October 2012 Webinar• Motivational Interviewing• Self-Management Support

PDSA Sharing• NCQA Requirements, Resources

Motivational InterviewingComplimentary Technique to Use with 5 A’s

Not everyone seems to benefit from our treatment?• Data and knowledge are important…• But may not be enough.• Need to translate to Behavior Change!

Motivational Interviewing• A directive patient-centered counseling

style for increasing INTRINSIC motivation by helping the patient explore and resolve ambivalence

• Avoid the “Blame game” – a patient’s resistance does not equal noncompliance

• Initially developed for use in the alcohol and drug abuse field

Ambivalence• Can you imagine yourself saying or

thinking this:• “Perhaps I should exercise more. I’m a

little concerned about it, but I don’t think I’ll do anything today.”

Ambivalence• Ambivalence is a normal and defining

state of human experience• Most of us are ambivalent about most

things most of the time• Motivational Interviewing is the practice

of disentangling competing and often obscured motives

Some Basic Assumptions• Patients talk themselves into changing.• Patients don’t change just because we want

them to change.• Patients rarely change just because we tell

them to change.• The process of changing may be accelerated

by practitioners—but it might also be inhibited.

Advantages of Using MI• Improved patient satisfaction• Decrease personal frustration with difficult

patients (burnout)• Better clinical outcomes

A Meta-Analysis of Research on Motivational Interviewing Treatment Effectiveness (MARMITE)Hettema and Miller: Hettema and Miller: Annual Review of Clinical PsychologyAnnual Review of Clinical Psychology (2005)(2005)

Mean Combined Effect Size by Problem Area (N=72 Clinical Trials)

MARMITE

Motivational Interviewing• Ask permission• Listening skills:

• Open ended questions• Patient does the talking• Provider is ‘curious’• Provider summarizes with gentle direction

Establishing Rapport• Acknowledge setting• Change gears from H&P

“Now that this is out of the way, can we take a few minutes to talk about other things that are affecting your diabetes?”

Start with OARS• Open-ended

questions• Affirm• Reflective

listening • Summarize

Allows us to make sure we fully understand what the patient means.

O. Open-ended questions• Closed question: Do you always take your

insulin?• Open ended question: Tell me a little about

how it’s going with taking your insulin?• Or if you strongly suspect adherence issues:

• Many people find it challenging to take their insulin daily. How is it going for you?

A. Affirm• Finding something positive about the

patient’s behavior • Making that finding verbally explicit• Appreciation vs. approval (“You” vs. “I”)• Genuineness is critical• What if I can’t find anything positive about

my patient?

R. Reflect• Demonstrates a desire for mutual

understanding• Good follow up to open-ended question• Being selective as we hold up a mirror for

the people we work with

Sentence stems for reflections• It sounds like you…• You mean that…• You’re wondering if…• So you feel… You’re feeling…• You…

S. Summarize• Indicates attentiveness on the part of the

interviewer (“Let me make sure I’m getting this…”)

• Allows patient statements to be clarified, consolidated, and reinforced

• Builds discrepancy and provides direction

Sentence stems for reflections• It sounds like you…• You mean that…• You’re wondering if…• So you feel… You’re feeling…• You…

Start with OARS• Open-ended

questions• Affirm• Reflective

listening • Summarize

.

TRY IT?MAYBE EVEN TAPE YOURSELF WITH PERMISSION

To Learn More• Motivational Interviewing in Health

Care• By Rollnick, Miller, and Butler published

by Guilford Press (2008)• Available at Amazon and elsewhere

• MotivationalInterviewing.org

Conclusion: Improving Outcomes

• Education is necessary, but not sufficient.• Need to work with patients to help with

behavior change.• People don’t change just because we tell them

to.• Counseling style is key.• Ask the patient and use open-ended questions.

PDSA SharingWhat self-management support have you been testing?

How’s it been going for you?Share your PDSAs!• Goal-setting forms• Goal-setting process• Staff training• Provider role• Patient reception• Data capture

NCQA Self-Care RequirementsIncluding Numerous Resources to Assist You

NCQA: Self-Care Support • Element A: Support Self-Care Processes

• Must pass element!• 6 Factors: First 2 factors require provision of

educational resources for patients• Factor 3: Develops and documents self-

management plans and goals in collaboration with at least 50% of patients/families.• NCQA expects written self-care (action) plans.• Critical factor!

