Patient Self-Management
Sheraton Wall Centre VancouverNov. 23, 2011
Introductions and Objectives
Liza Kallstrom and Connie Davis
3
Housekeeping & other issues
4
What did you hope to accomplish today?
5
Objectives for the day
6
Learning on (possibly) two levels - three types of things
� New ideas and skills
� Some to share
� From PSP module
� Some as background information or
additional ideas to try: FYI
� How to present new ideas and skills (learning about learning)
About today
Experiences in Self Management Panel Conversation
Sek Cheung
Shirley Parent
Andre Van Wyk
Leslie Whyte
Christina Southey, Facilitator
8
What surprised you in the panel conversation?
How does the conversation coincide with your experience?
What additional questions do you have for the panel?
Table Discussion – 15min
9
What additional questions do you have
for the panelists?
Questions for the Panel
Break and Activity
Stepped Model for Self-
management Support
12
� Describe a stepped care approach to supporting patient self-
management
� Define health literacy, cultural humility and patient activation
� Demonstrate teach back
� Describe an approach for working across cultures
� Experience a way to TAKE PART in medical visits
� Define minimally disruptive medicine
Objectives for this section
13
HealthyCommunities and Supportive Family, Friends, andCaregivers
Honorculture
Develop sharedunderstanding
Use Self-management Support Core Techniques:Goal Setting, Action Planning,
Problem solving, Follow-up
Stepped Care for Self-management Support
Provide Advanced Approaches(MI, Case Mgmt, PST, Group Interactions, etc.)
Offer ExpertMethods
Promote activeself-management
Based on the work of the Indian Health Service Improving Patient Care Self-management Support Workgroup and Division of Diabetes Treatment Program with input from the British Columbia Ministry of Health Services Patients as Partners Committee and ImpactBC, 2011.
14
Self-management relates to the tasks that an individual must
undertake to live well with one or more chronic conditions. These
tasks include gaining confidence to deal with medical management,
role management, and emotional management.
Adams, Greiner, and Corrigan (2004)
What is Self-Management? (definition used in BC)
15
� Self-management support is defined as the systematic provision
of education and supportive interventions by health care staff to
increase patients’ skills and confidence in managing their health problems, including regular assessment or progress and
problems, goal setting, and problem-solving support.
Adams et. Al. (2004)
What is Self-Management Support? (definition used in BC)
16
Treatment NNT Time
Antibiotics for H.
pylori ulcers
2 to heal 1 ulcer 1 yr
Statins in people
with previous MI
or known
disease
48 to prevent 1
death
5 yrs
Statins in people
with risk factors
70-250 to
prevent 1 MI or
stroke
5 yrs
Therapeutics initiative
For the numbers people…
17
Lifestyle
interventions in
Diabetes
Prevention
Program
7 to prevent 1
person from
developing
diabetes
~3 yrs
Metformin in DPP 14 to prevent 1 ~3 yrs
Nurse-led home
exercise program
for > 80 yo
17 to prevent 1
serious fall
injury
1 yr
Source: DPP & Robertson, 2001 BMJ
NNT, cont
18
Patient
19
ßß
Condition
specific skills
and
information
Condition
specific skills
and
information
Condition
specific skills
and
information
Condition
specific skills
and
information
Condition
specific skills
and
information
Condition
specific skills
and
information
Condition
specific skills
and
information
Condition
specific skills
and
information
Self-management
education
20
HealthyCommunities and Supportive Family, Friends, andCaregivers
Honorculture
Develop sharedunderstanding
Use Self-management Support Core Techniques:Goal Setting, Action Planning,
Problem solving, Follow-up
Stepped Care for Self-management Support
Provide Advanced Approaches(MI, Case Mgmt, PST, Group Interactions, etc.)
Offer ExpertMethods
Promote activeself-management
Based on the work of the Indian Health Service Improving Patient Care Self-management Support Workgroup and Division of Diabetes Treatment Program with input from the British Columbia Ministry of Health Services Patients as Partners Committee and ImpactBC, 2011.
21
What constitutes our culture?
Four Corners
22
Traditionalists(born before 1945)
Baby boomers (1945-1961)
Generation X (62-80)
Generation Y (81-2000)
Four Corners – Generations
23
› What do we say about those from your generation?
› What would you want others to know about people of your
generation?
