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Key Tools for Patients’ Successful Behavior
Change for Use in Telephonic Coaching
Mary Ann Hodorowicz, RD, MBA, CDE, Certified Endocrinology Coder
June 25, 2015
Mary Ann Hodorowicz RD, LDN, MBA, CDE, CEC
Mary Ann Hodorowicz, RD, LDN, MBA, CDE, CEC, is a licensed
registered dietitian and certified diabetes educator and earned her
MBA with a focus on marketing. She is also a certified endocrinology
coder and owns a private practice specializing in corporate clients in
Palos Heights, IL. She is a consultant, professional speaker, trainer,
and author for the health, food, and pharmaceutical industries in
nutrition, wellness, diabetes, and Medicare and private insurance
reimbursement.
Her clients include healthcare entities, professional membership
associations, pharmacies, medical CEU education and training firms,
government agencies, food and pharmaceutical companies,
academia, and employer groups. She serves on the Board of Directors
of the American Association of Diabetes Educators.
Mary Ann Hodorowicz Consulting, LLC
www.maryannhodorowicz.com
hodorowicz@comcast.net
708-359-3864
Twitter: @mahodorowicz
1. Explain the key differences between compliance counseling
and motivational interviewing (MI) counseling.
2. Name the 5 motivational interviewing/adult learning tools
reviewed in the presentation to help positively change patient
behavior.
3. Explain what the “Strike 3 Rule” is.
4. Define what “S.M.A.R.T.” stands for in relation to helping
patients create behavior change goals.
5. Name the steps recommended when addressing the
patient’s barriers to his/her behavior change goals.
LEARNING OBJECTIVES
Key tools in this presentation were selected from the
research on motivational interviewing and adult learning
principles (see references).
MI is a conversational style of working with and/or coaching
patients that is designed to increase motivation to change
and reduce resistance to changing lifestyle and health
behaviors.
FIRST, COMPARISON OF KEY DIFFERENCES IN:
COMPLIANCE COUNSELING
(considered less effective in prompting positive
behavior change in outpatient chronic care)
vs.
MOTIVATIONAL INTERVIEWING
(considered more effective) 1,2,3,4
COMPLIANCE:
Coach Asks Close-Ended Questions: • Will you? • Could you? • Do you? • Did you? • Have you?
MOTIVATIONAL INTERVIEWING:
Coach Asks Open-Ended Questions: • What … ? • How … ? • Why … ? • Describe … ? • Explain … ? • Tell me about … ?
COMPLIANCE:
• Coach is sage on the stage
• Coach selects topics per agenda
• Coach does most of the talking
MOTIVATIONAL INTERVIEWING:
• Coach is guide on the side
• Patient selects topics per need
• Coach does most of the listening
REQUEST THAT PATIENT SELECTS TOPIC(S) for each visit
Ask patient at each visit:
• What is your most pressing need or problem that we can work on together
today, or the topic you’d like to talk about?
• Consider giving patient list of topics for specific disease intervention
to select from
• See AADE7 Self-Care Behaviors list on next slide
Always think ‘patient-centered’ coaching …
not ‘agenda-centered’ or ‘curriculum-centered’.
Healthy eating
Menu planning, label reading, healthy cooking, portion
control, dining out, carbohydrate, protein, fat, fiber, sugar,
sugar-free foods, omega 3 fats, dietary cholesterol,
saturated fat, vitamins, minerals, etc.
Being active Simple exercises for everyday life, and why.
Reducing risks Risks of complications of uncontrolled diabetes: heart
disease, teeth and gum problems, kidney disease, nerve
and vision problems, infections, etc.
Monitoring Monitoring of blood glucose, blood pressure, blood
cholesterol, other health indicators.
Taking medications How medication works, how to take it, precautions, side
effects, how to prevent side effects, etc.
Healthy coping Coping with diabetes, adapting to lifestyle changes at work,
home, etc.
Problem solving Solving problems with high/low blood sugar, stress, anxiety,
traveling, relationships, etc.
Ongoing support Diabetes self-care support resources in community.
TALK MUCH LESS and prompt patient to talk more
Ask open-ended questions to prompt patient to:
• Answer his own questions
• Most patients have most of the answers within them, but have the answers
buried deep due to fear, anger, busy schedules, denial, etc.
• Tell his story about the selected topic/need/problem
• Analyze his need/problem from his own point of view
• Start thinking about ways to meet his need, fix his own problem, create his
own behavior change goals
TALK MUCH LESS and prompt patient to talk more
Ask open-ended questions to prompt patient to:
• Review all treatment options to help solve her problem
• Arrive at treatment option that best fits her “I.V.s” … Issues and Variables
related to her own life
• SAY … from her lips to your ears … the key core message related to topic
selected or to specific behavior change
• Example: “I’m pretty sure that my high A1c and my 10 pound weight
gain is related to the 6 or more carbohydrate servings that I
eat at nearly every meal.”