Self-Management Resources• “Helping Patients Manage Their Chronic Conditions,” California

Healthcare Foundationhttp://www.chcf.org/~/

media/MEDIA%20LIBRARY%20Files/PDF/H/PDF%20HelpingPatientsManageTheirChronicConditions.pdf

• “Facilitating Behavior Change,” American Society on Aging, American Society of Consultant Pharmacists Foundation

http://www.adultmeducation.com/downloads/Adult_Med_Facilitating.pdf• Patient Assessment of Chronic Illness Care, MacColl Institute at

Group Healthhttp://www.improvingchroniccare.org/downloads/2004pacic.doc.pdf• Community Health Center, Inc.

http://www.diabetesinitiative.org/programs/DICHC.html

NCQA: Self-Care Support • Factor 4: Documents self-management abilities for

at least 50% of patients/families.• NCQA suggests using motivational interviewing or

forms to assess patient readiness to change.

Patient Assessment Resources• A few “readiness to change” assessment tools:

• http://aom3.americaonthemove.org/~/media/B62B030924954B2A95AC74436519BD2C.ashx

• http://www.adultmeducation.com/downloads/Readiness-to-Change_INSTR.pdf

• http://www.ama-assn.org/ama1/pub/upload/mm/433/patientreadiness.pdf

• http://www.lsuhospitals.org/cmo/hcet/docs/obesityclinical/Patient_Readiness.pdf

• http://www.nationalobesityforum.org.uk/index.php/lifestyle/adults_/obesity-care-pathway/219-patient-motivation-readiness-to-change.html

More Assessment Resources• Summary of Diabetes Self-Care Activitieshttp://care.diabetesjournals.org/content/23/7/943.full.pdf• Morisky Medication Adherence Questionnairehttp://media.mycme.com/documents/30/11-

136_case_3_table_2_rev_7413.pdf• Patient Health Questionnaire (PHQ-9) and PHQ-2 (depression)http://steppingup.washington.edu/keys/documents/phq-9.pdfhttp://www.cqaimh.org/pdf/tool_phq2.pdf• Case-finding and Health Assessment Tool (CHAT)http://www.bpac.org.nz/magazine/2009/adultdep/

appendices.asp#appendix9

NCQA: Self-Care Support • Factor 5: Provides self-management tools to

record self-care results for at least 50% of patients/families.• Need to give patients forms (or other tools) to collect

health information at home. • Blood pressures• Blood sugars• Weight

• Along with instructions and information about home monitoring. • How to do it• How/when to provide the data to the practice• How to titrate medicines based on data being collected

Patient Reporting Resources• American Diabetes Association online tracking

system: http://www.diabetes.org/living-with-diabetes/treatment-and-care/247.html?loc=contentpage-promo-247

• University of Wisconsin Diabetes Self-Management Tools: http://www.uwhealth.org/living-with-diabetes/self-management-and-tracking-tools/10397

• University of Pittsburgh Diabetes Self-Management Assessment Report Tool (D-SMART): http://knowledgetranslation.ca/sysrev/articles/project21/RefID931-Charron-Prochownik-20090620001517.pdf

NCQA: Self-Care Support • Factor 6: Counsels at least 50% of patients/

families to adopt healthy behaviors.• NCQA suggests evidence-based counseling like

motivational interviewing or coaching.• What are you doing about tobacco cessation

counseling?• What resources or assistance do you provide?• How are you capturing this counseling for your data

reports?• Meaningful Use requirement too!

What else do you need?What can you share?Share freely… steal shamelessly!

Upcoming Webinars…..

Because of the approaching holiday season, we have scheduled our next webinars for:

November 15 December 20

Both webinars will be held from 12-1pm

Please be in touch!• South Central – Sharon Adams

814-344-2222, sadams@scpa-ahec.org• North West – Patty Stubber

814-217-6029, pstubber@nwpaahec.org