Briana Contreras:
All right. We will get started. Hello, everyone. Welcome to today’s live broadcast, How to Get Patients to Actually Follow Your Recommendations. I’m Briana Contreras, Associate Editor of Managed Healthcare Executive, and I’ll be your moderator for today’s event. Joining me today is Cori Hawkins, PharmD and Director of Clinical Solutions at Biologics by McKesson Specialty Pharmacy. She’s inspired by the oncology patients she has served over the last six years and truly believes empowering patients through education sets them up for success. Her professional interests include the impact of motivational interviewing on outcomes, as well as exploring innovative clinical solutions for adherence. In her presentation today, Cori will be going over how to understand the spirit of motivational interviewing skills, sharing strategies and techniques that motivate patients, exploring potential roadblocks and how to apply motivational interviewing to support medication adherence.
Briana Contreras:
Before we began and I turn it over to Cori, here a few notes. This webcast is designed to be interactive and we encourage you to submit questions using the Q&A tool underneath the video player. We will take the last 10 or 15 minutes of the program to answer audience questions. The slides will advance automatically during the event. And lastly, if you’re having problems viewing or hearing the webcast, click on the Support Icon to report your issue. And Cori, you can take it away.
Cori Hawkins:
Thank you so much, Briana. Good afternoon. Happy Thursday, also known as Friday Eve. It’s also a Veterans Day, so if we have any previous or active military in the audience, thank you so much for your service. And thanks to everyone for sharing an hour of your time with me today. And before we dive into the deck, I’m going to ask you all a question. Have you ever felt discouraged when you’ve made a recommendation that had absolutely no impact on the other person’s behavior? I bet every single one of you on this call can identify at least one time you felt frustrated when you made a suggestion and someone did the exact opposite. I’m sure parents of teens have endured this, and clinicians actually experience that all the time when we interact with patients and provide advice that goes in one ear and out the other.
Cori Hawkins:
So today, I’m going to share with you a method of communication that’s utilized in the clinical setting called, motivational interviewing, that actually gets patients to follow our recommendations. So we’re going to be covering a lot of content today. Just to recap some of those key objectives that Briana reviewed, we’re going to make sure that we understand the spirit behind motivational interviewing skills and why they’re actually thought to be effective. We’ll talk about strategies that can be used to motivate patients. We’ll also venture off the happy path and talk about potential roadblocks that you may encounter. And finally, we’ll explore how to apply motivational interviewing to support medication adherence.
Cori Hawkins:
So I know you guys are on edge waiting to hear what this transformative method of communication called, motivational interviewing, actually entails. So most simply put, it’s just a counseling style and it’s an effective way of talking with patients about changing their behaviors. Motivational interviewing can really help resolve ambivalence and it can elicit a person’s own motivation to change. So it really puts the patient in the driver’s seat in the decision making process. The method is evidence base, there are more than 1,200 publications available on this topic worldwide, that just goes to show how effective it’s really been within the medical community.
Cori Hawkins:
Motivational interviewing was originally developed by William Miller and Stephen Rollnick back in the 1980s. They developed it to support people who had substance disorders. And over time, it’s really evolved and been proven to be effective in the management of various disease states. Some of those include irritable bowel syndrome, cardiovascular disease, diabetes, weight management and even eating disorders. And specifically for my area of practice, it has been shown to be highly effective in increasing medication adherence. Some of my favorite quotes regarding MI are captured on this slide and they really speak to the heart of this approach. And the common themes are just surrounding activating a patient’s internal motivation and communicating in a non-judgmental or non-confrontational manner. This really helps the patient remain open and less defensive, and ultimately leads them to embrace the idea of change.
Cori Hawkins:
So let’s really talk about the common objectives with motivational interviewing. So number one, we’re actually aiming to reduce and minimize any resistance. Resistance is really detrimental because when a patient is resistant, they’re more likely to go deeper into their shell of defensiveness, and this becomes counterproductive to them getting to change their behavior. Number two, we want to resolve ambivalence. Ambivalence can be resolved by working with the patient’s intrinsic motivation and values. The collaborative partnership between a healthcare provider and the patient is really key in providing an environment that’s empathetic, supportive and directive. The environment that’s created should really be a safe zone for the patient to share freely and allow the patient to, again, drive the decision making process. And number three, the ultimate goal is to get the patient to really start to embrace the idea of change and elicit what we refer to as change talk, and we’re going to explore that more in depth later in the deck.
