usual intervention: health professionals try to convince give information and advices”...

44

Upload: diane-dalton

Post on 26-Dec-2015

216 views

Category:

Documents


1 download

TRANSCRIPT

USUAL INTERVENTION:

Health professionals try to convince give information and

“advices”advices”:

WHYWHY patient must change…

WHATWHAT must change…

HOW HOW to change… !

1. Introducing a practical clinical tool facilitating the mentorship of patients in modifying behaviours

2. Structuring the clinical tool in an intervention platform that would be universally applicable to any behaviour change and may be used by any healthcare professional who is part of the healthcare team

3. Formatting the clinical tool to fit in a (realistic) short 3-minute intervention

Learning DynamicsLearning DynamicsLearning DynamicsLearning Dynamics

“ “BEHAVIOUR CHANGE”BEHAVIOUR CHANGE”

1) EVALUATION1) EVALUATION “Stage of Change” GOAL GOAL (Prochaska)

“Conviction – Confidence” TARGET TARGET (Miler Rollnick)

2) INTERVENTION:INTERVENTION:

“MOTIVATIONAL INTERVIEWING” (Negotiated Approach)

EVALUATION: Stages of changeEVALUATION: Stages of change

50%50%

20 - 30%20 - 30%

10 – 20%%10 – 20%%

5 – 10 %%5 – 10 %%

EVALUATION

STAGE:

“ “What would you think about…?What would you think about…? (Have you thought about …?) Taking your pills more regularly? Losing some weight? Changing your eating habits…? Doing more physical activities

Quitting smoking?”   

““I have tried walking every day. The temperature is horribleI have tried walking every day. The temperature is horriblein Quebec! Do you think a stationary bike or a treadmill would in Quebec! Do you think a stationary bike or a treadmill would be better?”be better?”

““I’ve lost 3 pounds in two months! On bad weather days, I goI’ve lost 3 pounds in two months! On bad weather days, I gowalking at the shopping mall…”walking at the shopping mall…”

““I am always alone; all my children live far away. Smoking is allI am always alone; all my children live far away. Smoking is allI have left…!”I have left…!”

““My grandfather died at the age of 94. He drank like a fish andMy grandfather died at the age of 94. He drank like a fish andsmoked like a chimney!”smoked like a chimney!”

““It’s not good to smoke, but if I quit, I gain weight. I’m replacing one It’s not good to smoke, but if I quit, I gain weight. I’m replacing one problem with another!”problem with another!”

““Drinking Scotch may not be good for my high blood pressure butDrinking Scotch may not be good for my high blood pressure butIt relaxes me coming back from work.”It relaxes me coming back from work.”

STAGES OF BEHAVIOURAL CHANGE

EXERCISES:1.

2.

3.

4.

5.

6.

1) STARTING POINT OUTCOME (next Stage)

2) TARGET:TARGET: TARGET:TARGET: Barriers ADVANTAGES Strategies

3) MEASURE (success failure) Immediate, Future

4) Determine « READYNESS »:

ADVANTAGES FOR USE IN PRACTICE:

Optimal use of Professional Consultation, Rx…

“BEHAVIOUR CHANGE”

1) EVALUATION “Stage of Change” GOALGOAL (Prochaska)

“Conviction – Confidence” TARGET (Miler Rollnick)

2) INTERVENTION:

“MOTIVATIONAL INTERVIEWING” (Negotiation Approach)

INTERVENTION’S TARGET:

“CONVICTION”:Recognizing the benefitsof changing a behaviour.

““If you decided to… how wouldIf you decided to… how would that benefit you?” that benefit you?”

“CONFIDENCE”:Sense of our ability

to modify a behaviour.

““If you really decided to… If you really decided to… do you think you could do it?”do you think you could do it?”

