Motivational Interviewing in Cardiac Rehabilitation Avani Shah, MSW, PhD School of Social Work

Where is Heart Disease the worst? Center for Disease Control http://www.cdc.gov/heartdisease/facts.htm

Overview Your current approach & barriers to patient engagement? What is Motivational Interviewing? What is the evidence behind Motivational Interviewing in health behavior change? How can we use Motivational Interviewing to improve patient engagement? Let’s Practice

Barriers to Cardiac Rehabilitation Compliance or Attendance In your experience, what are the barriers to attendance? What are the barriers to actually changing a health behavior?

Compliance (Taylor, 2011) 40% of CHD patients DO NOT Complete Why? -F>M -Younger>Older -Depression> No Depression -Employment>No Employment -MI/Angina>CABG -High risk of future MIs>Low Risk

Ways of Improving Compliance 1 Convince them that their condition has serious consequences 2 Increase their confidence in managing their condition and treatment What do you do to help patients begin or maintain change?

Your experience In interacting with a healthworker, other professional, family member, or friend, what worked to convince you to make the behavior change (e.g. smoking, diet, exercise,…)? What do you think would not have worked? How long did it take from when you first recognized a need to make a change to actually making the change? Were you successful in making the change? Did you ever backslide?

Why it’s so hard to keep moving? Stages of Change Why it’s so hard to keep moving?

How to Intervene Precontemplation: Here is some information about how CR can help you Contemplation: What do you think the pros & cons are of starting CR? Preparation: What do you think you need to do or have in place to get started with CR? Action: So you hurt pretty bad after the first session, which exercise gave you the most difficulty and which one do you think you could handle doing today? Maintenance: You have been coming regularly for the past month but have missed a few visits, what can help you get back on track?

Motivation Melts Obstacles Away Internal MoTivation VS External Motivation?

What is Motivational Interviewing? “person-centered counseling style for addressing the common problem of ambivalence about change” (Miller & Rollnick, 2013, p. 29)

What Motivational Interviewing is NOT!!! Advice Giving Motivational Speaking Confrontation Agreeing Using Logic to Persuade Threatening

Evidence MI is considered an evidence-based treatment with 31 studies out of 57 supporting its use for health issues (Knight, McGowan, Dickens, & Bundy, 2006). A review of MI in OAs (Cummings et al., 2009) indicated that a total of 11 out of the 15 available randomized controlled studies led to improvements in varying health behaviors (e.g., smoking cessation, diet, physical activity, cardiovascular risk factors). Half of the therapy sessions were delivered completely or partially by telephone within a limited number of sessions (range: 1 to 12). MI was also delivered by various disciplines: nurses, dieticians, exercise counselors, and psychologists.

Borrowed from Motivational Interviewing presentation by Dr. Nolan

Evidence in CR Study Intervention Outcome Scales 2003 3 sessions MI + CR + in physical activity Scales 1998 MI vs CR + diet, stress, physical activity Hughes 2002 30 min of MI after CR vs nothing +increase in leisure physical activity Brodie 2005 MI vs CR vs MI+CR +all increased distance 6 min walk test +more exercise in both MI groups McGrady 2014 4 sessions MI + CR vs CR +more CR sessions completed +fewer dropouts Beckstead 2010 MI+CR vs MI in F +QOL Chair 2013 MI+CR +HQOL

How Can We Use Motivational Interviewing to Improve Patient Engagement?

Experiential Exercise Introduce yourself to your neighbor. Inform them about some health behavior change (drinking more water, not eating chocolate bar after work, etc) that you want to incorporate in 1 minute. Next let the neighbor give you some advice on how to make that change happen for 2 minutes. Just listen to the advice without comment. On the handout, write down what it was like to obtain the information and what it was like to give the information. Would you follow the advice; yes or no? Why or why not? Did you already know the advice that the other person gave you?

Diabetes and Exercise MI Video https://www.youtube.com/watch?v=SIi96Jp1_vo How was this exchange different?

Spirit of Motivational Interviewing Partnership Acceptance Compassion Evocation-letting the patient find their own internal motivation and resources to accomplish change

Core Skills Non-confrontational and empathic style Good listening, positive non-verbal communication, empathic listening, the use of open questions, affirmation of positives, and the use of reflections Flexibility Respect Autonomy-Roll with Resistance Emphasis on solutions and strengths Reinforcing prosocial behaviors Using problem solving with patients interpretation of problems. Confidence in the patient’s ability to change

OARS Open-Ended Questions-How is this exercise plan working out for you? Vs. Do you like this machine? Affirmations-How do you feel about reaching your goal this week? Reflections- Patient: I just do not feel challenged by this exercise plan, why should I keep coming. Exercise Physiologist: You think a you have progressed past the exercise plan so you are feeling frustrated. Summaries- So far, you have mentioned taking care of your grandkids, pain in your knees, and your work schedule as reasons that you have not been able to come to CR.

Evaluating Confidence and Readiness for Change Learning to Use Motivational Interviewing Effectively: Modules Ruth Widder, 2017 What would you like to gain from the program? On a scale from 1 to 10, how confident are you that you can accomplish this goal? What would it take to make your confidence a 10? What do you think could prevent you from reaching this goal?

Elicit – Provide – Elicit Ellicit- Ask the patient what they know or what they want to know. Tell me what you know about CR. What do you think the benefits of exercise are? What do you want to know about CR? What do you think about using this machine? Provide Information or Advice-Ask permission. Would you mind if I told you some of the benefits of CR? Do you mind if I show you a different way of using that machine or doing that? Can I share some ways other people with work problems have been able to adjust their schedule? Elicit-Ask for feedback; commitment or reaction Do any of those benefits seem like something you are looking for? How did doing that exercise differently feel? Do you think any of the things others did regarding their work schedules would work for you?

Let’s Practice 1) Ask your neighbor using EPE about some health behavior change (drinking more water, not eating chocolate bar after work, etc) that they want to incorporate in 1 minute. Client response 2) Ask the neighbor: what do you already know about how to change that ____________. and what do you wish you knew? 3) Reflect/summarize what they just told you. 4) Then ask permission about if you can provide them with some information. Provide resources or suggestions without being attached to them. 5) Ask: I am interested in hearing how you think any of those might work. Or Would you be willing to try those? Or What are your thoughts on those? Client response: Provide feedback about those suggestions and whether they can be used. 6) Reflect and Summarize client comments.

Resources to Develop More MI Skills http://www.motivationalinterviewing.org/

100 % of RDA (Recommended Daily Activities)