Cori Hawkins:
So now, let’s take a look at this, Stages of Change Model. This visual is really important because it helps depict and helps you understand where is the patient in the process of change, so that you can ultimately decide how to help them progress. So there are five stages of change, and they are pre-contemplation, contemplation, preparation, action, and maintenance.
Cori Hawkins:
Pre-contemplation is a stage in which there’s really no intention to change behavior in the foreseeable future. Many individuals in this stage are unaware or under aware of their problems, and they’re just simply not ready yet. Contemplation is a stage in which people are aware their problem exists and they’re seriously thinking about overcoming it, but they really haven’t committed to take action. And then there’s separation, this is a stage that combines intention and behavioral criteria. Individuals in this stage are really intending to take action in the near future, they also are working on developing a plan.
Cori Hawkins:
And action is what I like to call the sweet spot. This is a stage where individuals are modifying their behaviors in order to overcome their problems. Action involves the most avert behavioral changes, and I would say that this stage requires considerable commitment in terms of time and energy. So this stage really requires a lot from the patient. And then finally, maintenance is a stage where people work to really maintain the change, it involves avoiding those former behaviors and actually keeping up with the new behaviors. During this stage, patients become more assured and more confident that they’re going to be able to continue to change. And for this stage, I would say it’s the most difficult because it’s really challenging to sustain new behaviors. And the example that I like to use is someone who has recently committed to working out, right. It’s easy at the beginning to go and show up, but as time moves on, it’s really difficult to maintain the pattern.
Cori Hawkins:
So, change is absolutely a process and the patient has to take time to work through these steps to actually implement the new behavior. It’s certainly not a race and patients will move along at different speeds. And really, the role of the healthcare provider is to have the skills and the tools to lead them and encourage them on their journey.
Cori Hawkins:
So now we want to explore and talk about the true spirit of MI. The spirit of motivational interviewing is the foundation of every MI conversation that takes place. The clinician communicates in a manner that is exhibiting compassion, acceptance, partnership and respect for the ideas that the patient shares. And all of these components overlap to combine and create an atmosphere in which the patient is more open to change.
Cori Hawkins:
So the first element, partnership, this describes the active collaboration that occurs between a healthcare provider and a patient, it’s a meeting of the experts. And notice that I’m referring to the patient as one of the experts. So the health care provider really maintain status as the expert in disease states, medications, treatment options, and the patient is considered the expert of his or her own life. Since the relationship between the healthcare provider and patient is viewed as a partnership, MI is really thought to be done for and with the patient and not to or on a patient. A good analogy that I’ve used to describe the interactional flow of motivational interviewing conversations is that it should really resemble dancing instead of wrestling.
Cori Hawkins:
So the second element, acceptance, refers to the profound acceptance of the patient as he or she is and not where we want them to be. Acceptance is valuing the patient’s inherent worth and potential and recognizing and supporting the individual’s autonomy to make the best decisions for his or her own life situations. Acceptance is having a really genuine interest in the patient and putting forth the effort needed to understand their perspective and trying to avoid any type of judgment on the situation. Affirming individual strengths and efforts are key components of exhibiting acceptance to patients.
Cori Hawkins:
The third element is compassion. To be compassionate is to actively promote another person’s welfare and to give priority to his or her own needs. Compassion is the deliberate commitment to pursue the wealth and really the best interest of others. And then the final element is evocation. Through evocation, the health care provider seeks to understand and focus on the patient’s strengths and resources. The health care provider draws out the individual’s thoughts and ideas instead of imposing his or her opinions and ideas on the patient. The thought here is that the patient has what he or she needs to get to a point of change and be successful, and they will eventually identify it by working with the healthcare professional.
Cori Hawkins:
So now that we’ve reviewed the spirit of MI, it’s important to really understand and grasp the four guiding principles that are used to achieve that collaborative relationship with patients to help them change. So these four guiding principles are represented by the acronym RULE, and they essentially capture the essence to MI. R stands for resisting the righting reflex. This is huge in motivational interviewing. The righting reflex occurs when you immediately point out risks or problems with the patient’s current behavior. And it’s so important to resist the urge to point out those risk or problems because a patient could potentially become defensive, they could continue their current behavior, and ultimately, it is not really the outcome that you’re trying to reach. So in forcing a patient to defend their behavior and verbalizing the disadvantages of change, the patient actually becomes more committed to maintaining their current behavior. As an alternative to the righting reflex, the clinician should use a non-judgmental tone and approach when communicating with the patient regarding their current behaviors.
Cori Hawkins:
U is for understanding the patient’s motivations, his or her own reasons for that change. The patient’s personal reasons will be influenced really by perceptions, his or her concerns, and their values, which in turn will affect his or her decision to change. So it’s very important to understand why the patient wants to make the change and how he or she plans to make it.
