motivational interviewing: helping people to change when they aren’t sure they want to or can....

Motivational Interviewing: Helping People to Change When

They Aren’t Sure They Want To or Can.

OCHI 2014 Fall ForumOctober 2014

Rebeka Radcliff, MSWF. Daniel Duffy, MD, MACP

Learning Objectives• Use motivational interviewing methods to

– Help patients voice ambivalence about adherence– Make their own arguments for self-care

• Guide patients through the stages of change using MI when it may be useful– Use Importance/Confidence and Readiness Ruler

to elicit change talk– Use Decisional Balance to amplify ambivalence– Use reflective statements (OARS) to elicit intrinsic

motivation and guide behavior change

Care Management Goals

• Guiding and encouraging patient self-care • Accessing support and resources, • Solving problems that Interfere with

adherence to treatment plan and achieving health and life goals

MI was designed to elicit internal motivation to help people stop addictive

behavior – works for other behaviors.

PrecontemplationPrecontemplation ContemplationContemplation

DeterminationDetermination

ActionAction

RelapseRelapse

MaintenanceMaintenance

New HabitNew Habit

Cycle of Behavior Change

F. D. DuffyJuly 19, 2013

Specific Guidance for Stage of ChangeFeedback, Advice, Empathy &

Self-Assessment

Elicit Change TalkSpecific target and time

Specific actionsWho/What will helpProblems & solutions

Guide Internal MotivationReadiness Ruler

Decisional BalanceReflective Listening: OARS

Interview Style and Skill

Directing Guiding Following0

5

10

15

20

25

30

35

40

45

50

TellingAskingListening

Barbara Walker p21 Rollineck, Miller, Buttler Motivational Interviewing in Health Care 2008 Gillford Press

Motivational Interview Methods

ASK

TELL

LISTEN

Permission

Open Question

Closed Question

Inform

Give Feedback

Advise

Appreciate

Reflect

Summarize

May we talk about…?

What do you know about…?

How much do you smoke?

Diabetes causes blindness.

Your tests show…

Exercise will benefit you.

You are very courageous

You want to change, but…

Let’s see if I got it…

Motivational Interview Methods

ASK

TELL

LISTEN

Permission

Open Question

Closed Question

Inform

Give Feedback

Advise

Appreciate

Reflect

Summarize

May we talk about…?

What do you know about…?

How much do you smoke?

Diabetes causes blindness.

Your tests show…

Exercise will benefit you.

You are very courageous

You want to change, but…

Let’s see if I got it…

ARS

O

SCENARIO #1

High Risk patient referred to Care Management to improve adherence to self-care for diabetes and asthma and reduce ED use and missed medical home appointments.

Rosa/Ross Carver• High-Risk patient with asthma, obesity, type-2 diabetes• Cancels appointments, takes meds erratically, uses the ED for

routine care• Diabetes education completed, metformin and glipizide., last

A1C was 9.7, no blood sugar log, BMI is 31%; she has gained 25 pounds.

• Has asthma treatment plan, stopped smoking, lives with smoker, likes to use the rescue inhaler.

• Manufacturing job, on spouse’s health insurance, 20% deductible, $25 PCP co-pay. and $100 ED/UC co-pay.

• Referral for Care Management to improve adherence, reduce ED use, improve quality of life and reduce risk of CVD and Respiratory Failure.

#1 Guide Pre-contemplation to Contemplation

• First Visit – Phone Call?• Clarify and simplify the current behavior• Clarify readiness to change

– Acceptance of health problem and its treatment– Importance of changing behavior to patient– Confidence patient can change behavior

Importance – Confidence Ruler

How confident are you that you will become more active in your care?Not At All Confident Totally Confident

0 1 2 3 4 5 6 7 8 9 10

How Important is it for you to be more active in your care?Not At All Convinced Totally Convinced

0 1 2 3 4 5 6 7 8 9 10

Why “4”? Why not “6”?

Importance/Confidence Score Stage of Change

0-2 on either Pre-Contemplation

3-7 on either or both Contemplation

< 7 on either Not motivated to change

8-10 on Conviction Determination

9-10 on Confidence Action or Maintenance

What would it take to move from a “5” to an “8”?

Role Play #1

Care Manager – Determine Readiness to change – use rulersPatient – Participate

Observer – Count MI Methods used

Observer Debriefing Conversation

• Ask the care manager what went well?• Ask the patient what went well?• Reflect your observations on what went well?• Ask care manager what he/she might do differently

next time?• Ask the patient what might work better from his/her

perspective?• Reflect your observations on what you might do

differently• Give feedback on the count of MI methods used.

SCENARIO #2

Same patient, explores ambivalence between strategy of proactive self-care and reactive rescue care. Elicit patient’s argument and internal motivation to change.

#2 Contemplation to Action

• Amplify ambivalence about changing behavior– Good/not-so-good outcomes from current

behavior– Good/not-so-good outcomes from new behavior

• Elicit enough discomfort to tip balance from internal debate to action

• Make patient argue for change, roll with resistance

Keep

Doi

ng

Wha

t I’m

Doi

ngBe

com

e M

ore

Activ

e in

Sel

f-Car

eReasons Not To Change Reasons To Change

What are GOOD things about your care now?

What are NOT-SO-GOOD things about your care now?

What are NOT-SO-GOOD things that might happen if you become more active in your care?

What are some GOOD things that might happen if you become more active in your care?

Decisional Balance

Role Play #2

Care Manager – Determine Readiness to take action

Patient – ParticipateObserver – Count MI Methods used

SCENARIO #3Same patient is ready to take action in improving self-care.

Listen for Change Talk

I want to

I should

I can

I must

I will I am doing

TreatmentAdherence

PlanRollineck, Miller, Buttler Motivational Interviewing in Health Care 2008p-41 Gillford Press

#3: Determination to Action

• Spontaneous change talk• Action Plan

– What will you achieve by when?– What will you do to achieve your objective?– Who or what will help?– What problems might arise? Solution?– Rehearse plan

Role Play #3

Care Manager – Determine Readiness for Action– elicit change talk and plan

Patient – ParticipateObserver – Count MI Methods used

Did We Reach Our Objectives?• Use motivational interviewing methods to

– Help patient voice ambivalence– Make their own arguments to take action

• Guide patient through the cycle of change– Use Importance/Confidence and Readiness Ruler

to elicit change talk– Use Decisional Balance to amplify ambivalence– Use reflective statements to elicit intrinsic

motivation and guide to taking action