UB-PAP (“Ultra-Brief Personal Action Planning”)

and Motivational Interviewing:

A Comprehensive Approach to Patient Activation

and Self-Management Support

Steven Cole, MD, Professor of Psychiatry,

Stony Brook University Health Center

Rural Quality Program Conference, Office of Rural Health Policy Health Resources Services Administration

September 1, 2009

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DISCLOSUREDISCLOSURE

Consulting Relationships• Magellan Health Services (2006-2008)

Other Financial Relationships• Principal, Comprehensive Motivational Interventions

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OutlineOutline

• The Problem

– Chronic Illness and the Quality Chasm

– Health Behaviors In Chronic Illness

– Linkages/Mental And Physical Health

• Changing The System Of Care/ Chronic Care Model

• Patient Self-Management in the Chronic Care Model: New Theory

– UB-PAP

– 6As

– MI

• CMI = Comprehensive Motivational Interventions

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Institute of Medicine Quality Report:Institute of Medicine Quality Report:Description of the ProblemDescription of the Problem

http://www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument

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High Prevalence of Chronic Conditions

> 33% have chronic illness (100 M)

> 20% have CV disease (64 M)

> 12% have arthritis (37 M)

> 6% have diabetes (17-18 M)

> 5% have asthma (15 M)

> 5% have depression (15 M)

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Current Gaps in CareCurrent Gaps in Care

• 25% of depressed pts

receive adequate treatment

• 50% of CHF patients

readmitted in 90 days

• 30% of persistent asthma pts

on maintenance inhalers

• 29% of diabetics have well controlled lipid levels

• 26% of diabetics have well-controlled BP

• 35% of eligible atrial fibrillation pts receive anticoagulation

• 27% of people with high BP adequately treated

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BIO-PSYCHO-SOCIAL Model of Illness:Behavior Contributes to the

Onset, Course, and Outcome of All Chronic Illness

Diabetes

Heart Disease

Obesity

Asthma

Alcoholism

Depression

Hypertension

COPDOver-Eating

Risky DrinkingSmoking

Sedentary LifestyleNon-Adherence

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Risky Health Behaviors (Conditions)

• 20% of pop. are harmful/risky drinkers

• 33% of adults get inadequate exercise

• 33% of population are obese

• 25-50% of pop. with chronic illness do not take medications regularly

• > 400,000 deaths/year due to smoking

• 16% of pop. have lifetime major depression

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How Common is Patient Non-adherence?

• >80% patients given advice about lifestyle change DO NOT follow this advice

50% of patients with chronic ill DO NOT take their medications as prescribed

50% of cardiac pts DO NOT complete rehab 20%-30% of patients prescribed curative

medications (ie, antibiotics) DO NOT take their meds as prescribed

Haynes et al, 1979; Meichenbaum and Turk, 1987; DiMatteo et al, 1994; Clark & Becker, 1998

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How Common is Clinician Non-adherence?

• Clinicians ask smokers about smoking status only 50% of the time

• < 1/3 provide counseling/follow-up for smokers

• < 10% of visits include patients in decision-making

• Clinicians promote diabetic self-management only 50% of the time

Goldstein et al, 1997; 1998;Throndike et al, 1999; Braddock et al 1999; Glasgow et al, 2000

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Consequences of Non-Adherence

• In diabetes– Nonadherent patients had higher HgA1C,

higher BP, and higher LDL– Nonadherent patients had increased all cause

hospitalization (OR = 1.58, p<.001) and all cause mortality (OR = 1.81, p<.001)

• After myocardial infarction– Pts who discontinue meds after MI have

higher mortality (OR = 3.81)

Ho et al, Arch Int Med, 2006

Ho et al, Arch Int Med, 2006

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Why Are Our Health Outcomes So Poor?Why Are Our Health Outcomes So Poor?

““Systems are perfectlySystems are perfectly designed to get the designed to get the

results they achieve” results they achieve”

Don Berwick, IHI

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Institute of Medicine Report: Crossing the Quality Chasm

“Current care systems cannot do the job.”

“Trying harder will not work.”

“Changing care systems will.”

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CommunityCommunityHealth SystemHealth System

Organization of Health CareOrganization of Health Care

Self-Self-Management Management

SupportSupport

DecisionDecisionSupportSupport

DeliveryDeliverySystemSystemDesignDesign

ClinicalClinicalInformationInformation

SystemsSystems

A Model for Improving Chronic Illness Care*

Prepared,Proactive

Practice Team

Informed,Activated

Patient

Productive Interactions

Functional and Clinical Outcomes*E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound

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What is Self-Management?