Cori Hawkins:
L stands for listen. Listening really and truly involves so much more than just using your ears to hear the words that a patient is saying. It is actually an active process in which the listener is paying attention to the information the patient is conveying. Patients who feel their concerns are actually heard, are generally more comfortable with their healthcare providers and they’re more satisfied with the care that they’re receiving. This translates into them being more likely to adhere to the care plans in place and to feel more comfortable discussing problems and issues as they arise. This is actually a huge concern from a medication adherence perspective, because you cannot assist a patient when navigating adverse events if they’re not opening up and sharing their problems with you. So establishing an atmosphere where they feel heard goes a long way in being able to support them in their treatment journey long term.
Cori Hawkins:
E stands for empower your patient. Empowering a patient’s ideas about changes he or she can make to improve their health is just very impactful. You can empower patients by encouraging them to engage in positive health behaviors and to make changes that will have a positive effect overall in their life.
Cori Hawkins:
So, we’ve reviewed the foundation of the motivational interviewing, the spirit behind it and the guiding principles. So now what I want to do is switch gears and start to explore some of those specific skills that are necessary to implement this particular technique. So there are four core motivational interviewing skills that are collectively referred to as OARS, another acronym, it’s O-A-R-S, stands for open-ended questions, affirmations, reflective listening, and summarizing. Together, these are the basic interaction techniques and skills, and they are most effective when they’re used early and often in the MI approach. So right out the gate, you want to start using those OARS skills. And really, again, they’re the foundation of the MI based conversation.
Cori Hawkins:
So we’re going to take a deeper dive into each of these skills. So open-ended questions, these are encouraged in motivational interviewing because they elicit a patient’s thoughts, their feelings, preferences, their goals. They’re really patient-centered because they don’t lean towards a right or wrong, or even a yes or no answer. One easy strategy for asking open-ended questions is focusing on the very first word. For example, think about how you would respond if someone said, do you or are you. These generally lead to a yes or no response. But if you think about how you might respond with a question that starts with how, what, or why, for example, asking the patient, how do you feel? Instead of, are you in pain? You can see how it leaves the door open for them to elaborate and for you to collect more information about what they’re experiencing.
Cori Hawkins:
Also, another example of how you could phrase one of these open-ended questions would be, why are you concerned about your new medication? Instead of just simply asking, do you have any concerns? So the open-ended questions really lead the patient to provide that deeper level of detail and provide you with more insight. I do want to provide one word of caution, you have to be careful when leading a question with why, because the tone can lead the patient to become a little defensive. So an example of this could be saying, why did you miss your dose? Versus, what happened that led you to miss your dose? So you can see how the why in some instances can come across as judgmental and potentially a little confrontational. So just be careful with the whys. And I think it can feel like you’re having to overthink your wording at first when you are implementing motivational interviewing, but this skill eventually becomes very natural and flows, and that tends to happen once you have some practice.
Cori Hawkins:
All right, affirmations, these are statements of appreciation, statements this understanding and provide positive feedback. They acknowledge a patient’s effort, their willingness or abilities, and they also communicate positive regard, and that’s really by focusing and emphasizing a patient’s strengths and resources. For affirmations to be effective, they must be genuine, but they don’t have to be complex. It could be as simple as, you’ve really given this a lot of thought, or you worked really hard on them. Affirmations can be viewed as a way to support the patient’s self-efficacy. So self-efficacy is the patient’s ability to believe that they can be responsible for their own decisions and their own lives. And when you recognize that a patient is doing great with an aspect of his or her behavior, it’s a good time to provide some affirmation.
Cori Hawkins:
So for example, a patient whose imaging results have come back and they’ve shown decreased tumor burden, you may say, your scans are looking great, you’re doing a wonderful job of taking your medication consistently. So affirmation is always recognize the patient’s strengths, and they’re really a strong tool that you can use to build a bridge in developing rapport and trust with the patient.
Cori Hawkins:
All right, reflective listening, this is the primary skill that is used to demonstrate empathy, interest and understanding. So remember, understanding is one of our guiding principles that we talked about earlier. Reflective listening really helps to clarify, manage conflict, and to explore reasons for change. It can also be a really wonderful opportunity to toss in some positive affirmations as well. So reflective listening encompasses being interested in what the patient has to say and having a desire to truly understand how the patient sees things with their perspective. It’s certainly a skill that takes time to develop. It can become really easy for beginners to get trapped in what becomes an interrogation, asking question after question with little or no reflection. But with practice, again, it becomes a very effective tool in the MI approach.