› How do you think being from this generation impacts your
approach health?
Discussion questions
24
First Nations, Metis and Inuit
Grandparents or earlier immigrated = third + generation
parents immigrated = second generation
You immigrated = first generation.
Four Corners – Longevity in Canada
25
› What are some of the things we grow up knowing and
believing?
› What would you want others to know about being from this
group?
› How do you think being from this group impacts how you
approach health?
Discussion Questions
26
Eldest
Middle
Youngest
Only
Four Corners – Birth Order
27
› What are the stories we tell about birth order?
› What would you want others to know about being from this
group?
› How do you think being in this birth order impacts how you
approach health?
Discussion Questions
28
City
Suburb
Small town
Rural/Remote
Four Corners - Residence
29
› What do we say about where people live? What are city
people like? Those who live in the suburbs? Small towns, rural
locations?
› What would you want others to know about being from this
group?
› How do you think living where you do impacts on how you
approach health?
Discussion Questions
30
� What surprised you about this activity?
� How could you use this in a learning session?
Four Corners - Reflection
31
� Culture is a way of life of a group of people—the behaviors,
beliefs, values, and symbols that they accept, generally without
thinking about them, and that are passed along by communication
and imitation from one generation to the next.
› New Dictionary
What is culture?
32
Honour culture
33
Cultural humility is a lifelong commitment to self-evaluation and self-
critique... and to developing mutually beneficial and non-paternalistic
clinical and advocacy partnerships with communities on behalf of
individuals and defined populations.
› Tervalon & Murray Garcia, 1998
What is cultural humility?
34
� Maintain control of the interaction
� Have a pre-session
› After introducing yourself to the patient, introduce yourself to the untrained interpreter
› Ask them to interpret everything the pt. says exactly (no “he said” or “she said”)
› Have them position self behind and to the side of the pt.
Tips for using non-professional interpreters
Cross Cultural Health Care program, video available www.xculture.org/
35
� Speak to the patient, not the interpreter
� Insist that everything be interpreted
› No side conversations
› Understand there may be no exact equivalent in the
language or culture
� Speak in short sentences at moderate pace
› One question at a time
› Avoid jargon
› Avoid slang
Cross Cultural Health Care program, video available www.xculture.org/
Interpreters, cont.
36
� Check for understanding
� Ask questions about cultural beliefs and traditional treatments
� Stay positive
Your efforts will save you time in the future by avoiding
misunderstandings
Cross Cultural Health Care program, video available www.xculture.org/
Interpreters, cont.
37
E = Explanation (How do you explain your illness?)
T = Treatment (What treatment have you tried, want
to try?
H = Healers (Have you sought advice from any
healers?)
N = Negotiate options (AND instead of OR)
I = Agreed on interventions
C = Collaboration (with patient, family and healers)
American Association of Medical Colleges, 2005
Model of Effective Cross-Cultural
Communication and Negotiation
38
� Cultural safety online modules:
http://web2.uvcs.uvic.ca/courses/csafety/mod1/index.htm
� PHSA Indigenous Cultural Competency Training
http://www.culturalcompetency.ca/ (no charge for HA staff)
� Medical Assistants addressing culture videos
http://www.vimeo.com/15822032
Resources
39
HealthyCommunities and Supportive Family, Friends, andCaregivers
Honorculture
Develop sharedunderstanding
Use Self-management Support Core Techniques:Goal Setting, Action Planning,
Problem solving, Follow-up
Stepped Care for Self-management Support
Provide Advanced Approaches(MI, Case Mgmt, PST, Group Interactions, etc.)
Offer ExpertMethods
Promote activeself-management
Based on the work of the Indian Health Service Improving Patient Care Self-management Support Workgroup and Division of Diabetes Treatment Program with input from the British Columbia Ministry of Health Services Patients as Partners Committee and ImpactBC, 2011.
Develop Shared Understanding
41
“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (I.O.M, 2004)
Health Literacy is:
42
“the ability to access, understand, evaluate and communicate
information as a way to promote, maintain and improve health in a
variety of settings across the life-course” (Rootman and Gordon-El-
Bihbety, 2008)
Health Literacy is:
43
“The ability of professionals and institutions to communicate effectively so that community members can make informed decisions and take appropriate actions to protect and promote their health.”
adapted from Rootman and Gordon-El-Bihbety, 2008 and Health and Literacy Partnerships, Focus on Basics, World Education, Vol. 9, Issue B, September, 2008.