“The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition”

Barlow et al, Patient Educ Couns 2002;48:177

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What Is Self-Management Support (SMS)?

• “The systematic provision of education and supportive interventions by the health care system to increase patients’ skills and confidence in managing their health problems, including:– regular assessment of progress and problems, – goal setting, and

– problem-solving support.”

• Emphasis on the patient’s central role in managing his or her own illnesses

Institute of Medicine, USA, 2003

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SMS Is Not Education!

Education• Begins with provider

determination of need• Information and technical skills

are taught• Usually disease-specific• Assumes knowledge leads to

behavior change (false)• Goal is compliance• Teachers are always

professionals

SMS

• Begins with the patient’s self-identified problems

• Problem-solving skills are taught

• Skills are generalizable• Assumes self-efficacy leads

to change (true)• Goal is more self-efficacy• Teachers can be

professionals or peers

Bodenheimer et al JAMA 2002;288:2469

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Evidence-Base: SMS Works

• Arthritis– SMS improves health and reduces costs

• Lorig, Medical Care 1999

• Diabetes– SMS lowers HbA1c (meta-analysis of 31 RCTs)

• Norris, Diabetes Care 2002; 25:1159

• Asthma– 7 of 11 RCT shows SMS improves outcomes

• Bodemheimer, JAMA, 2002; Calif. Healthcare Foundation, 2005

• General dietary modifications– SMS improves outcomes (104 RCTs)

• Ammerman, Preventive Medicine, 2002

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6 A’s of SMS6 A’s of SMS

Adapted by Cole, from Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87

ASSESS:Client’s goals, beliefs, knowledge,conviction, confidence, readiness

ADVISE:Share

information abouthealth risks and

benefits of change

AGREE:Collaboratively set

goals based on clients’ preferences, conviction and confidence in their ability to

change or self-manage

ASSIST:Identify barriers, build strategies to problem-

solve and engage social support

ARRANGE:Specify plan for

follow-up (e.g., visits,phone calls, mailed

reminders)

Personal Action Personal Action

PlanPlan1. List specific goalsgoals

in behavioral terms

2. Determine confidence confidence

levellevel

3. Specify follow-upfollow-up plan

ALLY:Build relationship, Address emotions

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UB-PAP: Ultra-Brief Personal Action Planning

• Highly-focused method (3 question framework) to

support pt. self-management in limited time

– Assess, Agree, Arrange (3 As)

• Patient generates his/her action plans

• Behaviorally specific planning

• Motivates transition from contemplation/preparation to

action

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UB-PAP: What is the Evidence-Base?

Self-Management Research

Self-Efficacy Research

Motivational Interviewing Research

‘Transtheoretical’ Stage of Change Research

Rogerian Psychology Research

Operant Conditioning Research

Cognitive-Behavioral Theory/Therapy Research

A-theoretical Psychotherapy Research

A-theoretical Communication Research

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UB-PAPUltra-Brief Personal Action Planning

Three question framework:

1. “Is there anything you would like to do for your health before we talk again?” (what, when, where, how often?) (Ask patient to restate plan.)

2. “We all have trouble meeting our goals, what is your level of confidence you will be able to carry out this plan?” (if <7, help patient problem-solve)

3. “When would you like to come back to discuss how the plan has gone?”

Cole, unpublished document, 2005

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Categorical Responses to Question One:Rule of Quarters*

“Is there anything you would like to do for your health?”

• Category 0 (about 25%) = “Not really; things are OK”– OK from general health (and clinician’s) point of view

• Category 1 (about 25%) = “Ok, I think I should….”– Patient develops concrete, specific plan

• Category 2 (about 25%) = “I’m not sure, what should I do?”– Patient would like menu and/or suggestions

• Category 3 (about 25%) = “Sure, but nothing works.”– Patient has refractory behavior; ambivalence, resistance

*Rule of Quarters is very rough approximation based on anecdotal experience, reports from colleagues, and unsystematic clinical experience with >500 patients in Dr. Cole’s medical-psychiatry practice over 5 years

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Category Zero Response

• MD: Is there anything you would like to do for your health?• Pt: No, not really. There’s really not anything I can do.

MD point of view: Pt’s lack of interest in behavioral plan is relatively adaptive given his/her current state of health.

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Category One Response

• MD: Is there anything you would like to do for your health?