Cori Hawkins:
Using reflections allows you to convey your understanding of the patient’s situation, and they can feel understood. So for example, a patient might say that her daughter used to come with her to the doctor’s appointments, but now her daughter moved away and she rarely sees her as much and definitely isn’t able to attend her doctor’s visit. So a reflective response might be, your daughter isn’t living at home anymore and this has been difficult for you. Then depending on the response, she may follow up with an open-ended question to gain additional insight and explore that thought further.
Cori Hawkins:
So generally, when you’re using reflections, if you’re on point and your reflection is correct, the patient typically will let you know, you just can tell by their response and their body language. And this really increases the emotional intensity of the interaction. If for some reason you hit a nerve and you’re not correct, the patient may just not be ready to discuss the issue, but you definitely can pick up on it and you’ll know that you need to move the conversation forward. So there are many different types of reflections, and I’ve broken them down on the slide. So a simple reflection just really repeats the patient’s exact words back to them. This approach isn’t really my first choice because it can come across inauthentic. The example that I just reviewed with the patient’s daughter moving away is really an example of reflecting feelings, because identifying what she said and then reflect to her what she’s feeling.
Cori Hawkins:
So reflecting behavior can be utilized to really reflect body language as well. So, for example, you may say to a patient, I noticed you just got tears in your eyes, what are you feeling right now? So that’s a great way to get them to open up if you notice that they are having some emotional response. And then a amplified reaction utilizes an exaggerated term to emphasize the patient’s words. You can say, you’re feeling overwhelmed because … But actually, instead of just repeating it to them you want to use a stressful turn, like, you’re feeling overwhelmed because … and that really just re-emphasizes what they’re feeling.
Cori Hawkins:
A double sided reflection is using a client’s words and noting the ambivalence to point out a discrepancy. It’s a short summary of both sides of the ambivalence. So an example might be, you feel two ways about this. On one hand, you feel it’s hard to live with extreme diarrhea every day. And on the other hand, you love your family and want to take your cancer drug correctly, so you can live as long as possible. So it’s identifying that there are two sides to the story to help the patient start to open up and think about changes that could be beneficial for them.
Cori Hawkins:
Shifting focus is a strategy to provide understanding for the patient’s situation and to diffuse discord. So a patient might say, how could you ever understand the fatigue this drug is giving me? Or express some reluctance to engage in the conversation. So you might say back to that patient, it’s hard to imagine how I could possibly understand or relate, and that shows empathy and also prevents you from directing or coming across judgmental.
Cori Hawkins:
Rolling with resistance, this is to really just be able to take the conversation down a different path, right. So you want to always, always avoid those direct arguments. Sometimes you may need to apologize or shift the conversation. You might say, you’re right, we’re not ready to increase your exercise right now, you’re still focused on getting your blood sugar under control through diet. So it’s identifying that the patient is feeling resistant, but then shifting the focus to their efforts and providing those affirmations.
Cori Hawkins:
And finally, reframing is really looking at a situation, a thought or a feeling from a totally different angle. So an example, what a patient may say is, this isn’t fair, my spouse can eat anything, he never gains weight. This really shows that the patient’s emotions are really dominating here, right, it’s shame, fear, anger, anxiety. So the patient is really blaming the spouse and it’s causing conflict and isolation. So what you may do for this situation is reframe the experience and then that opens the door for better outcomes. You could suggest, and get the permission of the patient first, to consider looking at it from another angle. Instead of feeling like it’s not fair and they’re at a disadvantage, you may say, what if you thought about the weight control in this way, I can do this, I have a support system, I have the resources I need to eat better, and I’m going to start exercising or exercising might be beneficial. So reframing really elicits the gratefulness and optimism which ultimately leads to a better result.
Cori Hawkins:
So one note that I wanted to make, when you’re using these skills, if you encounter resistance, it’s usually because a patient isn’t quite ready for change. And that’s okay, right, we’re trying to meet them where they are. So the final OARS skill is summarizing, this is bringing key points together and reflecting on the progress. You can utilize the OARS skill to bring the conversation to a reflective space.
Cori Hawkins:
So for example, use an open-ended question to really engage the patient further. You might say, so what do you think we’ve accomplished today? Right. It’s open ended but it transitions easily into a summary. Summaries are used to reflect back to the patient the information that he or she has been telling you, and they’re an effective way to really communicate your interest and your concern about the patient, it also helps to build rapport, it’s a great chance for you to bring attention to the key points from the conversation, and if you need to shift attention and/or direction. So they are a phenomenal tool and they can really accomplish a lot within the MI mindset.
