Transcript Motivational Interviewing

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
DISCLOSURE
Consulting Relationships
• Magellan Health Services (2006-2008)
Other Financial Relationships
• Principal, Comprehensive Motivational Interventions
2
Outline
• 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
3
Institute of Medicine Quality Report:
Description of the Problem
http://www4.nas.edu/onpi/webextra.nsf/
web/chasm?OpenDocument
4
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)
5
Current Gaps in Care
• 25% of depressed pts
receive adequate treatment
•
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
• 50% of CHF patients
readmitted in 90 days
• 30% of persistent asthma pts
on maintenance inhalers
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BIO-PSYCHO-SOCIAL Model of Illness:
Behavior Contributes to the
Onset, Course, and Outcome of All Chronic Illness
Diabetes
Hypertension
Heart Disease
COPD
Obesity
Depression
Over-Eating
Risky Drinking
Smoking
Sedentary Lifestyle
Non-Adherence
Asthma
Alcoholism
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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
8
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;
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DiMatteo et al, 1994; Clark & Becker, 1998
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 decisionmaking
• Clinicians promote diabetic selfmanagement only 50% of the time
Goldstein et al, 1997; 1998;Throndike et al, 1999; Braddock et al
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1999; Glasgow et al, 2000
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)
Ho et al, Arch Int Med, 2006
• After myocardial infarction
– Pts who discontinue meds after MI have
higher mortality (OR = 3.81)
Ho et al, Arch Int Med, 2006
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Why Are Our Health Outcomes So Poor?
“Systems are perfectly
designed to get the
results they achieve”
Don Berwick, IHI
12
Institute of Medicine Report:
Crossing the Quality Chasm
 “Current care systems cannot do the job.”
 “Trying harder will not work.”
 “Changing care systems will.”
13
A Model for Improving Chronic Illness Care*
Community
Health System
Organization of Health Care
SelfManagement
Support
Informed,
Activated
Patient
Decision
Support
Productive
Interactions
Delivery
System
Design
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
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*E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound
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 selfidentified 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 SMS
ALLY:
ASSESS:
Build relationship,
Address emotions
Client’s goals, beliefs, knowledge,
conviction, confidence, readiness
ARRANGE:
ADVISE:
Specify plan for
follow-up (e.g., visits,
phone calls, mailed
reminders)
Personal Action Plan
1. List specific goals
in behavioral terms
Share
information about
health risks and
benefits of change
2. Determine confidence level
3. Specify follow-up plan
ASSIST:
Identify barriers, build
strategies to problem-solve
and engage social support
AGREE:
Collaboratively set
goals based on clients’
preferences, conviction and
confidence in their ability to
change or self-manage
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Adapted by Cole, from Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87
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-PAP
Ultra-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”
–
•
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?”
–
•
OK from general health (and clinician’s) point of view
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
Regular exercise
Taking medications
consistently
Avoiding
health
problems
Mood

Eating better
Meaningful
Activities
Smoking
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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
Skin care
Taking medications
to help control
blood sugar
Taking insulin
Diet
Depression

Losing weight
Daily foot care
Smoking
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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
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Courtesy of Bill Miller
MI Publications by Year
Courtesy of Bill Miller
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MI Outcome Studies by Era
100
80
60
40
20
0
1988-94
Courtesy
of
Bill Miller
Alcohol
Offenders
HIV Risk
Health Prom
Dental
1995-99
Drugs
Eating Dis
Cardiac
Family
2000-02
Dual Dx
Adh/Retention
Diabetes
Violence
2003-06
Gambling
Smoking
Psychiatric
Asthma
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MI Trainers and Translations
•
•
•
•
•
•
•
•
•
Afrikaans
Bulgarian
Chinese
Croatian
Czech
Danish
Dutch
English
Estonian









French
Gaelic
German
Greek
Hebrew
Italian
Japanese
Korean
Norwegian
•
•
•
•
•
•
•
•
•
Polish
Portuguese
Romanian
Russian
Sign (U.S.)
Slovenian
Spanish
Swedish
Swiss
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Courtesy of Bill Miller
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 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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Results
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)
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)
7. BEST predictor of behavioral followthrough 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
strongly predict client outcomes
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Motivational Interviewing: 4 Core Principles
Miller WR, Rollnick S:
Motivational Interviewing,
2002
Rollnick S, Miller WR, Butler CC:
Motivational Interviewing in HealthCare,
2007
“RULE”
•
•
•
•
Roll with resistance
Develop discrepancy
Express empathy
Develop self-efficacy
•
•
•
•
Resist righting reflex
Understand motivations
Listen empathically
Empower the patient
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MI Interventions
for Category Three Response
Basic Interventions: OARS
1. O = open-ended questions
2. A = affirmations
3. R = reflections
4. S = summaries
Complex Interventions
5. Roll with resistance/resist the righting reflex
6. Elicit and clarify ambivalence
7. Develop discrepancies
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“Doing” 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 Model
Prochaska & DiClemente (1992)
1.
2.
3.
4.
5.
PRECONTEMPLATION
CONTEMPLATION
PREPARATION
ACTION
MAINTENANCE
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Stages of Change
Precontemplation
Contemplation
Relapse
Preparation
Maintenance
Action
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
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-PAP
2. “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 Interventions
www.ComprehensiveMI.com
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Pilot 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
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– Average increase in exercise = 144 minutes/week
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
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