• Pt. Sure, I would actually like to…..

• MD: Help patient make plan concrete and specific

– What?

– Where?

– How often?

– How long?

• MD: Ask for commitment statement

– Great, sounds like a plan. So, would you mind repeating back what it is that

you have decided to do?

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Category Two Response

• MD: Is there anything you would like to do for your health?

• Pt: Sure, but I really don’t know what to do. What should I do?

MD: Ask permission to share ideas/information

Use Menu of Bubble-Diagram

Elicit concrete and specific action if patient desires

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MENU or BUBBLE DIAGRAM

Here are some things many individuals like to do for their health. Would you like to set some goals for any of them?

Monitoring your health Taking medications

consistently

Eating betterMood

Smoking

Regular exerciseAvoiding healthproblems

MeaningfulActivities

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MENU or BUBBLE DIAGRAM

If you have diabetes, here are some things many individuals try to do for their health. Would you like to set any goals concerning any of them?

Blood glucose monitoring

Taking medications to help control blood sugar

Losing weight

Daily foot care

Depression

Smoking

Skin careTaking insulin

Diet

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Category Three Response

• MD: Is there anything you would like to do for your health?

• Pt: I don’t know; nothing I ever try seems to work. I just

don’t know what to do.

MD: Use Motivational Interviewing Skills

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1991 2002

Courtesy of Bill Miller

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MI Publications by YearMI Publications by Year

Courtesy of Bill Miller

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MI Outcome Studies by Era

020406080

100

1988-94 1995-99 2000-02 2003-06

Alcohol Drugs Dual Dx GamblingOffenders Eating Dis Adh/Retention SmokingHIV Risk Cardiac Diabetes PsychiatricHealth Prom Family Violence AsthmaDental

Courtesy of Bill Miller

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MI Trainers and Translations

• AfrikaansAfrikaans• BulgarianBulgarian• ChineseChinese• CroatianCroatian• CzechCzech• DanishDanish• DutchDutch• EnglishEnglish• EstonianEstonian

• PolishPolish• PortuguesePortuguese• RomanianRomanian• RussianRussian• Sign (U.S.)Sign (U.S.)• SlovenianSlovenian• SpanishSpanish• SwedishSwedish• SwissSwiss

FrenchFrench GaelicGaelic GermanGerman GreekGreek HebrewHebrew ItalianItalian JapaneseJapanese KoreanKorean NorwegianNorwegian

Courtesy of Bill Miller

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Current Status

• MI book translated in 16 languages

• 10 other books on MI published

• >180 outcome trials, 10 multisite trials

• >800 publications, doubling every 3 years

• >1200 trainers in at least 27 languages

• State- and nation- level implementation

Courtesy of Bill Miller

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Meta-Analyses of MIMeta-Analyses of MI

• Hettema, Steele, Miller: Ann Rev Clin Psychology, 2005

• Rubak, Sandbeck, Lauritzen, Christensen: Brit Journal Gen Practice, 2005

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Meta-Analyses of MI

• Hettema, Steele, Miller: Ann Rev Clin Psychology, 2005

• Rubak, Sandbeck, Lauritzen, Christensen: Brit Journal Gen Practice, 2005

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ResultsResults

72 RCTs

1. Overall, ¾ studies positive

2. Strong effect sizes for alcohol

3. Modest effect for BMI, BP, cholesterol

4. No effect (yet) for smoking or HgA1c

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Results (con’t)Results (con’t)

5. Manualized MI programs appear to be less effective than non-manualized

6. MI especially effective with clients who are more angry and resistant, or less ready for change. Conversely, MI may be less suitable for clients who are already committed to change and ready for action.– Ahluwalia, Addiction, 101, 883, 2006– Bill Miller, “MI is not for everyone” Interlaken, 2008

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Results (con’t)Results (con’t)

7. BEST predictor of behavioral follow-

through is statement of commitment

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Motivational Interviewing: For Challenging/Less Ready to Change Behaviors

Definitions:

Miller WR, Rollnick S: Motivational Interviewing, 2002• We define motivational interviewing as a

client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

Rollnick S, Miller WR, Butler, CC: Motivational Interviewing in Health Care, 2007• Motivational interviewing is a …skillful clinical style for

eliciting from patients their own good motivations for making behavior change in the interest of their health.

• Motivational interviewing is a refined form of the familiar process of guiding…(vs. directing).

Miller WR, Rollnick S: Sitges, Spain, June 2009• MI is a collaborative, person-centered form of guiding to elicit and strengthen

motivation for change.