Cori Hawkins:
Ideally, summary should contain three components, they should begin with an explanation that you’re about to summarize or highlight certain parts of the conversation. You should always offer a patient the opportunity to add anything that was left out or anything you forgot. And then usually they conclude with an open-ended question. So, what I thought would be helpful is just to walk through an example. So you might say something like, let me take a minute to recap what we’ve talked about. You’re not really sure that you want to make the changes your doctor told you to make, and you feel overwhelmed at the thought of making these changes. Did I miss anything? What are your thoughts about these changes? So that’s an example of how you would compose the three components of a summary.
Cori Hawkins:
So collectively, summaries highlight key ideas, and the collective summary specifically really work most effectively main conversation. An example could be, so let’s go over what we talked about so far, and then you highlight those key points. You can also tack on the chance for the patient to add content, and wrap up with an open-ended question to steer the conversation on to the next point. Linking summaries are best used when you encounter resistance. They allow you to revisit a topic or shift the conversation. So an example might be, a minute ago you said you wanted to talk about X, would you like to talk more about how you might try it? So you can use those linking summaries to shift the conversation, right. These are very, very effective for resistance, especially when used with some of the other skills that we’ve talked about and if it’s wrapped up in the being concerned.
Cori Hawkins:
And then finally, transitional summaries can be used to just close a conversation. So an example might be, you’ve just described your plan, and we’re always happy to help you in any way that we can, we’re here for you, what other questions do you have before we wrap up the call? So again, you can hear those three components within that transitional summary. So summaries are just very, very effective at guiding the conversations and you can plug them in where you deem appropriate within your conversation.
Cori Hawkins:
So the next section, we’re going to review evoking change talk and then planning for change as well. So change talk is any express language that a patient uses that is an argument for change, it’s literally the precursor to change. During the conversation, anytime a patient makes a comment that’s either implying or they mention a real or possible change to their feelings, attitudes, belief, or behaviors, they’re engaging in what we call change talk.
Cori Hawkins:
So asking the patient to discuss the pros and cons of both changing and not changing a behavior can assist in identifying the need for change. Change talk typically occurs after the patient has had a positive shift in their perspective. And it’s important that change talk is recognized by the clinician and reinforced. You can recognize change talk by praising the patient’s actions, thinking and feelings, and you can praise their need for change and really reinforce the change talk by affirming positive aspects of the change. This really helps the patient to talk more and open up.
Cori Hawkins:
So when the patient verbalize a need for change, it really reinforces their commitment to making the change. And on the slide you can see the acronym DARN, which represents indicators of change talk. These are really a guide for what to listen for. They’re words that show a desire to change, the ability to change, the reasons to change, or a need to change. And those key words that you want to be listening for are words like, I want, or statements like, I wish, the reasons are, or when a patient says, I can. Or even if they identify some positive factor like, it would solve problems if. Anytime you hear these types of statements, you should respond to the patient’s change talk using your OARS skills to elicit and reinforce the change talk and get the patients to dedicate themselves to the change.
Cori Hawkins:
It’s also important when you hear small change talk from a patient you don’t really want to push for a larger commitment. Doing this can really scare the patient and they may respond defensively and tell you all the reasons he or she should not make a larger commitment, that’s really not what you’re trying to accomplish. So for an example, a patient might share that he’s thought a little bit about needing to cut back on eating salty foods. Asking him the question, so when are you going to cut back on those foods, may result in him stating he’s only really thought about it, he’s not really ready to cut back and he’s not really planning to in the near future. So it can result, again, in that defensiveness and then throw you off the goal of getting to the core of the patient’s thoughts about why they may have considered it. So you might want to, in this instance, consider asking, tell me more about why you think you need to cut back on eating salty food. And then listen to the reasons for the need to change before empathizing and reinforcing them.
Cori Hawkins:
So DARN statements predominate when a patient is still deciding to make a change, but CAT statements indicate that the patient is ready to take action. A patient has either committed to change, taking small steps in preparation for the change, or may have already started changing. You can see that the CAT statements are much more decisive. They typically start with the words, I am or I have. These statements are most predictive of a positive outcome, and it’s important to provide positive affirmation when you hear them. The next step when you hear these types of statements is to encourage the patient to create a plan to change by asking open-ended questions.