CO

NV

ICT

ION

CO

NV

ICT

ION

MOYENNNE:MOYENNNE: ABSTRAIT (CONNAISSANCES)« Ma santé serait meilleure, je vivrais plus vieux… Mon risque de maladie diminuerait, mon risque d’infarctus serait plus petit,Mon taux de cholestérol serait meilleur. »

0

10

6

3

Conviction:Conviction: “How would that benefit you…?”

AVERAGE: Abstract (Knowledge)

HIGH: Positive - Emotional - Personal

LOW: Absent or Abstract «May be… » … » 

Adapted Keller V et al. JCOM 1997. , , Miller WR et al. Guilford Press, 1991.

““Confidence”Confidence”““Confidence”Confidence”

CONFIDENCECONFIDENCE

LOW:LOW: Powerless feelingLOW:LOW: Powerless feeling

““If you really decided to…If you really decided to…do you think you could?”do you think you could?”““If you really decided to…If you really decided to…do you think you could?”do you think you could?”

HIGH:HIGH: Unwavering confidenceHIGH:HIGH: Unwavering confidence

Adapted Keller V et al. Journal of Clinical Outcomes Management 1997. Miller WR et al. Guilford Press, 1991.

IntegrationIntegration of the models of the models

IntegrationIntegration of the models of the models

CASE STUDY #1: Marc 60 YO

1) Myocardial infarction 2005 ( Angioplasty LAD) 2) Dyslipidemia 3) COPD: cough++ Shortness of breath 5/6

Medication: AAS 80, Atenolol 50, Atorvastatin 40 Combivent inh. PRN

Stable clinical conditionStopped ROH 4 years ago.

Smokes since age 12. Never made real attempt to stop.

CASE STUDY #1: Marc 60 YO

STAGEProfessional: “What do you think about quitting smoking?”Marc: “I will stop smoking eventually but I’m not ready yet.”

CONVICTIONProfessional: “If you decided to quit smoking, how would it

benefit you?”Marc: “My health would be better.” CONFIDENCEProfessional: “Do you think you could do it?”Marc: "Hey, I quit drinking 4 years ago. I know I could do it if

I set my mind to it."

INTEGRATED MODELSINTEGRATED MODELS

INTEGRATED MODELSINTEGRATED MODELS

CASE STUDY #2: Edith

Patient 43 years old referred for gain of weight of 60 pounds in 3 years without changing eating habits.Clinical and lab evaluation disclose no endocrine problem.

She was physically very active (gym 5 days a week) upto the buying of a small trucking business 3 years ago.She did not change significantly her eating habits.

She stopped all physical activities since 3 years, waking up at 5.30, she’s at work at 7.00 AM and works non stoptill 7.00 PM. Back home she eats and go bed early being totally exhausted. (3000 calories = 1 pound)

STAGEProfessional: “Have you thought about integrating physical activity Into your daily routine?”

Edith: “Yes, I’d like to be more active. I should be able to do more in about 6 months, by then we might be able to hire somebody to help with my work.”

CONVICTIONProfessional: “What good do you think it would do you to become physically active?”

Edith: “I could finally lose the weight that I’ve gained over the past 3 years. I used to work out 5 times a week. I was in shape and had a lot more energy. Those were the good old days.”

CONFIDENCE

Professional: “If you decided to get in shape now, do you believe you would be able to do it?”

Edith: “It’s impossible to do it right now. I have no help.”

CASE STUDY #2: Edith

INTEGRATED MODELSINTEGRATED MODELS

INTEGRATED MODELSINTEGRATED MODELS

Simultaneous multiple behaviours interventions:

1 Catalytic behaviours: Physical activity

2 Effect of simultaneous interventions: POSITIVE: - physical activity + diet, - physical activity +smoking cessation NEGATIVE: - diet: low salt (HBP) +

low calory (obesity) - Simultaneous alcool and smoking

cessation

3 Behaviour and pharmacology Medication Adherence

Intervention DIRECTIVE mode of communication when patient says: “YES BUT….” Patient convinces himself of the opposite!