But there is another important component:
44
Health Literacy: A Prescription to End Confusion, Institute of Medicine, 2004
� Health literacy emerges when the expectations, preferences and
skills of individuals seeking health information and services meet
the expectations, preferences and skills of those providing
information and services.
Health literacy is a state of being…
45
How can you help people experience what having low health literacy is like?
46
I had a pain in my stomach. The doctor did some tests.
He said I had a blgrkrdmr.
I didn’t understand the word he used.
I asked him, “What is a blgrkrdmr?”
He said it was a grtiytuhr of the ptorjfmbtgbba.
I still didn’t understand.
He asked me, “Do you understand?”
I just said yes. Source: Literacy Partners of Manitoba
47
Tiny.cc/k5h8d
Health Literacy Video Clip
48
A Bézier curve is a parametric curve important in computer graphics and related fields. Widely publicized in 1962 by the Frenchengineer Pierre Bézier, who used them to design automobile bodies, the curves were first developed in 1959 by Paul de Casteljau using de Casteljau's algorithm.
In the diagram above, a quartic Bézier curve is constructed using control points P0 through P4. The green line segments join points moving at a constant rate from one control point to the next; the parameter t shows the progress over time. Meanwhile, the blue line segments join points moving in a similar manner along the green segments, and the magenta line segment points along the blue segments. Finally, the black point moves at a constant rate along the magenta line segment, tracing out the final curve in red. The curve is a fourth-degree function of its parameter. t.
Source: Wikipedia, courtesy of Leona Gadsby
49
I am writing to you at this time to advise you that I have received a referral for your child to have a hearing test. The referral was dated Oct 21, 2010, upon receipt and is being held on the waiting list accordingly.
Doctor Smith has referred your son Bobby to me for a hearing test. I have put him on the waiting list.
Source: Literacy Partners of Manitoba
Letter from a specialist
50
This is to certify that the surgical procedure known as
____________ (name of operation), the reason why it is considered
necessary, its advantages and possible complications, as well as
possible alternative methods of treatment have been explained to
me by_________(name of Physician or Surgeon), and in light of the
information the anaesthetic deemed advisable, the operation stated
above and also to perform such additional procedures as may be
held to be therapeutically necessary on the basis of findings in the
course of the operation. Any tissues surgically removed may be
disposed of by the surgeon or the hospital in accordance with their
accustomed practice.
Consent Form
Source: Literacy Partners of Manitoba
51
I give permission for the surgeon, Dr._________, to operate on me.
During the operation, he/she
� May perform any other surgery that may be necessary
� May use any anaesthetic that may be necessary
� May dispose of any tissue that is cut out
Source: Literacy Partners of Manitoba
52
� The following passage simulates what a reader with low general literacy sees on the printed page
� Read the entire passage out loud as a group.
� You have 1 minute to read.
� Hint: The words are written backwards and the first word is “cleaning”
What Is It Like?
53
GNINAELC – Ot erussa hgih ecnamrofrep,
yllacidoirep naelc eht epat sdaeh dna
natspac revenehw uoy eciton na
noitalumucca fo tsud dna nworb-der edixo
selcitrap. Esu a nottoc baws denetsiom htiw
lyporposi lohocla. Eb erus on lohocla
sehcuot eht rebbur parts, sa ti sdnet ot yrd
dna yllautneve kcarc eht rebbur. Esu a pmad
htolc ro egnops ot naelc eht tenibac. A dlim
paos, ekil gnihsawhsid tnegreted, lliw pleh
evomer esaerg ro lio.
54
� How do you clean the capstan?
� Reflections on that experience:
So….
55www.hetemeel.com/einsteininform.php
56
Understanding Instructions
84%
8%
59%
57
Jargon is everywhere
58
� Health literacy office practice survey
� Teach Back (video)
� Plain Language check list
� Brown Bag medication review
Health Literacy Tools
59
The Health Literacy Umbrella
Health Problems & Risks
B e t t e r H e a l t h
Relationships Understanding
Developed by the Health Literacy in Communities Prototype Faculty:
Connie Davis, Kelly McQuillen, Irv Rootman, Leona Gadsby, Lori Walker, Marina Niks, Cheryl Rivard, Shirley Sze, and Angela Hoviswith Joanne Protheroe, July 2009. IMPACT BC.