Cori Hawkins:
Planning really is the who, what, when and where I’m taking action. I’ve included some questions for examples that you can use to evoke a plan out of the patient who’s ready to change. Planning change requires negotiating a plan and getting the patient to buy in or commit to the plan. You also want to listen for statements that indicate a patient may be ready to commit to generating the change. Once a change plan is identified, you want to summarize it. So if a patient is not ready to commit to the change, that’s fine, you just circle back to those OARS skills and revisit the issue and address any ambivalence that they’re experiencing.
Cori Hawkins:
It is important to note, planning isn’t supposed to really dominate these conversations, right? You’re not trying to race to the goal creating a plan. So even if the patient’s plan is simple and straightforward, it is still very meaningful. The efforts on the part of the health care provider are never a failure despite the level of detail in the plan. So anytime you’re able to implement these strategies and lead a patient to embrace and take action to change, it’s really an opportunity to applaud yourself. It’s a whole new way of communicating, it’s certainly never ever easy to shift the patient’s mindset. So wins, no matter what size, should always be celebrated.
Cori Hawkins:
So my hope is that every MI conversation you have is smooth and it leads down the happy path to positive changes. But realistically, I know that at some point there are times when you may encounter some roadblocks, so I wanted to dive into these. So there are 12 roadblocks outlined that are really counterproductive to the act of listening and also just being able to communicate effectively with your patient to get them to embrace their change.
Cori Hawkins:
In the interest of time, we won’t dive into all of these, but I’m just going to touch on the key ideas. A lot of these are very obvious, you of course want to avoid negativity taking on the role of the expert, right, and talking to the patient and telling them you want them to come up with their own solutions and embrace the change that they are trying to work towards. So remember, the intention of motivational interviewing is really to create that partnership with the patient and trying to persuade or argue, that really just slows the patient down and prevents their progress.
Cori Hawkins:
On this slide, number six stands out to me. Judgmental behavior implies to the patient that something is wrong with someone that they’ve shared, and it’s going to cause them to go into their shell and not be open and not share with you. So again, just counterproductive to getting the patient to change.
Cori Hawkins:
Number seven really is interesting. So it talks about agreeing, approving and praising. And you would think at first glance, this don’t look like a roadblock at all. But it’s really the way that you use them. So we often think that a positive evaluation or agreement helps others feel better, it helps them continue to talk and work through their problems. But contrary to that belief is that it often can have very negative effects on a patient when they’re already experiencing negative feelings and problems. So a positive evaluation doesn’t really fit with the patient self-image, so it evokes denial.
Cori Hawkins:
Patients sometimes also infer that if you’re judging them positively you can also just as easily judge them negatively. If praise is used too frequently, they may interpret the absence of that praise as criticism, right? If you’re constantly saying, I think you did the right thing, I couldn’t agree more, the same thing happened to me, they get used to the praise, and then if it’s missing they feel like something’s wrong. So you have to be very careful not to agree or praise negativity. And really and truly, you should reserve the affirmations for positive statements or progress. And then obviously, shaming, ridiculing or name calling, those are just inappropriate even outside of the context of MI. You want to be careful not to interpret or analyze what is being said, sometimes this can be a really difficult habit to write for some clinicians.
Cori Hawkins:
Number 10 is similar to the example we discussed in the previous slide, you don’t want to provide so much reassurance and consoling that the topic at hand, which is getting them to change their behavior, ultimately gets lost in the drama. Number 11, you want to be mindful of the questions that you ask to ensure that they keep the conversation flowing and that they’re leading to a deeper understanding. Sometimes unintended questions can get the discussion off track and then it can eventually lead to the patient becoming defensive. And then number 12, these have a tendency to come across as dismissive. I know personally, I’ve used humor to lighten the mood sometimes, but in a clinical setting it can make patients feel as though you don’t really understand and you’re trying to minimize their feelings and perspectives.
Cori Hawkins:
So these are the 12 roadblocks, and the overarching message here is that they really interfere with the patient’s momentum towards change. And for the purposes of MI, it’s important to avoid the roadblocks even if you perceive them to be effective potentially in other settings.
Cori Hawkins:
Okay, so wheels of change. I’m going to add another layer to something that we talked about earlier. So you all probably remember at the beginning of our discussion today, I think around slide five, we looked at the stages of change, and it was a picture of a man at the base of the stairs, and it worked through the stages of change up to maintenance. That was actually a little misleading because change is not really linear or stepwise, it’s more of a cycle. So to complete the cycle we need to include relapse, right. Relapse occurs when the patient falls back into those old patterns of behavior, and it’s only natural that it occurs from time to time. Let’s face it, change is difficult to maintain.
