1. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Enhancing Motivation to Change: Motivational Interviewing in an Integrated Primary Care Clinic Suzanne Bailey, Psy.D. Licensed Clinical Psychologist Behavioral Health Consultant Cherokee Health Systems Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session G1b October 28, 2011 10:20 AM

2. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Faculty Disclosure I have not had any relevant financial relationships during the past 12 months.

3. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Need/Practice Gap & Supporting Resources www.motivationalinterview.org www.motivationalinterview.org Rollnick, S., Mason, P., & Butler, C. (1999). Health Behavior Change: A guide for practitioners. NY: Churchill Livingstone. Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping patients change behavior. NY: Guilford Press. Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change (2 ed.). NY: Guilford Press. Prochaska, J.O., & DiClemente, CC. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy. Homewood, IL: Dow/Jones Irwin.

4. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Objectives 1. 1.Describe motivational interviewing as a conceptual model for enhancing patient motivation 2. 2.Identify why the use of highly confrontational interventions are less likely to evoke behavior change 3. 3.List the basic concepts and techniques of motivational interviewing 4. 4.Implement a method to train providers to use motivational interviewing in integrated care

5. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Expected Outcome Participants will utilize motivational interviewing as a conceptual tool to enhance patients’ ability to engage in behavior change Participants will utilize motivational interviewing as a conceptual tool to enhance patients’ ability to engage in behavior change Participants will implement a model of training providers to use motivational interviewing Participants will implement a model of training providers to use motivational interviewing

6. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Cherokee Health Systems’ Integrated Care Model Embedded Behavioral Health Consultant (BHC) on the Primary Care team Embedded Behavioral Health Consultant (BHC) on the Primary Care team Real time behavioral and psychiatric consultation available to PCP Real time behavioral and psychiatric consultation available to PCP Focused behavioral interventions in primary care Focused behavioral interventions in primary care Behavioral medicine scope of practice Behavioral medicine scope of practice Encourage patient responsibility for healthy living Encourage patient responsibility for healthy living A behaviorally enhanced Healthcare Home A behaviorally enhanced Healthcare Home

7. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Poor Treatment Adherence A systemic problem A systemic problem Management of chronic disease requires behavior change interventions Management of chronic disease requires behavior change interventions Directly impacts treatment efficacy Directly impacts treatment efficacy Frustrates providers Frustrates providers “I’ve told him a thousand times. He just doesn’t care.”

8. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Why don’t patients change? Our focus on overall health may not be the patient’s priority. Our focus on overall health may not be the patient’s priority. Ambivalence Ambivalence “I don’t want to change, I just want to feel better.” Decisional Balance- Costs vs. Benefits Decisional Balance- Costs vs. Benefits Stage of Change Stage of Change

9. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Stages of Change Precontemplation Precontemplation I don’t have a problem. Contemplation Contemplation I have a problem, and might change someday. Preparation Preparation I think I will change soon. Action Action I’m taking action to change. Maintenance Maintenance I’m working to maintain the changes I’ve made. Prochaska and DiClemente (1984)

10. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Ready for Action? Providers are in the action stage. Providers are in the action stage. Are patients? Are patients?

11. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Common Pitfalls Give a lecture Give a lecture Give them a hard time Give them a hard time Give up Give up

12. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Why it doesn’t work… Creates resistance Creates resistance Causes patients to become defensive Causes patients to become defensive “Yes, but…” “Yes, but…”

13. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Changing our thinking about changing our patients “Motivation to change is elicited from the client, and not imposed from without.” “Motivation to change is elicited from the client, and not imposed from without.” www.motivationalinterview.org Accept that patients may leave our office and behave exactly as they did before they arrived. Accept that patients may leave our office and behave exactly as they did before they arrived. View ambivalence as part of the disease process. View ambivalence as part of the disease process. Not a flaw within the patient

14. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Imperative for MI Training Implementation of SBIRT Implementation of SBIRT PCPs “close the sale” PCPs “close the sale” Introduction of the BHC Introduction of the BHC

15. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems The MI Informed PCP Training Goals- Training Goals- 1.Become familiar with the core concepts and principles of MI 2.Learn fundamental MI skills 3.Practice using MI skills and applying key concepts

16. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Providing MI Training For PCPs Episodes of Training Episodes of Training Training Length Training Length Training Intensity Training Intensity Follow-up Follow-up

17. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Introduction to Motivational Interviewing Duration: 45 minutes Duration: 45 minutes Objectives Objectives – To be familiar with the core components of MI – To be acquainted with theoretical background and evidence of efficacy Adapted from Sample Training Agendas provided by motivationalinterview.org

18. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems What is Motivational Interviewing “Motivational Interviewing is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” “Motivational Interviewing is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” (Miller & Rollnick, 2009) Style of Interacting Style of Interacting A collaborative conversation about change that elicits motivation and commitment from the patient.(Miller & Rollnick, 2010) A collaborative conversation about change that elicits motivation and commitment from the patient.(Miller & Rollnick, 2010)

19. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems MI Efficacy Well-researched Well-researched Research conducted in settings providing direct care Research conducted in settings providing direct care Substance use, smoking cessation, obesity, diabetes, hypertension, adherence, and many more Substance use, smoking cessation, obesity, diabetes, hypertension, adherence, and many more

20. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Motivational Interviewing: Core Components Develop Discrepancy Develop Discrepancy Express Empathy Express Empathy Roll with Resistance Roll with Resistance Support Self-Efficacy Support Self-Efficacy (Miller & Rollnick, 2002)

21. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Motivation and Confidence Rulers On a scale of 1-10 how important is it for you to make the change? On a scale of 1-10 how important is it for you to make the change? On a scale of 1-10 how confident are you in your ability to make the change? On a scale of 1-10 how confident are you in your ability to make the change?

22. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Example of Motivational Interviewing

23. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Application of MI Duration: 1 hour Duration: 1 hour Objectives Objectives – To learn basic MI skills – To practice an MI style of patient interaction Adapted from Sample Training Agendas provided by motivationalinterview.org

24. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems OARS Algorithm O – Open-ended Questions O – Open-ended Questions A – Affirmations A – Affirmations R – Reflective Listening R – Reflective Listening S – Summaries S – Summaries (Miller & Rollnick, 2002)

25. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems O – Open-ended Questions Cannot be answered with “yes” or “no” Cannot be answered with “yes” or “no” – “What changes have you considered making to your diet?”

26. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems A - Affirmations Reinforce Reinforce Recognize Recognize Encourage Encourage – “I can see that your health is important to you and you would like to feel better.”

27. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems R – Reflective Listening Listen Listen Restate Restate Ask for clarification and confirmation Ask for clarification and confirmation – “I hear you saying that you’d like to stop smoking, but you worry that it would be difficult.”

28. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems S - Summaries Restate with emphasis Restate with emphasis – “So, what you have said is that… Did I understand you correctly?”

29. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Change Talk Listen for it Listen for it Guide the conversation Guide the conversation Don’t elicit resistance Don’t elicit resistance – Say it first Strengthens commitment to change Strengthens commitment to change

30. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Practice Provider generated scenarios Provider generated scenarios Role-playing Role-playing Feedback Feedback

31. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Follow-Up Handouts Handouts E-mail “Tip of the Week” E-mail “Tip of the Week” “Curbside consultation” with BHC “Curbside consultation” with BHC

32. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Lessons Learned Brief training can be beneficial Brief training can be beneficial “It’s not really that different.” “It’s not really that different.” Planning and prioritization Planning and prioritization

33. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Contact Information Suzanne Bailey, Psy.D. suzanne.bailey@cherokeehealth.com

34. Cherokee Health Systems Together…Enhancing Life Together…Enhancing Life © 2010 Cherokee Health Systems Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!