Partnering
60
Easy to use survey
61
Plain Language-Checklist
Literacy Partners of Manitoba
62
Find anything you give to your patients
Check it out with the “Clear Doc” list
Let’s try it now!
63
Brown Bag Medication Review
Ohio Patient Safety Institute
• All meds, herbals, traditionals,
• OTC to visit in a bag
• Ask
• How do you take this medication?
• What is it for?
• Check refill dates
• Do you use any aides? (mediset,
blisterpack, etc.)
64
� After information or instruction has been given, say:
� “Could you tell me back what we just talked about to see if I was
able to make it clear?”
� “After you leave this appointment a family member or friend might
ask you what happened today. What are you going to tell them
about what you are going to do?”
� If teaching a skill, use “Show me.”
� “Show me how you are going to do this at home so I know if I was
clear.”
Try Teach Back
American Medical Association
65
Try using Teach-Back now
� Turn to someone seated next to
you
� Tell them how to get from your house to the post office
� Ask them a teach-back question
(can you tell me…so I know if I was clear)
� Repeat as needed
66
Reflections on Teach-Back
67Ley, Communicating with patients: Improving Communication, Satisfaction and Compliance. NYL Croom Helm, 1988,
68
Diabetic patients data for Past Two Years, courtesy of Dr James Hii
69
Literacy BC Health Literacy resources
www.literacybc.ca/PLRC/health_literacy.php
Simply
Putwww.cdc.gov/healthliteracy/pdf/Simply_Put.pdf
Health Literacy Missouri
www.healthliteracymissouri.org
Healthy Roads Media (examples of documents)
http://www.healthyroadsmedia.org/index.htm
Google:
Health Literacy Listserv
Plain Language Thesaurus (CDC)
Health Literacy Resources
70
HealthyCommunities and Supportive Family, Friends, andCaregivers
Honorculture
Develop sharedunderstanding
Use Self-management Support Core Techniques:Goal Setting, Action Planning,
Problem solving, Follow-up
Stepped Care for Self-management Support
Provide Advanced Approaches(MI, Case Mgmt, PST, Group Interactions, etc.)
Offer ExpertMethods
Promote activeself-management
Based on the work of the Indian Health Service Improving Patient Care Self-management Support Workgroup and Division of Diabetes Treatment Program with input from the British Columbia Ministry of Health Services Patients as Partners Committee and ImpactBC, 2011.
Promote Active Self-management
72
� Patient activation: a person’s ability to manage their health and
health care (Hibbard & Cunningham, 2008)
� Patient engagement: actions individuals take to obtain the
greatest benefit from the health care services available to them
(Center for Advancing Health, 2010)
Definitions
73
� Video of Dr Vic Montori, Mayo Clinic
http://www.youtube.com/watch?v=flcRKdoaiVk
Minimally Disruptive Medicine
74
Personalizing care
75
Activation
Accepting role
Gaining knowledge and skills
Using skills to manage health
Use skills under stressHibbard, Hlth Serv Rsch, 2004
76
Professionals match what they do to
activation level
Accepting role: peer interactions, stories, linking behavior to health status, analogies, skills to understand the patient (open-ended questions, reflections, summaries, listening)
Gaining knowledge and skills: clear language
information, programs, training, action plansabout current behavior
Using skills to manage health: goal setting, action planning, problem solving, follow-up new behaviors. Motivational support!
Use skills under stress:Problem-solving
77
Prepare
keep track
report
list
Ask
Repeat
Take Action
Take PART
Chronic Disease Self-Management Program, Stanford University
78
Thoughts about patient activation and the PSM module?
78
79
Lunch
LUNCH
79
80
HealthyCommunities and Supportive Family, Friends, andCaregivers
Honorculture
Develop sharedunderstanding
Use Self-management Support Core Techniques:Goal Setting, Action Planning,
Problem solving, Follow-up
Stepped Care for Self-management Support
Provide Advanced Approaches(MI, Case Mgmt, PST, Group Interactions, etc.)
Offer ExpertMethods
Promote activeself-management
Based on the work of the Indian Health Service Improving Patient Care Self-management Support Workgroup and Division of Diabetes Treatment Program with input from the British Columbia Ministry of Health Services Patients as Partners Committee and ImpactBC, 2011.
