Transcript Communication Skills to Improve Patient Engagement

Moving Toward Patient Centered
Communication: Motivational
Interviewing as a Tool in Medication
Adherence
Mary Winkels, PharmD, CDE
September 11, 2016
NHPA meeting
Objectives:
After participating in this activity, health care
practitioners will improve ability to:
• Identify commonly encountered patient
barriers to medication adherence in practice.
• Describe key components and benefits of
Motivational Interviewing in patient
encounters.
• Employ basic Motivational Interviewing skills
in a practice case
INTRODUCTION OF CASE
Introduction of Patient Case
CK a 68-yr old male, is a new to your pharmacy. The few times
you have met, he has been pleasant and interested in conversing.
Past Medical History
Medications
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Hypertension (20 y),
Hypothyroidism (11 y),
Back pain (8 y),
Osteoarthritis (4 y),
Peripheral neuropathy (9 y)
Overactive bladder (6 y)
levothyroxine 75 mcg QD
amlodipine 10 mg QD
lisinopril 20 mg QD
oxybutynin 5mg TID
Cymbalta 60mg QD
celecoxib 200 mg QD
acetaminophen 500 mg TID prn pain
aspirin 81 mg QD
WHAT IS ADHERENCE
Adherence
Adherence:
• Extent to which a patient’s health behavior(s) coincides with plan
developed and agreed upon by the patient in partnership with
his/her healthcare provider
Compliance:
• Often used in place of adherence
• refers to the patient following the medical plan as determined by
the health care provider alone
• Adherence is a patient-centered approach
• Compliance is a health care provider–centered approach
• Adherence implies a partnership, whereas compliance implies
judgment and has negative connotations
Medication Non Adherence
• Medication adherence: the extent to which
patients take their medication(s) as prescribed.
• Medication nonadherence: failure to take or use
medication(s) as prescribed, which can be
intentional or unintentional
• Forms of nonadherence include:
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not filling an initial prescription
not refilling an existing prescription,
discontinuing a medication before course is complete,
not following dosing instructions (taking more or less
medication or medication at the incorrect time)
US Patients Do Not Take
Medications as Prescribed
–12%
–12%
–29%
100%
88%
76%a
47%a
Rx Prescribed
Rx Filled
Rx Taken
Rx Continued
–53%
a22%
of US patients take less medication than is prescribed.
AHA. Statistics you need to know. http://www.americanheart.org/print_presenter.jhtml?identifier=107.
Accessed January 21, 2010.
Medication Non Adherence
Medication nonadherence in the US results in:
• 33% to 69% increase in medication-related
hospitalizations
• 89,000 to 125,000 premature medicinerelated deaths
• an additional $2,000 per patient in medical
costs and medical provider visits
• Adherence to long-term chronic treatment
averages 50%
Impact of Medication Adherence on
Health Care Costs and Hospitalization
Risk in Diabetes
Hospitalization Risk
Total Diabetes-Related Health
Care Costs
Total Cost, $
8000
7000
8867
35
7124
6522
6291
6000
5000
4570
4000
3000
2000
1000
0
Hospitalization Risk, %
9000
30
25
20
a
30
a
26
a
25
a
20
15
13
10
5
0
1-19 20-39 40-59 60-79
Adherence Rate, %
80100
1-19 20-39 40-59 60-79
Adherence Rate, %
N=182, 259, 419, 599, and 1801 in the 1%-19%, 20%-39%, 40%-59%, 60%-79%, and 80%-100%
adherence groups, respectively.
aP<0.05 vs 80%-100%.
Sokol MC et al. Med Care. 2005;43:521-530.
80100
WHO Dimensions of Adherence
Adherence is a cluster of behaviors;
simultaneously affected by multiple factors
Adherence and patient-provider
interactions
Adherence is likely to be improved when:
• pts feel they can ask questions and honestly
share their experience with HCP
• providers listen to their patients and impart
relevant information and skills.