«MOTIVATIONAL INTERVIEWING» Provoke perception of BENEFITS

(CONVICTION) Followed by solutions for BARRIERS (CONFIDENCE) WITH« OPEN - ENDED QUESTIONS »

« CONVICTION » INTERVENTION: increase

1MOTIVATE:

Provoke expression of benefits that are: POSITIVE - PERSONNAL - EMOTIONAL

«  How would it benefit you, If you decide to…  ?»

REFORMULATE - REINFORCE - REFOCUS

2INFORM:

Of the advantages if needed (with empathy).

CONCLUDING INTERVIEW:Information, Questions, Exercises…

INTERVIEW CONCLUSION: INTERVIEW CONCLUSION:

CONVICTION CONVICTION

• INFORMATIONS: (verbally or documentation) - reinforce Cognitive Conviction (4 - 6/10)

• QUESTIONS: “How does it benefit…?” - reinforce new stage: Cognitive Conviction (Contemplation)

- initiate travelling toward Affective Conviction (Preparation)

WHAT IF BARRIERS….?

Pre-Contemplation to Contemplation:

INTERVENTION: « CONVICTION »

« How DOES it benefit you…? »

BARRIER… ? “How WOULD it benefit You…? “How COULD it benefit You…?

BARRIER…? «BYPASS» : depersonalise « How could it benefit to SOMEBODY else…? »

BARRIER… ? Give pertinent informations (with empathy)…

CONTEMPLATION to PREPARATION:

• QUESTIONS: “How does it benefit…?”

provoque expression AFFECTIVE Conviction (7 – 9/10)

POSITIVE - EMOTIVE - PERSONNAL…

OR• CONFIDENCE: Barriers, Strategies….

INTERVIEW CONCLUSION: INTERVIEW CONCLUSION:

CONVICTION CONVICTION

CASE STUDY #1:CASE STUDY #1: Marc 60 YOMarc 60 YO

1) Myocardial infarction 2005 ( Angioplasty LAD) 2) Dyslipidemia 3) COPD: cough++ Shortness of breath 5/6

Medication: AAS 80, Atenolol 50, Atorvastatin 40 Combivent inh. PRN

Stable clinical conditionStopped ROH 4 years ago.

Smokes since age 12. Never made real attempt to stop.

CASE STUDY #1: Marc 60 YO

STAGEProfessional: “What do you think about quitting smoking?”Marc: “I will stop smoking eventually but I’m not ready yet.”

CONVICTIONProfessional: “If you decided to quit smoking, how would it

benefit you?”Marc: “My health would be better.” CONFIDENCEProfessional: “Do you think you could do it?”Marc: "Hey, I quit drinking 4 years ago. I know I could do it if

I set my mind to it."

« INCREASE CONVICTION »

Physician: “If you decided to stop smoking… what good do you think it would do you?”Patient : “I’d be healthier.”

Medicine : “What benefits would you enjoy by being healthier?”Patient : “I wouldn’t cough as much or be as short of breath.”

Medicine : “What other activities would you like to do if you weren’t so short of breath?”Patient : “My life would be completely different. The other day,

for instance, I tried to play with my grandchildren, but I had to stop after 30 seconds because I was out of breath. Also I could also go out and take trips.”

Reinforcement :“It would indeed be wonderful to be less short of breath and to do the things you enjoy most in life.”

CASE STUDY #1:CASE STUDY #1: Marc 60 YOMarc 60 YO

INTEGRATED MODELSINTEGRATED MODELS

CONCLUDING INTERVIEW: Questions to reinforce new stage or switch on “right”, (Barriers and strategies) to address Confidence and pass to Action

« CONFIDENCE »

Build on earlier SUCCESSES

1 « If you really decide to…

do you think you could do it? »

2« What would prevent you from…? »

« BARRIERS»

3« How do you think you can..? »

« STRATEGIES »

INTERVENTION: increase

CASE STUDY #2: Edith

Patient 43 years old referred for gain of weight of 60 pounds in 3 years without changing eating habits.Clinical and lab evaluation disclose no endocrine problem.