Patient-self management support:
Core Techniques
82
� Demonstrate making an action plan
� Experience problem solving
� Consider how to work into daily practice
Objectives for this section
83
1. Individual-centered
2. Collaborative
3. Respects right of not changing
4. SMART
5. Commitment statement
6. Behavioral menu
7. Measure confidence
8. Follow-up
9. Occurs in every interaction
9 Core Principles & the Evidence Base
84
Action planning is individual-centered, i.e. what the person wants,
not what he/she is told to do.
“Spirit” of Motivational Interviewing: Evocation
Core Principle #1
Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, Guilford Press, 2002
85
• Work in pairs, not with your boss or supervisor
• Speaker: Think of something you are considering, something you
are thinking about changing in your life but definitely haven’t
decided. It might be something you think will be good for you or
that you should do. Something you feel comfortable sharing. Tell
this to your partner.
Persuasion
86
Partner: your task is to try as hard as you can to convince the
speaker to make the change they are considering. Do these five
things:
1. Explain why they should make the change
2. Give at least three specific benefits that would result from
making the change
3. Tell the person how they should make the change
4. Emphasize how important it is for them to make the change.
This might include the negative consequences of not doing it.
5. Tell the person to do it.
Persuasion, cont.
87
Debrief
What did the speaker feel or think while
their partner was talking to them?
88
• Work with one other person
• Not with your boss or supervisor
• One will be the speaker and the other
will be the listener
– If time permits, you can reverse
roles.
– Subject: something you are
ambivalent about
A Taste of MI
89
• TOPIC: something about yourself that you
– Want to change
– Need to change
– Should or ought to change
– Have been thinking about changing
• But you haven’t changed yet
– i.e., something that you are ambivalent about
The speaker
90
• Listen carefully with a goal of understanding the dilemma
• Give no advice
• Ask these four open-ended questions:
– Why would you want to make this change?
– How might you go about it, in order to succeed?
– What are the three best reasons for you to do it?
– On a scale from 0-10, how important would you say it is for you to make this change?
• Why is it a ___ and not a zero?
The listener
91
Debrief
What did the speaker feel or think while
their partner was talking to them?
92
Action planning is collaborative.
“Spirit” of Motivational Interviewing: Partnership
Core Principle #2
Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, Guilford Press, 2002;
Heisler et al, JGIM, 2002
93
After the plan has been formulated, the clinician/coach elicits a final
“commitment statement.”
Strength of the commitment statement predicts success on action
plan.
.
Core Principle #3
Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, Guilford Press, 2002
94
Action Planning is “SMART”: Specific, Measurable, Achievable,
Relevant and Timed
.
Core Principle #4
Based on the work of Locke (1968) and Locke & Latham (1990,
2002); Bodenheimer, 2009
95
After the plan has been formulated, the clinician/coach elicits a final
“commitment statement.”
Strength of the commitment statement predicts success on action
plan.
Core Principle #5
(Aharonovich, 2008; Amrhein, 2003)
96
Offer a behavioral menu when needed or requested
“Spirit” of Motivational Interviewing: Autonomy
Core Principle #6
Rollnick, Miller & Butler, 2008. Motivational Interviewing in Health Care
97
“Here are the things we have talked about. Which one is most important to work on right now?”
Behavioral Menu
Smoking
Avoidingtriggers
Exercise
Taking meds
(write others
here)
Adapted from Stott et al, Family Practice 1995; Rollnick et al, 1999, 2010
98
There are many things people do to improve their health. Here are some things you might want to talk to your health care team about.
�Consider the items in circles and add other concerns in the blank circles.
Monitoringyour health Taking medications
Eating habitsMood
Smoking
Activity
Avoidinghealth
problems
MeaningfulActivities
99
Confidence levels are evaluated and problem-solving utilized for confidence levels less than 7.
Higher self-efficacy is associated with healthier behaviors and better outcomes.
Core Principle #7
(Bandura, 1983; Lorig et al, Med Care 2001; Bodenheimer review, CHCF 2005; Bodenheimer, Pt
Ed Couns 2009.)
100
People’s beliefs about their capabilities to perform specific behaviors and their ability to exercise influence over events that affect their lives. Self-efficacy beliefs determine how people feel, think, motivate themselves and behave.