• providers exhibit warmth and empathy
Studies of Motivational interviewing (MI) support
positive impact that communication can have on
adherence
Patient centered care and HIV
outcomes
Patients who reported “My provider knows me
as a person” were more likely to:
• Receive anti-retroviral therapy
• Be adherent
• Have undetectable serum levels of HIV
Beach et al. J Gen Intern Med. 2006 Jun; 21(6): 661–665
Meta analysis of MI
• Examined 72 RCT; showing significant support
for efficacy of MI
• Adding MI to the beginning of treatment led
to sustained outcome improvements
• Outcomes were better when no manual was
used
– focus more on the alliance/relationship between
provider and patient
Hettema, Steele, and Miller; Annual Review of Clinical Psychology
Vol. 1: 91-111 (Volume publication date April 2005)
Patient case: Adherence
CK asks you to fill as many Rx as possible generically. He
wants them filled on the same day since he lives alone and
does not have a car.
Of the 5 domains of adherence, how might each impact KC?
• Social and economic?
• Health Care System?
• Condition-related?
• Treatment-related?
• Patient-related?
Motivational interviewing is a….
• Method that has been found to be successful in
increasing intrinsic motivation to change by
exploring and resolving ambivalence
• Collaborative effort between the provider and
the patient
• Helps patients identify and address roadblocks to
change (ie fears, lack of skills/information,
needed supports, etc)
• Focuses on the way we as providers can evoke
positive change in the lives of patients
Miller and Rollnick 2002
“Spirit” of MI
Collaborative
Evocative
Coming along side; non judgemental
Exploring what motivates patient
Viewing the patient as the “expert”
Making no assumptions
Cooperative partnership between
patient and clinician, not directive,
with joint decision-making process
Evoke patient’s reasons for change by
connecting health behavior change
with their values/concerns
Respect Autonomy
Focusing on patient choice
Asking “permission” to provide
assistance, info
Inform, advise, and warn but
ultimately it is the patient who
decides what to do
Appreciate Ambivalence
Patient feels 2 ways about something
Normal to the process of change
If we argue for change, patient may
argue for the status quo, decreasing
likelihood of change
Rollnick S, et al. Motivational Interviewing in Health Care. Helping Patients Change Behavior. New York, NY: Guilford Press, 2008, pp. 6 and 7
MI Spirit and its mirror
Motivational Interviewing
Biomedical Model
Patient centered
HCP centered
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Collaboration
Evocation
Autonomy
Mutual respect
Inform
Negotiate adherence
• Confrontation &/or
Directive
• Persuade and argue
• Education
• Authority
• Expect compliance
Provider stance
• Guiding or coaching (versus directing) and
supporting
• Respecting individual autonomy &
empowerment
• Expressing belief in the patients ability to
make decisions (support self-efficacy)
• Resisting the reflex to make it “right” or label
actions as “good vs bad”
Tips to remember
• It is not about us
• Responsibility lies with the individual patient
and what they feel they need in their life
• Our role is to be active, caring observers who
are present to help the patient
• Because individual behaviors can change over
time, we need to check-in at each encounter
Four Processes of MI
• Engaging: listening to understand – OARS
• Focusing: agenda setting, finding a common
and strategic focus, exploring ambivalence,
offering information and advice
• Evoking: selective eliciting, responding,
summaries toward change talk
• Planning: moving toward commitment and
change
OARS Interaction Technique
OARS
• Open-ended questions
– Invites elaboration and thinking about the issue
– Helps the patient explore the reasons for and possibility of change
• Affirmations
– Assists in building rapport, change is possible
– Key element in facilitating self-efficacy
• Reflections
– Brings to life the principle of expressing empathy
– Core intervention toward guiding the patient toward change (resolving
ambivalence), supporting the goal-directed aspect of MI
• Summaries
– Communicates interest, understanding and call attention to important elements
of the discussion
– Can amplify discrepancies by selecting what information should be
included/excluded
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf Accessed May 18, 2012
Open-ended Questions
Tips on ways to ask open ended
questions
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How can I help you with ___?
What brings you here today?
What’s been going on since we last met?
How would you like things to be different?
What are the good things about ___ and what are the less good things
about it?
When would you be most likely to___?
What do you think you will lose if you give up ___?
What have you tried before to make a change?