She was physically very active (gym 5 days a week) upto the buying of a small trucking business 3 years ago.She did not change significantly her eating habits.

She stopped all physical activities since 3 years, waking up at 5.30, she’s at work at 7.00 AM and works non stoptill 7.00 PM. Back home she eats and go bed early being totally exhausted. (3000 calories = 1 pound)

STAGEProfessional: “Have you thought about integrating physical activity Into your daily routine?”

Edith: “Yes, I’d like to be more active. I should be able to do more in about 6 months, by then we might be able to hire somebody to help with my work.”

CONVICTIONProfessional: “What good do you think it would do you to become physically active?”

Edith: “I could finally lose the weight that I’ve gained over the past 3 years. I used to work out 5 times a week. I was in shape and had a lot more energy. Those were the good old days.”

CONFIDENCE

Professional: “If you decided to get in shape now, do you believe you would be able to do it?”

Edith: “It’s impossible to do it right now. I have no help.”

CASE STUDY #2: Edith

Increase confidence 1) Provoke expression of BARRIERS by the patient:

Physician: “What prevent you from starting to exercise?”

Edith: “It’s impossible to do it right now. I get up at 5:30 a.m. and work until 7:00 in the evening. During the day, I don’t have a spare

moment. We don’t have the money right now to hire someone to help out.

Physician: “I see that you are extremely busy. Would you still like to look more closely at whether something could be done so that you can get back to how you used to feel when you were exercising?” Edith: “We can still do that but I already get up at 5:30 a.m. and work until 7:00 p.m. I cannot get up any earlier.”

CASE STUDY #2: Edith

INCREASE CONFIDENCE 2) Provoke expression of SOLUTIONS by the patient:

Physician: “Your days are very long. Do you think you would be less effective at work if we could find 20 minutes in the day to give to yourself as a gift to get you back in shape? You certainly deserve it.”

Edith: “That might be possible. I already have gym equipment in the basement, including a treadmill.”

Physician: “Than would it be possible to cut your day by 20 minutes in the afternoon and take this time to wind down on your treadmill?”

Edith: “Yes, that wouldn’t be too difficult.”

Physician: “Would you be willing to make the decision today to give yourself 20 minutes every afternoon and use your treadmill? We will revisit

this during the next visit. Edith: “Yes, that’s fine… I’ll start tomorrow.

We’ll see what becomes of it.”

CASE STUDY #2: Edith

INTEGRATED MODELS

CONCLUDING INTERVIEW: Negotiate an Action (even partial)

Simultaneous multiple behaviours interventions:1 Catalytic behaviours:

Physical activity

2 Effect of simultaneous interventions: POSITIVE: - physical activity + diet, - physical activity +smoking cessation NEGATIVE: - diet: low salt (HBP) +

low calory (obesity) - Simultaneous alcool and smoking

cessation

3 Behaviour and pharmacology Medication Adherence

3 Minute Empowerment and Royal College Physicians

Take Home messages:

1) Efficacious, targeted, personalised approach for behaviour change require determination of:

STAGE of change, GOAL (next stage) TARGET of intervention (Conviction,

Confidence). FEW SECONDS..! 2) Traditional DIRECTIVE (professional centered) approach (information + directives), leading to the “YES BUT…”

syndrome, should be avoided.

Take Home messages:

3) Motivational Interviewing (patient centered communication technique) reinforce and accelerate the movement along the path of change.

“ASK DONT TELL!”

Small step for the physicians Big step for the patients…!

« INITIATE A BEHAVIOURAL CHANGE IN 3 MINUTES; BREAK THE BARRIERS »

PALM  DOCUMENTS TO GO 

www.lemieuxbedard.com/emc