1. Workshop Track One: Relationship-centered Communication to Improve Clinical Quality and Patients' Experience of Care Session Three: Education, Negotiation and Motivation AACH ENRICH 2011

2. Agenda for Session 3 Review learning in Sessions 1 & 2 Review objectives for this session Didactic –Ask-Tell-Ask –Motivational Interviewing Practice skills Prepare to Re-enter

3. Review Evaluate the success and challenges of first two sessions –Understanding the 3 function model –Getting the patient-family’s story –Responding with empathy (NURS) –Using PEARLS –Practicing the skills

4. Objectives For Session 3 Acquire relationship-centered care skills which improve patient care –Ask-Tell-Ask –Motivational interviewing Practice using these skills Identify strategies for use of these skills in home institution Objectives from participants

5. Didactic Last phase of interview –Educate patient about diagnosis –Negotiate plan of care –Counsel and motivate patient Skills important for patient and family education and collaboration on a treatment plan –Ask, Tell, Ask –Motivational Interviewing

6. ASK, TELL, ASK Google search yielded 8,640 hits Used in a variety of settings –Clinician-patient communication –Giving feedback in evaluation –Patient strategy for communicating with clinician –Used to communicate “bad news” –Has been called the “sandwich approach” Bread-meat-bread

7. ASK-TELL-ASK 3 step approach Step 1 –Can include asking permission to proceed –Ask for the perspective or understanding of other party Step 2 –Tell your perspective, diagnosis, additional information which was lacking Step 3 –Ask the other party to repeat, clarify, confirm

8. ASK-TELL-ASK Alternate “telling” and “asking” –Ask history or data gathering phase –Tell diagnosis, problem, recommendations –Ask about FIFE- feelings, ideas, fears, expectations Assess readiness and commitment Adjust and align action plan with science, FIFE and readiness

9. Motivational Interviewing Seek to understand the person's frame of reference, particularly via reflective listening Express acceptance and affirmation Elicit and selectively reinforce the person's own self motivational statements expressions of problem recognition, concern, desire and intention to change, and ability to change Monitor the person's degree of readiness to change, and ensuring that resistance is not generated by jumping ahead of the client. Affirm the person's freedom of choice and self- direction [ After Miller and Rollnick]

10. Motivational Interviewing Principles (Miller and Rollnick) –Understand the patient's view accurately –Support self-belief –Express empathy –Avoid or de-escalate resistance –Develop discrepancy

11. Motivational Interviewing Open-ended questions, gradually narrowing to more specific inquiry Ask about patient’s beliefs, values, expectations, and perspectives Use facilitative encouragers Repeat / reflect (aspect(s) of prior statement or conversation) Steer without dominating Check and summarize

12. Brief Action Plan (Cole) Elicit patient’s desires for change –Get specific details –Offer suggestions if needed Evaluate confidence –Use 1-10 scale –Probe about choice of number –Probe if <7 Arrange for follow-up –Get details for check-in and review www.ComprehensiveMI.com

13. Practice Practice using the skills for educating the patient/family and collaborating on a treatment plan Solicit anonymous cases from practice or use ready made cases Work in groups of 3 to role play with 2 actors and 1 observer.

14. Prepare to Re-enter Identify skills you are willing to practice to improve patient/ family outcomes and experience of care Identify strategies to use in your home institution to make a positive impact on care of patients Identify allies who are willing to assist in changing the culture