What do you want to do next
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Tell me more about……
What concerns you about these medicines?
http://homeless.samhsa.gov/Resource/View.aspx?id=32840&AspxAutoDetectCookieSupport=1 Accessed May 18, 2012
Rollnick S, et al. Motivational Interviewing in Health Care. Helping Patients Change Behavior. New York, NY: Guilford Press, 2008, pp. 48
Activity Exercise: Open-ended
Questions
Activity
Make these closed questions into open ended
ones
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Are you taking your diabetes medications?
Did you start checking your blood glucose in the morning?
Are you exercising?
Have you cut down sugar in your diet?
Are you losing any weight yet on your diet?
Why did you not call us when your blood sugar was low?
Have you stopped smoking?
Did you make an appointment with the dietitian?
Affirmations
Tips on Affirmation
• Must be genuine and congruent
• Examples
– Pharmacist: “Mr. Simmons, it’s great that you found a
way to take your medication every day”
– HCP: “I really believe you’re on your way to better
health since you are thinking about lowering your
cholesterol”
– CDE “I know it must have been hard to come to your
appointment today after your recent A1c test is
higher”
1http://homeless.samhsa.gov/Resource/View.aspx?id=32840&AspxAutoDetectCookieSupport=1
2Adopted
with permission from Berger Consulting, LLC
Reflections
Tips on reflections
• Repeating or rephrasing
– Repeat or substitute synonyms or phrases, and stay close to what the patient
has said
• Paraphrasing
– Make a restatement in which the patient’s meaning is inferred
• Reflection of feeling
– Listener emphasizes emotional aspects of communication through feeling
statements
– This is the deepest form of listening.
• Examples of beginning phrases
– So you feel…
– It sounds like you…
– You’re wondering if…
http://homeless.samhsa.gov/Resource/View.aspx?id=32840&AspxAutoDetectCookieSupport=1 Accessed May 18, 2012
Summaries
Tips on Summaries
• Be concise
– Let me see if I understand so far…
– Here is what I’ve heard. Tell me if I’ve missed anything
• If the patient expresses ambivalence
– On the one hand…, on the other hand….
• End with an invitation
– Did I miss anything?
– If that’s accurate, what other points are there to consider?
– Anything you want to add or correct?
http://homeless.samhsa.gov/Resource/View.aspx?id=32840&AspxAutoDetectCookieSupport=1 Accessed May 18, 2012
Guiding Principles of Motivational
Interviewing: R U L E
• R: Resist the Righting Reflex
Suppress “fixing” the problem by having patient “voice”
arguments for change
• U: Understand Your Patient’s Motivations
Evoke patient’s perception of their situation and
motivation for change
• L: Listen to Your Patients
• E: Empower Your Patients
Help patients explore how they can make a difference
in their own health
Rollnick S, et al. Motivational Interviewing in Health Care. Helping Patients Change Behavior. New York, NY: Guilford Press,
2008, pp. 7-10.
Express Empathy
• When patients feel that they are understood, they may be
more willing to share their experiences
• Sharing their experience allows providers to assess motivation
and support needs in order to facilitate behavior change
• Importantly, when patients perceive empathy, they may be
more open to “gentle challenges” for behavior change
• Patients may be more comfortable examining ambivalence
about change and less likely to defend ideas like their denial of
problems
• An accurate understanding of the patient’s experience can
facilitate change
Wagner C and Conners W. Motivational interviewing. Motivational Interviewing Principles. Available at
http://www.motivationalinterview.net/clinical/principles.html. Accessed May 12, 2011.
Empathy statements
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“You seem…”
“In other words…”
“You feel____ because____”
“It seems to you…”
“You seem to be saying…”
“I gather that…”
“You sound frustrated/concerned/worried…”
AVOID “I understand”
– The patient decides whether you understand
Adopted with permission from Berger Consulting, LLC
Express Empathy
• Pt: Everyone makes it sound so easy… just take
the medicine twice daily, quit smoking, change
your diet, and exercise more!
• HCP: You sound overwhelmed and frustrated. You
have been asked to make a lot of changes to
control your diabetes and people don’t seem to
appreciate how overwhelming and challenging
the task.
• Pt: That is right.
