qual/literacy/healthliteracttoolkit.pdf Copyright 2012, Mullahy and Associates, LLC 29

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

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

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

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, 91 111, 2005) 36

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

Learning Motivational Interviewing Skills and Techniques Processes Principles VETERANS HEALTH ADMINISTRATION Spirit 38

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

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

MI is Dancing rather than Wrestling VETERANS HEALTH ADMINISTRATION 41

Goals/Phases of MI Build a therapeutic alliance Elicit and encourage change talk and strengthen commitment to change VETERANS HEALTH ADMINISTRATION 42

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

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

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

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

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

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

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

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

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

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

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

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

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

Process I Engaging: OARS (Review) Open ended questions Affirmations Reflections Summaries VETERANS HEALTH ADMINISTRATION 57

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

Learning Motivational Interviewing Skills and Techniques Processes Principles VETERANS HEALTH ADMINISTRATION Spirit 59

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

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 27705 (919) 383 7874, ext. 240 Michael.goldstein2@va.gov www.prevention.va.gov VETERANS HEALTH ADMINISTRATION

Thank you! Question and Answer Session Commission for Case Manager Certification 15000 Commerce Parkway, Suite C Mount Laurel, NJ 08054 Corporate: 1 856 380 6836 Email: ccmchq@ccmcertification.org www.ccmcertification.org 62 Proprietary to CCMC