motivational interviewing : a pathway to and a feature of the patient-centered medical home
DESCRIPTION
Motivational Interviewing : A 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. The PCMH:. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/1.jpg)
Motivational Interviewing:A Pathway to and a Feature of the Patient-Centered Medical Home
Ronald Adler, MD, FAAFPDaniel Mullin, PsyD
UMass Medical School
STFM Faculty Development WorkshopDecember 5, 2009
![Page 2: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/2.jpg)
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.
![Page 3: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/3.jpg)
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.
![Page 4: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/4.jpg)
Easy Access to a PCP
• Access– Open access scheduling– Customized communication
• Interactions– Family-centered– Personal attention– Relationship is key
![Page 5: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/5.jpg)
High-Functioning Team
• Nurse• Care Coordinator• Social Worker• Mental Health Provider• Nutritionist• Pharmacist
• (Plus learners: students, residents)
![Page 6: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/6.jpg)
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
![Page 7: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/7.jpg)
![Page 8: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/8.jpg)
• For individuals, change requires:
• Motivation – Why to change
• Information – What to change
• Ability/Resources/Effort – How to change
![Page 9: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/9.jpg)
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?
![Page 10: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/10.jpg)
Is Your Patient’s 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?
![Page 11: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/11.jpg)
Facilitating Positive Change
• Identify your patient’s barriers to change.
• Tailor your interventions to address these:
• If Motivation, help inspire them.
• If Information, educate them.
• If Ability, provide helpful resources.
![Page 12: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/12.jpg)
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.
![Page 13: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/13.jpg)
Motivation
• Assess:– How important is it for you to change right now?
• Improve/Enhance:– Create context: patient’s life goals– Review prior efforts, including lessons from
successes and failures– Recognize your lack of power– Acknowledge your lack of power– Identify your patient’s strengths– Promote your patient’s power
![Page 14: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/14.jpg)
Facts about Flossing
• Flossing removes food debris and plaque.
• Plaque causes tooth decay and gum disease.
• Regular flossing can help prevent MI and CVA.
![Page 15: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/15.jpg)
Why don’t you floss more?
• Do you lack info re: the benefits?
• Is it difficult to acquire floss?
• What’s really missing?
![Page 16: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/16.jpg)
There is something in human nature that resists being coerced and told what to do. Ironically, it is acknowledging the other’s right and freedom not to change that sometimes makes change possible.
Rollnick, Miller, and Butler (2008)
![Page 17: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/17.jpg)
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.
![Page 18: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/18.jpg)
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)
![Page 19: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/19.jpg)
• 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)
![Page 20: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/20.jpg)
Motivational Interviewing
is
a patient-centered, goal-oriented method of communication
for enhancing intrinsic motivation to change
by exploring and resolving ambivalence.
![Page 21: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/21.jpg)
Four Principles of MI
Resist Righting Reflex
Understand and explore patient’s motivations
Listen with empathy
Empower patient, encouraging hope and optimism
![Page 22: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/22.jpg)
Resist Righting Reflex
• Tolerate incorrect information that is irrelevant or useful.
• Ask permission before educating or informing.
![Page 23: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/23.jpg)
Understand and Explore Patient’s Motivations
• Explore the patient’s 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 patient’s life say about their behavior and how does this impact their motivation?
![Page 24: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/24.jpg)
Listen With Empathy
• What is the difference between empathy and sympathy?
Empathy is the cognitive process of understanding another person’s emotions.
• Unfortunately, many people react negatively to the assertion “I understand how you feel.”
![Page 25: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/25.jpg)
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.
![Page 26: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/26.jpg)
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
![Page 27: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/27.jpg)
Resolving Ambivalence
• Change follows the exploration and resolution of ambivalence.
• Providers are successful when patients talk themselves into change.
![Page 28: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/28.jpg)
Thinking About The Costs and Benefits of Change
What specific behavior change are you considering? _______________________
STAY THE SAME MAKE SOMEIMPROVEMENT
BENEFITS I like: I will like:
COSTS I don’t like: I won’t 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. Welch, G., Rose, G., & Ernst, D. (2006)
![Page 29: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/29.jpg)
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.
![Page 30: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/30.jpg)
0|
1|
2|
3|
4|
5|
6|
7|
8|
9|
10|
On a scale of 0 to 10, how IMPORTANT is it for you rightnow to change?
On a scale of 0 to 10, how CONFIDENT are you that youcould make this change?
0|
1|
2|
3|
4|
5|
6|
7|
8|
9|
10|
![Page 31: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/31.jpg)
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
![Page 32: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/32.jpg)
• For individuals, change is very difficult.
• For organizations, the complexities and challenges associated with change increase -- dramatically with the size of the organization.
![Page 33: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/33.jpg)
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.
![Page 34: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/34.jpg)
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, ..."
![Page 35: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/35.jpg)
Exercise
• Does the resident understand that it is important to explore the patient’s perspective?
• Does the resident have confidence that she can be successful in exploring the patient’s perspective?
• Is the resident ambivalent about exploring the patient’s perspective?
• How can you help the resident adopt this patient’s perspective?
![Page 36: Motivational Interviewing : A Pathway to and a Feature of the Patient-Centered Medical Home](https://reader034.vdocuments.mx/reader034/viewer/2022051401/56813998550346895da1323d/html5/thumbnails/36.jpg)
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?“