Motivational Interviewing: A Pathway to and a Feature of the Patient-Centered Medical Home

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Motivational InterviewingA Pathway to and a
Feature of the Patient-Centered Medical Home

• Ronald Adler, MD, FAAFP
• Daniel Mullin, PsyD
• UMass Medical School
• STFM Faculty Development Workshop
• December 5, 2009

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The PCMH

• Is a physician-directed practice providing care
  that is comprehensive, preventive, coordinated,
  and centered on the needs of patients (and their
  families, as appropriate).
• Uses HIT, registries and other process
  innovations to assure high-quality,
  evidence-based care that is efficient and readily
  accessible.
• Promotes and supports patient self-management and
  systematically measures its own performance to
  facilitate continuous quality improvement.

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A Medical Home Provides

• Easy access to a PCP,
• Who is working with a high-functioning team
• And a robust IT system,
• To provide comprehensive care to
• Activated, informed patients and families.

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Easy Access to a PCP

• Access
• Open access scheduling
• Customized communication
• Interactions
• Family-centered
• Personal attention
• Relationship is key

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High-Functioning Team

• Nurse
• Care Coordinator
• Social Worker
• Mental Health Provider
• Nutritionist
• Pharmacist
• (Plus learners students, residents)

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Robust IT System

• EMR/Electronic Prescribing
• Decision Support
• Relevant, up-to-date info available at
  point-of-care
• Tracks Data
• Registry Process and Outcomes
• Satisfaction Patients, Staff and PCPs

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• For individuals, change requires
• Motivation Why to change
• Information What to change
• Ability/Resources/Effort How to change

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Insanity

• Insanity Doing the same thing over and over
  again and expecting different results. -- Albert
  Einstein
• Current state Provide our patients with
  information and repeated exhortations and hope
  they get it.
• Can we do BETTER?

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Is Your Patients Positive Change MIA?

• Motivation
• Is s/he inspired to make changes?
• Information
• Does s/he understand the reasons for change?
• Ability
• Does s/he have the resources necessary to create
  the change?

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Facilitating Positive Change

• Identify your patients barriers to change.
• Tailor your interventions to address these
• If Motivation, help inspire them.
• If Information, educate them.
• If Ability, provide helpful resources.

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Barriers to Change

• Each patient faces multiple barriers.
• Consider the relative contributions of deficits
  in
• Motivation
• Information
• Ability
• Motivation is always a factor, usually the most
  significant.

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Motivation

• Assess
• How important is it for you to change right now?
• Improve/Enhance
• Create context patients life goals
• Review prior efforts, including lessons from
  successes and failures
• Recognize your lack of power
• Acknowledge your lack of power
• Identify your patients strengths
• Promote your patients power

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Facts about Flossing

• Flossing removes food debris and plaque.
• Plaque causes tooth decay and gum disease.
• Regular flossing can help prevent MI and CVA.

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Why dont you floss more?

• Do you lack info re the benefits?
• Is it difficult to acquire floss?
• Whats really missing?

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• There is something in human nature that resists
  being coerced and told what to do. Ironically,
  it is acknowledging the others right and freedom
  not to change that sometimes makes change
  possible.
• Rollnick, Miller, and Butler (2008)

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The Fundamental Attribution Error

• When explaining the behavior of others, we tend
  to overestimate personal factors and
  underestimate environmental factors.
• When explaining our own behavior, we tend to
  underestimate personal factors and overestimate
  environmental factors.

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• When a patient seems unmotivated to change or to
  take the sound advice of practitioners, it is
  often assumed that there is something the matter
  with the patient and that there is not much one
  can do about it.
• Rollnick, Miller, and Butler (2008)

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• These assumptions are usually false.
• Motivation for change is actually quite malleable
  and is particularly formed in the context of
  relationships.
• Rollnick, Miller, and Butler (2008)

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Motivational Interviewing

• is
• a patient-centered, goal-oriented method of
  communication
• for enhancing intrinsic motivation to change
• by exploring and resolving ambivalence.

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Four Principles of MI

• Resist Righting Reflex
• Understand and explore patients motivations
• Listen with empathy
• Empower patient, encouraging hope and optimism

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Resist Righting Reflex

• Tolerate incorrect information that is irrelevant
  or useful.
• Ask permission before educating or informing.

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Understand and Explore Patients Motivations

• Explore the patients values what are the
  functional limitations that result from their
  illness?
• What has motivated them to make changes in the
  past?
• What do others in the patients life say about
  their behavior and how does this impact their
  motivation?

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Listen With Empathy

• What is the difference between empathy and
  sympathy?
• Empathy is the cognitive process of understanding
  another persons emotions.
• Unfortunately, many people react negatively to
  the assertion I understand how you feel.

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Empower Patient,Encourage Hope and Optimism

• Create the expectation of success.
• Give positive attention to any change the patient
  makes.
• Offer to give examples of other successes you
  have witnessed.
• Set realistic goals to increase chances of
  success.

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Ambivalence

• is characterized by conflicting thoughts and
  feelings for and against change.
• People often think
• First of reasons to change,
• Then of reasons not to change.
• Then they stop thinking of change

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Resolving Ambivalence

• Change follows the exploration and resolution of
  ambivalence.
• Providers are successful when patients talk
  themselves into change.

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Thinking About The Costs and Benefits of Change What specific behavior change are you considering? _______________________ Thinking About The Costs and Benefits of Change What specific behavior change are you considering? _______________________ Thinking About The Costs and Benefits of Change What specific behavior change are you considering? _______________________
STAY THE SAME MAKE SOME IMPROVEMENT
BENEFITS I like I will like
COSTS I dont like I wont like
Create some ideas and reflections for each of the four boxes above. This will help clarify your thoughts about what you want to do next. Create some ideas and reflections for each of the four boxes above. This will help clarify your thoughts about what you want to do next. Create some ideas and reflections for each of the four boxes above. This will help clarify your thoughts about what you want to do next.
Welch, G., Rose, G., Ernst, D. (2006)
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Listening for Change Talk

• We tend to believe what we hear ourselves say.
• The more patients verbalize the disadvantages of
  change, the more committed they become to
  sustaining the status quo.

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Becoming a Medical Home

• Requires meaningful transformation
• All personnel in your practice must engage
• Change is difficult
• Especially for busy health care providers
• ESPECIALLY for doctors

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• For individuals, change is very difficult.
• For organizations, the complexities and
  challenges associated with change increase --
  dramatically with the size of the organization.

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Aha! Moment

• Techniques to support and facilitate behavior
  change in patients, may be useful when helping
  your colleagues achieve behavior change in the
  work environment.
• Just as for chronic illness to be managed
  effectively, the patient must actively
  participate in the process, so must the entire
  health care team participate in change processes.

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An Illustrative Vignette

• Resident presents a woman with DM-2 whose A1C had
  gone from 7.0 to 9.5 over 6 months.
• I ask "To what extent do you think she
  understands diabetes?
• Resident replies "I explained it to her she has
  to take her medicine, eat a better diet, ..."

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Exercise

• Does the resident understand that it is important
  to explore the patients perspective?
• Does the resident have confidence that she can be
  successful in exploring the patients
  perspective?
• Is the resident ambivalent about exploring the
  patients perspective?
• How can you help the resident adopt this
  patients perspective?

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An Illustrative Vignette

• Resident presents a woman with DM-2 whose A1C had
  gone from 7.0 to 9.5 over 6 months.
• I ask "To what extent do you think she
  understands diabetes?
• Resident replies "I explained it to her she has
  to take her medicine, eat a better diet, ..."
• I reply "I didn't ask if YOU understand diabetes.
  How can we help HER do better?