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Spirit of Motivational Interviewing

• Collaboration– Provider and patient equal

• Evocation– Ideas for change should come from patient

• Respect for Autonomy– Patient has the right to change or not

Clinicians’ global MI Spirit adherence ratings Clinicians’ global MI Spirit adherence ratings strongly predict client outcomesstrongly predict client outcomes

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Motivational Interviewing: 4 Core Principles

Miller WR, Rollnick S: Motivational Interviewing, 2002

• Roll with resistance • Develop discrepancy• Express empathy• Develop self-efficacy

Rollnick S, Miller WR, Butler CC:

Motivational Interviewing in HealthCare,

2007

“RULE”

• Resist righting reflex• Understand motivations• Listen empathically• Empower the patient

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MI Interventions for Category Three Response

Basic Interventions: OARS1. O = open-ended questions2. A = affirmations3. R = reflections4. S = summaries

Complex Interventions5. Roll with resistance/resist the righting reflex6. Elicit and clarify ambivalence7. Develop discrepancies

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““Doing” MI: ABCsDoing” MI: ABCs

• A ttitudes – elicit ideas about change (‘change talk’)

• B arriers – explore barriers/ambivalence

• C onvey understanding – express empathy

• D ata – share information

• E mphasize positives – affirm strengths

• F acilitate action planning (UB-PAP)

Cole, unpublished document

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Comparison of SMS and MI

SMS

Strong Evidence-Base

Patient-Centered

Builds Self-Efficacy

Relatively Non-Directive

Universally Appropriate

High Face Validity

Straightforward

(UB-PAP or 6 As)

MI

Strong Evidence-Base

Patient-Centered

Builds Self-Efficacy

Directive (Guiding)

Selectively Appropriate

Subtle

Complex

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Stage of Change ModelProchaska & DiClemente (1992)

1. PRECONTEMPLATION

2. CONTEMPLATION

3. PREPARATION

4. ACTION

5. MAINTENANCE

Stages of Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

Relapse

Stage of Change “Principles”

• Motivation exists along a continuum of readiness

• Stages occur in a spiral/circle (not linear)

• Interventions must be congruent w/stage of change

• Nonaligned effort ↑ resistance/ambivalence

• Recurrence or regression is common

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UB-PAP and Stage of Change Theory

Question One of UB-PAP

• Patients “at” contemplation/preparation are most ready to make action plans and require only basic level motivational skills to elicit action plan

(Category One and Two Responses)

• Patients “at” pre-contemplation or earlier levels of contemplation benefit from more complex, MI skills

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Comprehensive Motivational Interventions©

1. Early introduction of UB-PAP2. “Back-fill” with other 3 As as needed

• Ally (Cole, The Medical Interview: Three Function Approach)

• Reflection – “You seem upset”• Legitimation – “I can understand why you would feel…”• Support – “I am here to help”• Partnership – “We can solve this problem together”• Respect – “I’m impressed by the way you’re handling…”

• Advise• Assist

3. Use MI skills as needed

© Comprehensive Motivational Interventionswww.ComprehensiveMI.com

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Pilot EvidencePilot Evidence

Ultra-Brief Personal Action Planning (UB-PAP) and Motivational Interviewing: A Prospective, Controlled Pilot Efficacy Study of Stepped-Care Health Coaching

Cole S, Waxenberg F, McCarthy D, McClure T, Majesky SJ, Lee FC

Abstract presented at First International Conference on Motivational Interviewing: Interlaken,Switzerland, June 2008.

Controlled, prospective study of telephonic health coaching intervention• 269 employees at two sites (one intervention, one control) of one

employer • 16% improvement in HWB scores at intervention site (p<.05) and no

significant improvement at control site– 73% of all PAPs were completely or at least 50% fulfilled– Average weight loss = 6.6 lbs– 58% of employees went from sedentary lifestyle to moderate levels

of exercise– Average increase in exercise = 144 minutes/week

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SUMMARY: New, Integrative Theory of SMS

• UB-PAP– Short form on 5As (6As)– Adaptation of MI (aligned with the Spirit)– May lead to action plans in 25-50% of patients

• Other Three “As” added as needed• MI is a complex form of SMS most suited for

resistant patients or patients with chronic, refractory maladaptive behaviors

• UB-PAP + 3As + MI = CMI

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For Further Investigation

• www.motivationalinterviewing.org

• www.comprehensiveMI.com

• www.stevencolemd.com