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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

[email protected]

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



• 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:


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?


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?



• 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’


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.


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!


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!


Would you mind giving me a quick summary of

what we discussed on how to handle your insulin

injections when you are very sick?


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!


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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