• HCP: May I tell you what concerns me?
Adopted with permission from Berger Consulting, LLC
Putting it all together
CK tells you he sometimes forgets to take his
medications for days and most days doesn’t take
all his doses.
• Which is an empathetic response to CK?
a) “It sounds like you are feeling overwhelmed
with all the medications you are taking”
b) “It sounds like it is difficult to take your
medications as prescribed”
c) “It sounds like you don’t want to take your
medications anymore”
d) “It seems like you don’t like taking
medication”
CK later shares, “Well, I have trouble taking them all
because there are so many”
• Which is an appropriate open ended question?
a) “Why are you having trouble remembering to
take your medications?”
b) “What are your thoughts about using some
type of reminder to help in taking your doses?”
c) “Do you feel like you can do without some of
them?”
d) “How many medications are you taking?”
Revisit
Four Processes of MI
• Engaging: listening to understand – OARS
• Focusing: agenda setting, finding a common and
strategic focus, exploring ambivalence, offering
information Target one thing
• Evoking: selective eliciting, responding, summaries
toward change talk
• Planning: moving toward commitment and change
Goal: Patient voices “change talk”
• Exploring ambivalence and providing targeted
information to increase “pros” over “cons” of making a
change
• Change talk comes when a positive shift has occurred on
the “pros” of a behavior change
• When a patient engages in change talk: recognize and
reinforce it
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Praise patient’s actions, thinking or feeling about change
Reinforce by affirming efficacy of the change
Explore positive aspects of the change
Get the patient to talk about the change
Change Talk D A R N
Words that favor moving in the direction of change
• Desire: I want to get healthier
• Ability: I can do this if I set my mind to it
• Reasons: My high blood sugar is making me tired and
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thirsty all the time
Need: If I had a stroke, I couldn’t take care of my family
• When hearing small change talk from a patient, don’t push
for a bigger change
– Doing so may scare pt and make respond defensively
– Explore patients thoughts about making the change
Change Talk example
“I’ve thought more about cutting back salty foods”
Don’t: “When are you going to start cutting
back?”
– Patient may become defensive since he is only
thinking about it, he is not planning
• Try: “Tell me more about why you think you
need to cut back on those foods”
– Listen to his reasons for change, then reinforce the
positive aspects of those for him
Key Motivational Interviewing Tips
• Look for opportunities to reflect your
understanding
• Identify motivational issues
• Assess patient’s understanding of illness and
treatment
• Ask permission to give advice/information
• Explore decisional balance pros and cons
• When faced with ambivalence or resistance,
EXPLORE ̶ don’t explain
• Respect patient autonomy
Rollnick S, et al. Motivational Interviewing in Health Care. Helping Patients Change Behavior. New York, NY: Guilford Press,
2008.
Adopted with permission from Berger Consulting, LLC
Pt:”I don’t really want to change my
diet right now”
How might you best respond using MI principles?
a) “Ok, it’s up to you. You can do what you want”
b) “I really wish you would consider at least a
small change, it doesn’t have to be difficult”
c) “What would you be willing to do right now”
d) “Cutting your carbs would help you so much”
Pt:”I think I can cut out a few cigarettes a
day, but that’s all I can do right now”
How might you best respond using MI principles?
a) “We’ve been talking about this for a while, I
thought you would be completely quitting.”
b) “Cutting back on cigarettes would be a great
start. Will you let me know how its going?”
c) “Its your choice. Would you be willing to quit
by the end of the month?”
d) “Cutting out a few isn’t going to have the
health benefits that quitting entirely will.”
Which of these uses MI?
a) “Tell me the reasons you don’t want to quit
smoking”
b) “I know its hard to change, but you won’t get
healthier if you don’t”
c) “Anyone who smokes needs to quit smoking
to get healthier”
d) “Its great that you are thinking about quitting
smoking. Tell me more”
Key Take aways
• Non Adherence in the US impacts patient
outcomes and medical costs
• Multiple factors influence adherence
• Patient centered communication, including
Motivational Interviewing, can improve
adherence and outcomes
• Motivational interviewing is a collaborative,
evocative communication method to elicit a
patients own motivation for change