» Albert Bandura
Self-efficacy
101
Action planning includes arranging follow-up or other accountability.
Core Principle #8
(Resnicow, 2002; multiple condition specific studies)
102
Action planning is considered in all chronic, planned, or preventive
visits.
Non-physician staff are 9 times more likely to engage in goal-setting
than clinical staff. Technology (such as howsyourhealth.org) is
an option.
Core Principle #9
(Bodenheimer, 2009)
103
Other possibilities to demonstrate the principles?
104
Brief Action Planning (B.A.P.)
““““Is there anything you would like to do for your health In the next week or two?””””
““““How confident (on a scale from 0 to 10) do you feel about carrying out your plan?””””
““““When would you like to check in with me to review how you are doing with your plan?””””
Steven Cole, et. al.
SMART Behavioral Contracting Elicitation of Commitment Statement
If Confidence >7
105
Brief Action Planning (B.A.P.)
““““Is there anything you would like to do for your health In the next week or two?””””
““““How confident (on a scale from 0 to 10) do you feel about carrying out your plan?””””
““““When would you like to check in with me to review how you are doing with your plan?””””
Steven Cole, et. al.
SMART Behavioral Contracting Elicitation of Commitment Statement
If Confidence <7, problem solve barriers
Behavioral
Menu
Behavioral
Menu
106
1. Identify the problem.
2. List all possible solutions.
3. Pick one.
4. Try it for 2 weeks.
5. If it doesn't’t work, try another.
6. If that doesn't’t work, find a resource for ideas.
7. If that doesn't’t work, accept that the problem may not be solvable now.
Problem solving
Source: Lorig et al, 2001
107
Ways to teach problem-solving
108
� When?
› They ask for information
› You ask permission to give it
� How?
› Ask what they already know
› Fill in any gaps or gently correct misunderstandings
› Concentrate on key messages
› Use Teach-Back
Tips for Giving Information
courtesy of Bill Miller, 2010
109
� When?
› They ask for information
› You ask permission to give it
› You qualify your advice to emphasize autonomy
� How?
› Offer several suggestions instead of one
› End with a question about something they have thought of on
their own
› Emphasize it’s their choice
Tips for Giving Advice
courtesy of Bill Miller, 2010
110
Pre-visit
preparation
Question 1: “Is there anything …?”
Behavioral
menu
SMART action plan
Commitment statement
Question 2: “How confident
are you…?”
Problem solving
Question 3: “When can we
follow-up...?”
Documentation
Follow-up
Fitting this into office flow
111
Artinian et al, Circulation 2010
Regular contact over time better than 1x intervention
Builds trusting relationship
If happens often in early stages of change, can decrease frequency as behavior more secure.
112
� Try a wide variety of methods, whichever patient prefers (in
person, phone, email)
� Make sure follow-up happens, patient trust can be destroyed by
missed follow-up
� Use outreach and community opportunities
� Can be done by self or with a family member
Tips for Follow-up/Accountability
113
� Healthy and don’t need a plan
� Not ready? Let them know you are ready when they are
� No ideas? Behavioral menu
� Ready? Make a plan
� Resistant? Use more advanced skills
Question 1: Is there anything...
114
� and 50% of the time, you ask Question 1 = 10 patients/day
� Of those
› 25% will not be ready or not need help or are healthy (2 pts.)
› 25% will easily make a plan
› 25% will need a behavioral menu
› 25% will need advanced skills
So, if you have 20 patients/day in clinic
115
� About 70% will follow through
� In a study of goal setting in office practice (half safety net, half
private practice), of 274 patients
› 83% made a plan
› 3 wks later, 86% remembered the plan
› Of those, 66% did at least part of the plan• Handley, 2006
Of those who make a plan...
116
Thoughts about teaching B.A.P.
117
Feedback sandwich
118
� What they liked about what they DID
� Your statement about what you liked that they DID
� What they thought could have gone better
� Your statements about what could have gone better
› keep it simple
� End with a positive comment
Feedback sandwich
119
HealthyCommunities and Supportive Family, Friends, andCaregivers
Honorculture
Develop sharedunderstanding
Use Self-management Support Core Techniques:Goal Setting, Action Planning,
Problem solving, Follow-up
Stepped Care for Self-management Support
Provide Advanced Approaches(MI, Case Mgmt, PST, Group Interactions, etc.)
