1. October 2012 Webinar Motivational Interviewing Self-Management Support PDSA Sharing NCQA Requirements, Resources

2. Motivational Interviewing Complimentary Technique to Use with 5 A’s

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

4. 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

5. 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.”

6. 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

7. 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.

8. Advantages of Using MI Improved patient satisfaction Decrease personal frustration with difficult patients (burnout) Better clinical outcomes

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

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

11. Motivational Interviewing Ask permission Listening skills: Open ended questions Patient does the talking Provider is ‘curious’ Provider summarizes with gentle direction

12. 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?”

13. Start with OARS Open-ended questions Affirm Reflective listening Summarize Allows us to make sure we fully understand what the patient means.

14. 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?

15. 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?

16. 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

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

18. 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

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

20. Start with OARS Open-ended questions Affirm Reflective listening Summarize.

21. TRY IT? MAYBE EVEN TAPE YOURSELF WITH PERMISSION

22. 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

23. 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.

24. PDSA Sharing What self-management support have you been testing?

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

26. NCQA Self-Care Requirements Including Numerous Resources to Assist You

27. 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!

28. Self-Management Resources “Helping Patients Manage Their Chronic Conditions,” California Healthcare Foundation http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/H/P DF%20HelpingPatientsManageTheirChronicConditions.pdf “Facilitating Behavior Change,” American Society on Aging, American Society of Consultant Pharmacists Foundation http://www.adultmeducation.com/downloads/Adult_Med_Facilitati ng.pdf Patient Assessment of Chronic Illness Care, MacColl Institute at Group Health http://www.improvingchroniccare.org/downloads/2004pacic.doc.pd f Community Health Center, Inc. http://www.diabetesinitiative.org/programs/DICHC.html http://www.diabetesinitiative.org/programs/DICHC.html

29. 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.

30. Patient Assessment Resources A few “readiness to change” assessment tools: http://aom3.americaonthemove.org/~/media/B62B030924954B2 A95AC74436519BD2C.ashx http://aom3.americaonthemove.org/~/media/B62B030924954B2 A95AC74436519BD2C.ashx http://www.adultmeducation.com/downloads/Readiness-to- Change_INSTR.pdf http://www.adultmeducation.com/downloads/Readiness-to- Change_INSTR.pdf http://www.ama- assn.org/ama1/pub/upload/mm/433/patientreadiness.pdf http://www.ama- assn.org/ama1/pub/upload/mm/433/patientreadiness.pdf http://www.lsuhospitals.org/cmo/hcet/docs/obesityclinical/Patie nt_Readiness.pdf http://www.lsuhospitals.org/cmo/hcet/docs/obesityclinical/Patie nt_Readiness.pdf http://www.nationalobesityforum.org.uk/index.php/lifestyle/adul ts_/obesity-care-pathway/219-patient-motivation-readiness-to- change.html http://www.nationalobesityforum.org.uk/index.php/lifestyle/adul ts_/obesity-care-pathway/219-patient-motivation-readiness-to- change.html

31. More Assessment Resources Summary of Diabetes Self-Care Activities http://care.diabetesjournals.org/content/23/7/943.full.pdf Morisky Medication Adherence Questionnaire http://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.pdf http://www.cqaimh.org/pdf/tool_phq2.pdf Case-finding and Health Assessment Tool (CHAT) http://www.bpac.org.nz/magazine/2009/adultdep/appendices.a sp#appendix9

32. 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

33. 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 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 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/RefID 931-Charron-Prochownik-20090620001517.pdf http://knowledgetranslation.ca/sysrev/articles/project21/RefID 931-Charron-Prochownik-20090620001517.pdf

34. 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!

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

36. 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

37. Please be in touch! South Central – Sharon Adams 814-344-2222, sadams@scpa-ahec.orgsadams@scpa-ahec.org North West – Patty Stubber 814-217-6029, pstubber@nwpaahec.orgpstubber@nwpaahec.org