Cori Hawkins:
So when this occurs, patients are going to need some extra encouragement to revisit the change and try again. And it’s important for me to highlight the fact that you need to be sure to affirm all of the previous hard work and benefits that the patient was receiving prior to the relapse using those OARS skills, so that you can, again, elicit the change talk and ultimately have the patient reconsider their original plan or potentially even create a new one. So patients are always shifting around within this cycle with a new problem that may arise that needs change, and the wheel of change is really always moving for every single patient.
Cori Hawkins:
So once you start to use motivational interviewing skills, you can identify the stage a patient is currently in. And that helps you determine how you want to respond. And I shared this slide because I thought it’d be helpful to have a reference of responses and approaches for each of the stages to serve as a guide and to get a feel for how it would work. So for example, if a patient is in the contemplation stage, it’s important for a clinician to help the patient resolve ambivalence, right. If a patient is already in the action stage, you’ll want to ensure that they have a plan in place, really reinforce the changes that they’ve embraced and reiterate the plan to them. So just making sure that no matter what stage they are currently in, you’re a pillar of guidance and trying to help them when they potentially stumble during that maintenance phase or potentially relapse. So again, it all becomes very natural a practice, just requires a lot of thought and effort upfront to get comfortable with the approach, then it falls into place over time.
Cori Hawkins:
So how does motivational interviewing skills translate into supporting patients with their med adherence? So the next slide is actually my favorite, because it brings the topic full circle. These are examples of open-ended questions that elicit a patient’s own motivation to be adherent. Identify ambivalence, it’s an example of how you can exhibit empathy and respect from the perspective of the clinician. And then ultimately, these lead and evoke change talk. So again, everyone develops their own individualized approach and phrases, eventually it becomes less robotic. And really and truly, I feel that most clinicians are already using some of these skills in their current conversations with their patients, so it just takes a little additional effort to work them in with the other skills before you can fully master the MI technique.
Cori Hawkins:
So this concludes our discussion today. I hope the content was able to squeeze the most we can out of the hour that we had together. I hope it was easy to digest and meaningful. You really, truly could spend 40 hours diving into more specifics, but I just wanted to stick to the key components and the impacts of motivational interviewing on patient behavior. So it looks like we have about 13 minutes left, what questions do you all have?
Briana Contreras:
So we have our questions here. But first, thank you, Cori, for your insightful presentation. I will jump to some of our audience members’ questions now. But again, before I read some of these, just to remind other members, you can submit your questions by entering them in the Q&A box found right underneath the presentation window. So while you do that, I will jump to some that we have here.
Briana Contreras:
First, an audience member asks, they heard of a patient who made changes in their lifestyle when their doctor said that they should think about planning a funeral. Do you think this might be the best way for some patients or do you think there’s always a better way than using fear as motivation?
Cori Hawkins:
That is a great question. I always believe that fear as a motivation really isn’t sustainable, right? You don’t want a patient to change because they’re scared, you want them to change based on their own intrinsic motivation. So I absolutely feel that is more impactful to use, even beyond motivational interviewing, but a positive approach to the patient, help them understand, what are their goals? How can they maximize the time that they have? And really showing empathy and understanding and care go a long way into a patient feeling supported.
Briana Contreras:
Thank you. Next question, how do you truly address the fact that you know the patient is not picking up the refills?
Cori Hawkins:
That’s a great question. So using some of those OARS skills, I would suggest maybe asking an open-ended question. What has led you to not be able to pick up your prescription recently? Something that allows the patient to talk about their experience so that you can gain greater insight. It could be something as simple as transportation issues, it could be more complex that they’re dealing with some type of comorbidity. So the more you know, the easier it is for you to reflect back to them, use those reflective listening skills, and then also provide empathy and help the patient and guide them to creating the willingness to change and then also the plan.
Briana Contreras:
Okay. And the next one, using telehealth and a first time encounter with the patient, how do you engage and make a connection?
Cori Hawkins:
That is a great question. And one thing to consider is that in a telehealth setting, depending on the circumstances, you may or may not be able to see the patient and read their body language, so it’s very important that you manage your tone, tone is very important. And also that you give the patient your undivided attention and using those reflective listening skills so that they absolutely feel confident that you’re hearing what they’re saying and you understand them. So that actually builds that bridge of trust.
Briana Contreras:
Okay, next question. How do you distinguish between affirmations and false reassurances or complimenting that may not be genuine?
Cori Hawkins:
That’s a good question. So basically, just make sure that your interactions with patients are authentic and that you’re not over-utilizing compliments and plugging them in too frequently, right, because like we said, they may notice an absence in the next follow up conversation that makes them feel like something’s off. So you really want to reserve the compliments and affirmations for key points, right. When they make a commitment to change, or they identify or work through some ambivalence, or they make a plan, those are great times to throw in those affirmations. And otherwise, just trying to reserve them but still come across as empathetic.