Offer ExpertMethods
Promote activeself-management
Based on the work of the Indian Health Service Improving Patient Care Self-management Support Workgroup and Division of Diabetes Treatment Program with input from the British Columbia Ministry of Health Services Patients as Partners Committee and ImpactBC, 2011.
Break
Advanced Approaches
122
� Define motivational interviewing
� Describe the spirit of motivational interviewing
� Recognize change talk
� Demonstrate using complex reflections
Objectives for this section
123
Advanced Approaches
Motivational Interviewing
125
Has anyone taken a trip lately?
126
What MI is like?
127
It’s all about change!
128
• Change talk is any client speech that favors
movement in the direction of change
• Clinicians can learn to elicit more change talk from clients
• More change talk is linked to better outcomes
• Remember---DARN CATS
Change Talk
129
DESIRE to change (want, like, wish…)
ABILITY to change (can, could…)
REASONS to change (if…then)
NEED to change (need, have to, got to)
Preparatory Change Talk: DARN
130
COMMITMENT to change (intend, decide, promise…)
ACTIVATION (willing, ready, preparing…)
TAKING STEPS to change (started, tried…)
Mobilizing Change Talk: CATS
131
The MI hill
Pre-contemplation
Action
132
� When you hear sustain talk, do nothing.
� When you hear preparatory talk, drum
� When you hear mobilizing change talk, clap
Drumming for Change Talk
133
Reflections on Drumming for Change
Break and Activity
135
� Elaborate “Tell me more…”
� Affirm “You are the kind of person
who…”
� Reflect - simple or complex*
� Summarize “Let me see if I have this
right…”
*more on next slides
Responding to Change Talk: All EARS
135
136
� Stays close to the
speaker’s words
› repetition
› rephrase
Simple Reflections
137
Complex Reflections
Makes a guess
� Paraphrase and then continue
the paragraph
� Reflect feeling, metaphor
� Amplified reflection
� Double-sided reflection
138
� Speaker: Something you may not know about me
is … (a quality, trait or characteristic, not
something concrete!)
� Listener: give a simple reflection
� Speaker: respond with a Yes or No
� Listener: give a complex reflection
� Speaker: respond naturally to the reflection
� Observers: coach the listener as needed
Forming Reflections
139
What is going on here?
140
• Partnership (formerly Collaboration)Provider and client equal
• EvocationIdeas for change come from the client
• Acceptance (formerly Respect for Autonomy)Client has the right to change or not
• CompassionActing for the other person’s welfare
*Clinician’s global MI Spirit adherence ratings strongly predict patient outcomes
The Spirit of Motivating People for
Change
Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, Guilford Press, 2002; Miller & Rollnick, MINT, 2011
141
a person-centered counseling method for addressing the common problem of ambivalence about change.
-Miller, 2010
What is Motivational Interviewing?
142
1991 2002 2012
3 ed.
143
• MI books in 19 languages
• 11 books on MI published
• >200 outcome trials, 10 multisite trials
• meta-analyses & Cochrane review
• >800 publications, doubling every 3 years
• >1200 trainers in at least 38 languages
• State- and nation- level implementation
• used in substance use, corrections, human
resources, education, health…
Current Status
Courtesy of Wm. Miller
144
The Interaction Sequence
1. Engaging
2. Focusing
3. Evoking
4. Planning
Courtesy of Wm. Miller
145
� Awareness
� Exposure training
� Skills acquisition
� Experience and coaching/feedback
� Training experience and coaching/feedback
� Motivational Interviewing Network of Trainers
About training in MI
146
• Books:
– Motivational Interviewing in Health Care. Rollnick, Miller and
Butler, 2009, Guildford Press.
– Motivational Interviewing, Miller & Rollnick, 3 ed. due in 2012
• www.motivationalinterviewing.org
• www.cmirti.org
Selected Resources
147
Key messages about MI for physicians
148
Next Steps
149
(you may wish to move into RST specific groups for this discussion)
� What are your next steps with the GMV/HL/PSM module?
� Which of the activities/resources used today will you try?
� What additional support do you need?
Table discussion – 20 min
150
� One person from each RST please share:
› One this your can give the group moving forward?
› One thing you would like to receive to help you move forward
Gives and Gets
Evaluation