Mark: Why does everyone keep telling me that I have
to test my blood sugar with this meter?
HCP: Why do YOU think they are telling you this?
Mark: I really don’t know … no one explains it to me.
HCP: How do you feel about actually using the test results
to better control your sugar on a daily basis?
Mark: Yeh, I would think about that, if it would help.
HCP: If you don’t mind, can you share with me your thoughts
on how you might use a test result before dinner to better
control your after-dinner sugar?
EXAMPLE: MI Conversation between patient Mark and HCP:
TALK MUCH LESS and prompt patient to talk more
Adults learn and retain:
• 20% of what they HEAR
• 30% of what they SEE
• 50% of what they SEE and HEAR
• 70% of what they personally explain or SAY
90% of what they SAY and DO
SWEETEST SOUND TO PATIENTS …
• Their own voice
SWEETEST WORD TO PATIENTS …
• Their own name
SWEETEST TOPICS TO PATIENTS …
• Their own story
Sign over clock in HCP’s counseling office:
Why Am I Talking?
TALK MUCH LESS and prompt patient to talk more
Polling Question Number 1 Which of these is an open-ended question?
Mark, I see that you have had type 2 diabetes for 10 years
and own a fairly new blood glucose meter.
A. Can you share with me your experiences with using a
meter to test your own blood sugar?
B. Do you test your blood sugar with your meter?
TALK MUCH LESS and prompt patient to talk more
Ask open-ended questions to prompt patient to:
• Persuade SELF to change
• Avoid you doing the persuading … it will backfire!
- Patient will ‘dig in’ and protect and defend exact negative behavior you
are trying to change!
• How to help patient persuade SELF to change:
• Ask patient B.I.G.G.E.S.T. open-ended questions for ‘change talk’
- Helps patient find her buried ‘inner strength’
TALK MUCH LESS and prompt patient to talk more
B = How would you BENEFIT if you were to test your blood sugar with a meter 1 or 2
times a day?
I = What would IMPROVE or INCREASE in your life? What INCENTIVE would you
need to start testing?
G = Who else in your life would GAIN if you did test?
G =
What would you have to GIVE UP to start testing your blood sugar? How would
you GAUGE the importance of testing on a 1-10 scale?
E = What would you ENJOY about testing your blood sugar?
S = Would SOMEONE want to help you test your sugar before and after meals, or
fasting in a.m.?
T = What would it TAKE to:
• Get you started with your blood sugar testing?
• Keep testing on a regular basis?
• Reduce any barriers you may have to testing your blood sugar?
GIVE ADVICE / TELL, BUT … only when asked, only when patient cannot say “key core
message”, and only if you first ask permission
Consider using the “Strike 3 Rule”:
• Ask patient open ended question at least 3 times. If still cannot
say key core message, then tell, but first ask permission
• Remember: most patients have most of the answers within them
… it’s our job to get answers from their lips to our ears (not in
reverse!)
GIVE ADVICE / TELL, BUT … only when asked, only when patient cannot say “key core
message”, and only if you first ask permission
Avoid telling patient what her specific treatment will
be … instead:
• Lay out all treatment options for patient … and
• Lay out all pro’s and con’s of each treatment option
• Give patient opportunity to select best treatment option for her
own life’s ‘I.V.s’ … her Issues and Variables
Patient is to be at center of ALL decision making!
K.I.S.S. interventions / messages:
Keep It Simple and Short
Examples:
• Testing blood sugar regularly helps you to make healthier eating and exercise
decisions on daily basis
• High salt intake often increases blood pressure
• Type 1 diabetes means you don’t have any insulin
• Exercise is great tool to lower high blood cholesterol
USE ADULT LEARNING TOOLS along with MI tools
Polling Question Number 2 Which of these would be the best way to educate a patient on type 1 diabetes? A. Type 1 diabetes is an autoimmune disease that causes
beta cell dysfunction and makes you ketoacidosis prone.
B. Your body does not make any insulin at all, so you will
need to inject insulin into your body with a needle or with
an insulin pump.
USE ADULT LEARNING TOOLS along with MI tools
Avoid the righting reflex (very common among HCPs!):
• Jumping in to “right” the problem for the patient
• Not involving patient in her own problem solving
• Acting as the expert in the patient’s life
Summarize back to patient what she has said (focusing on key
core messages) about every 10 minutes
Ask patient to write down her own correct answers to your open
ended questions … do allow her to create her own handout!
USE ADULT LEARNING TOOLS along with MI tools
Ask patient to summarize back to you the info you had to tell her
(is usually complicated interventions such as DKA)
• This gives you opportunity to correct any errors in her summary … and this
increases learning and retention
Remember, every 10 minutes YOU are summarizing what patient
said … this is summarizing in reverse!
USE ADULT LEARNING TOOLS along with MI tools
Would you mind giving me a quick summary of
what we discussed on how to handle your insulin
injections when you are very sick?