Briana Contreras:
Thank you. Next, does reframing potentially cause self-pity?
Cori Hawkins:
That is a really good question. I haven’t really considered that before, but I could definitely see where it could lead to self-pity, so that’s a great call out.
Briana Contreras:
Next, how do you determine what stage the patient is in?
Cori Hawkins:
This is a very, very complex conversation. Again, there’s so much content available and so much more education to really be able to master this concept. But really it’s about understanding, through what they’re sharing with you, which stage they’re in, so to speak. So if we think back to the stair step, and I know we identified the wheel of change at the end but understanding where they are, have they made a plan? Have they taken short term steps to move forward with their change? There it is. So you can tell if they are just thinking about it, pre-contemplation. Contemplation, they’re taking things to the next level, they’re actually … I’m sorry, I misspoke that. Contemplation is thinking about it.
Cori Hawkins:
Preparation means that they’re taking things to the next level and creating that plan. So if they say, I plan to or I will increase my exercise X times a week, you know they’re in the preparation stage. The easiest scenario is if they’re already in the action stage, that’s not likely to occur in initial conversations much. But the more you use motivational interviewing, the more you can get a grasp for where the patient is in their journey to change.
Briana Contreras:
Okay. Another question here. What advice can you provide for patients that deny having adherence issues but fill gaps can be seen in their drug history? This person says they’ve tried to ask the question different ways, like providing examples, I’m sorry, sharing personal experiences, but it does not always work.
Cori Hawkins:
Yes, that is a very good point. So no method that is used is 100%, right? Challenges or barriers to motivational interviewing from the patient’s perspective can be a lack of insight into how their behaviors really impact their health. All you can do is really provide education, right, education is empowerment. They have to choose to accept it and embrace it. And there’s just going to be a handful of patients that aren’t as receptive to thinking about change. You also have to consider there are outside influences, people within their circle that don’t prioritize taking medication appropriately. So it’s hard to get the patient to change when they don’t have the support they need or they just don’t even have a desire. And then just naturally, from a disposition standpoint, some patients are more averse to change and they’re really stuck in their ways and have a tendency to make excuses and not wanting to give up bad habits.
Cori Hawkins:
So I would say, for these types of patients, just try not to give up on them. Sometimes you need to show people three and four times for it to really sink in. So continue to explain the implications, ask those open-ended questions to understand their perspective. And hopefully, at some point, if you use the OARS skill you’ll get through to them.
Briana Contreras:
Okay. And unfortunately, I only have a few minutes left, so I’m going to ask one more question. But before I do, someone asked if they can get slides of this talk. That’s an additional question. I don’t know if that’s possible.
Cori Hawkins:
Yes, that’s a great question. These are actually internal through McKesson, but there is a ton of content available out there. So feel free to research, also feel free to contact me with any additional questions or if you want to dive into a specific topic further.
Briana Contreras:
Okay. And for the last and final question, do you have any tips to move patients from pre-contemplation or contemplation stage into an action stage, especially for care management programs with a time limitation?
Cori Hawkins:
Yes, time constraints are huge, right. And that is a clear barrier from the clinician’s perspective, they have heavy workloads, they don’t have time to really fully implement the MI approach. And it’s really difficult to stay true to the spirit of MI, I would say, when work is just too heavy. So that being said, moving a patient along in their journey really can be accomplished by helping and leading the patient to identify their reasons for change. And you do that through those open-ended questions and trying to understand them, while also being respectful of their perspectives, trying not to be the expert and push your opinions or push your expert advice on to them, but allow them to come to it themselves.
Cori Hawkins:
So pointing out ambivalence in a neutral or empathetic way goes a long way to help keep the conversation flowing to get to a point where they’re ready to make some changes. And affirming through this conversations they may identify some positive outcomes or why it’s needed, and listening for those words that we talked about, the DARN and the CAT, when you hear those, affirming and digging in to get that commitment.
Briana Contreras:
Okay. Well, again, we’re out of time, so that will conclude our Q&A and webinar for today. But first, I just wanted to thank you, Cori, for joining us today and sharing your insights. And thank you to the audience for participating in this presentation. We hope you found it informative. And lastly, thank you to Biologics by McKesson for their continued support of PBMI. Thank you, everyone. Have a great rest of your day.
Cori Hawkins:
Thank you.
Video link: https://vimeo.com/653854821