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Adherence Treatment Not much has changed Patients want information and help Rates are below 50% Patients manage their diseases not us Old models of patient care don t work Things to think about Managing an illness requires behavior change 51% of the $1 trillion in health care costs required behavioral changes For every dollar of health care we pay a dollar to fix problems Psychosocial Models Patient Centered Information change Patient saves self negotiate behavior Adherence Negotiation Assess motivation Understand / accept Resistance is information Address issues Respect is earned Biomedical v Practitioner centered Information giving save the patient Dictate behavior Compliance Authority Provide motivation Persuade, manipulate Resistance is bad Argue Respect expected Change and Resistance Change questions our ability to do what is needed Resistance reflects disturbance; out of kilter A person s way of saying I need to understand this. Opposite sides of the same coin o Clear about what to do? o Do they have the skills? o Do nothing when they don t understand Four Forms of Resistance Negating: Blaming disagreeing excusing minimizing Arguing: Challenging, discounting, hostility Interrupting what you say Ignoring what you say Example: I don t like taking medicine . You know you need to take this v what bothers you about taking this? Motivational Interviewing Person centered, directive method of communication Seeks to enhance a patients intrinsic motivation to change Focuses on exploring MI: Aims to create dissonance between goals and noncompliant behavior o o o The patient experiencing dissonance between goals and noncompliant behavior The patient can reduce dissonance buy adopting more beneficial behaviors Creates a favorable platform for change Elicit information from the patient Provide the necessary information Elicit information to check for concerns or questions Uses a menu of strategies Uses 5 principles Two assessment techniques Readiness Rulers The envelope General Process Elicit Information about the patient How do you view the changes we have discussed? What are your thoughts? Tell me about your eating habits. How much do you exercise? Do you think you get as much exercise as you need? Get information about a typical day Tell me about a typical day When do you get up? Eat? Exercise? Work? Explore patient thoughts What does high cholesterol mean to you? What is your understanding of the consequences of not treating the What are the positive aspects? Negative What is overall your goal? illness KEY POINT: Dissonance is motivation Provide new Information Name of the drug, Dosing, Onset of action, What to expect, 2-3 most common side effects Elicit new concerns What are your thoughts now about managing your ___________? Where does this leave you now, about managing your depression? 5 Principles of MI: Assess motivation / create dissonance Role with resistance Express empathy Avoid argumentation Develop discrepancy Support self efficacy READS (Acronym) Express Empathy Used to ID and help understand resistance Ex: A patient smokes, HCP asks: Can t you think of something else relaxing? Alternative Response: It will be hard to give up something that is so relaxing. Remember . Warning, advising, judging, questioning = bad Develop Discrepancy What are the good things and less good things about change Restate the pros and cons Ask the patient to discuss his/her goals relative to the treatment Restate discrepancies Avoid Argumentation Want the patient to see us as being on their side Mrs. Jones, I see you are getting your refills every 40 days, but you should only have a 30 day supply, can you tell me what is happening? Roll with Resistance Ignore antagonistic elements in the patient s words PT: Look I haven t had any real problems with my smoking so far, so don t worry about it. HCP = I hope that continues to stay that way ..maybe you should get a checkup since many of the diseases don t have any early symptoms Support Self Efficacy A person s belief in the possibility of change Actual changes as well as contemplative changes Mrs. Smith, I think its terrific that you are taking you med every day as we ve discussed. SE is a self fulfilling prophecy . Readiness Rulers Used to elicit change talk Measure 2 concepts How important is the change? Does the patient think they can do it? Scale 1-7 How important is it for you to take your medicine every day? If patients answers 3, ask why not a 1 Then ask, what would have to happen for you to say a 4 or 5? A few RR questions can get a great deal of information from the patient. The envelope: I just don t want to quit smoking. If I were to hand you an envelope, what would the message inside have to say for you to quit smoking. Summary: MI addresses resistance and ambivalence Creates dissonance Encourage patient to elaborate on concerns Elicit information from pts Provide information to patients Elicit new concerns Focus on how goals and values relate to behaviors Emphasize empathy

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