USE ADULT LEARNING TOOLS along with MI tools
Start low & go slow: avoid ‘firehosing’ patient with
too many messages and too much information at one
time. Makes patient feel overwhelmed, and then
stupid! Ugh!
USE ADULT LEARNING TOOLS along with MI tools
More on start low and go slow!
• Do keep ‘key core messages’ very easy at first visits … do kids learn calculus
in kindergarten?
more complex
simple
Later visits
First few visits
TOGETHER WITH PATIENT, create 1 or 2 “S.M.A.R.T.” behavior change goals
S = Sensible (is doable for patient)
M = Measurable (amount, what, when)
A = Attainable (how … do skills training if needed)
R = Relevant (meets patient’s need or problem)
T = Time-based (time period to work on goal)
Polling Question Number 3 Which of these is a S.M.A.R.T. behavior goal?
A. Decrease the number of cans of regular soda that I drink
from 4 to 3 cans a day for the next 2 weeks.
B. Cut back on soda.
TOGETHER WITH PATIENT, create 1 or 2 “S.M.A.R.T.” behavior change goals
Steps to help patient identify goal barriers and ways to reduce:
• Ask patient:
• What her barriers are to each behavior change goal
• To what extent barriers may effect behavior change
• To ‘size’ barriers to prioritize: S, M, L and XL barriers
• To select L and XL barrier to tackle first
• To search for ways to reduce or eliminate L and XL
• Summarize the plan … then ask patient to write it down
• Praise even smallest patient successes at next visits
• Avoid even slightest criticism of patient’s failures
QUESTIONS?
REFERENCES • Ellen R. Glovsky, PhD, RD, LD, Gary Rose, PhD, Motivational Interviewing — A Unique
Approach to Behavior Change Counseling, Today’s Dietitian Vol. 9 No. 5 P. 50, May 2007
• Motivational Interviewing, A Taste of Motivational Interviewing Ellen R. Glovsky, PhD, RD, LDN,
11-6-13, http://www.slideshare.net/ellenglovsky/a-taste-of-motivational-interv
• Miller WR, Rollnick SR. Motivational Interviewing: Helping People Change, 2nd edition. New
York: Guilford Press; 2002
• Miller WR, Rollnick SR. Motivational Interviewing, Third Edition: Helping People Change
(Applications of Motivational Interviewing), , 3rd edition. New York: Guilford Press; 2013
• Rose GS, Rollnick SR, Lane C. What’s Your Style? A model for helping practitioners to learn
about communication and motivational interviewing. MINUET. 2004;11:2-4
• Hersen M, Eisler RM, Miller PM (ed). Progress in Behavior Modification. Belmont, Calif.:
Wadsworth; 1994
• Marc Steinberg, MD, FAAP, Clinical Perspectives on Motivational Interviewing in Diabetes Care,
Diabetes Spectrum, August 2011, vol. 24 no. 3, 179-181
• Rollnick SR, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners. London:
Churchill Livingstone; 1999
• Nutrition Practice Guideline for Diabetes Mellitus Type 1/Type 2 and Hypertension, and Disorders
of Lipid Metabolism Toolkit, www.andevidencelibrary.com, Academy of Nutrition and Dietetics;
accessed 2-2-15
• Suzanne E. Mitchell, MD, MS, Motivational Interviewing in the Management of Type 2 Diabetes:
An Expert Interview With Faculty and Disclosures, CME Released: 02/07/2012, Medscape
Education Diabetes & Endocrinology
• American Diabetes Association. Standards of Medical Care Diabetes Care Volume 38,
Supplement 1, January 2015, Position Statement 2015
RESOURCES BY MARY ANN HODOROWICZ Turn Key Materials for AADE DSME Program Accreditation
• Program Policy & Procedure Manual Consistent with NSDSME (72 pages)
• Medicare, Medicaid and Private Payer Reimbursement
• Electronic and Copy-Ready/Modifiable Forms & Handouts
• Fun 3D Teaching Aids for AADE7 Self-Care Topics
• Complete Business Plan
3-D DSME/T and Diabetes MNT Teaching Aids ‘How-To-Make’ Kit
• Kit of 24 monographs describing how to make Mary Ann’s separate 3-D teaching aids plus
fun teaching points, evidence-based guidelines and references
Money Matters in MNT and DSMT: Increasing Reimbursement Success in All Practice
Settings, The Complete Guide©, 5th. Edition, 2014
Establishing a Successful MNT Clinic in Any Practice Setting©
EZ Forms for the Busy RD©: 107 total, on CD-r; Modifiable; MS Word
• Package A: Diabetes and Hyperlipidemia MNT Intervention Forms, 18 Forms
• Package B: Diabetes and Hyperlipidemia MNT Chart Audit Worksheets: 5 Forms
• Package C: MNT Surveys, Referrals, Flyer, Screening, Intake, Analysis and Other Business/
Office and Record Keeping Forms: 84 Forms
THANK YOU
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