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Cynthia Batcher RN, BSN, PHN, CCM Integrated Care Collaboration  Austin, Texas 804-2090 ext.210  cbatcher@icc-cent

Breaking the Chains of Diabetes Non-Adherence 6 th Annual Diabetes Summit Saturday April 4 th , 2009 Program Adopted from CMAG Case Management Adherence Guidelines – Version 2. Cynthia Batcher RN, BSN, PHN, CCM Integrated Care Collaboration  Austin, Texas

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Cynthia Batcher RN, BSN, PHN, CCM Integrated Care Collaboration  Austin, Texas 804-2090 ext.210  cbatcher@icc-cent

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  1. Breaking the Chainsof Diabetes Non-Adherence6th Annual Diabetes Summit Saturday April 4th, 2009Program Adopted from CMAGCase Management Adherence Guidelines – Version 2 Cynthia Batcher RN, BSN, PHN, CCM Integrated Care Collaboration  Austin, Texas 804-2090 ext.210  cbatcher@icc-centex.org

  2. Ever Wonder Why you are not heard?

  3. Write your answers to these questions in the margins of your handouts! • Think about all the cars you’ve driven (actually driven, not just dreamed about driving), and write down your favorite. • Think about and write down one of the best meals you’ve ever eaten. • Think about and write down the best trip you’ve ever taken. Concept from “Add the Element of Surprise to your Classroom” by Robert Dancik

  4. Now take the paper with the questions in your hand hold it in front of you and turn it one full revolution clockwise. Then close your right eye and read your answers.

  5. You have just preformed a “Hemispheric Shift” • This exercise helped turn off the left side of the brain – logical and mathematical – so that the right side can entertain the ideas that are presented. • The right side takes in and uses ideas that are out of the ordinary, nonlinear, and creative. • The left side tells us that taking the time to do something with the information is nonproductive, self-indulgent, and not important and makes us feel guilty. • So turning off the left side gives permission to!!!!!!

  6. Accomplishments of the Shift • Quick way to separate persons from preoccupations of their world. • Allows the client to focus on what you are offering and help them gain access to their right side of the brain. • Allows for follow through – prevents the person retreating to what is known – opens the mind to become willing to go places. • Without change in a persons viewpoint, possibilities go unnoticed and unused.

  7. Motivational Interviewing or MI • MI is a process with specific techniques that address patient resistance and ambivalence for the purpose of creating dissonance. • Dissonance then leads to changes in behavior. • MI is patient centered and takes little or no additional time and can reap great rewards in terms of creating self motivational behavior, adherence, and therapy outcomes. • By becoming familiar with MI concepts you will add a powerful tool to your arsenal. • Rollnick S, Mason P, Butler C, Health Behavior Change – a guide for practitioners. Edinburgh, Scotland: Churchill Livingstone; 1999.

  8. Note the Difference Between Psychosocial and Biomedical Approach for Change! • Traditionally, healthcare providers have used a biomedical approach to convince patients to make specific behavior change. We tell the patient what to do and hope that they do it. Compliance • The Psychosocial model differs in that the interaction between the provider and patient is viewed as a meeting of experts for the purpose of reaching an agreement on action. Ultimately it is the patient’s decision and actions that result in a meaningful and lasting behavior change. Adherence • Understand that respect from the patient is not a given; it must be earned.

  9. Basic Rule! • Avoid arguing with patients about the need for change! Lets practice: • “I have told you several times how important it is to take your medicine. Why don’t you do it?” • “I have noticed that you have missed several doses of your medication. Is there something going on that I can help you with?”

  10. Resistance Behavior • When resistance occurs it is not negative outcome. • Resistance can take several forms: • Negating • Blaming, excusing, minimizing, unwillingness to change • Arguing • Hostility, challenging • Interrupting • Ignoring • Resistance signals a potential emerging state of dissonance. Appropriately addressing the reasons for resistance, leads to serious exploration of possibilities for change.

  11. What is Dissonance? • Dissonance is an observed or recognized discrepancy between the patient’s behaviors held values and attitudes. • Basically, humans do not like dissonance in their lives and once recognized they will take the necessary steps to resolve it. • The purpose of MI is to create dissonance in the patient so that the need for self-change is realized.

  12. Example: • Julie likes to garden and play with her grandchildren. But she becomes very short of breath from smoking. This creates a discrepancy between the behavior (smoking) and value (participating in her quality activities). This discrepancy results in dissonance and subsequently a desire to change (stop smoking). • By quitting the behavior that caused the dissonance, discrepancy is resolved and Julie has brought her behavior back in line with her values.

  13. Other Tools for MI • Collaboration: Spend less time giving advice and more time asking questions. Questions gain a degree of understanding about the patient’s level of ambivalence or resistance to changes in behavior that are necessary to achieve a given goal.

  14. Health Literacy • MI is about informed choices. It is important and ethical that the patient understands the information provided and how it relates to their situation and therapy. It is vital that healthcare providers are cognizant of health literacy issues and take appropriate action by assessing the patient. • Tool to use is a REALM-R Examiner • In low literacy situations, the use of simple analogies can help the provider gain understanding or insight from the patient.

  15. Question – Response – QuestionElicit – Provide - Elicit • Information is elicited from the patient so that the provider can understand attitudes, beliefs, values, and readiness to change. • After information is elicited, the provider can provide information or knowledge to induce discrepancy, or, at the right time, suggestions for change that may be useful to the patient in changing behaviors. • After information is provided, the provider again elicits more information from the patient to determine concerns or new questions that surface.

  16. Five Principles of Motivational Interviewing Roll with resistance Express empathy Avoid argumentation Develop discrepancy Support self-efficacy

  17. Rolling with Resistance • Rolling with resistance allow the provider to stay focused on resolving underlying issues brought up by the patient while avoiding getting caught up in a trap of antagonism. • Example: Patient: “I don’t need to take those pills. Even though my lipid levels are sky high, I feel good!” Reply: I hope you continue to feel well and you continue to have your lipid levels periodically checked. You just provided empathy, and opened the door for discrepancy and dissonance while avoiding a no-win argument about the value of pills to a patient who feels fine.

  18. Expressing Empathy • The ability to express empathy is critical to establishing and maintaining rapport with the patient. • Being able to express empathy is a primary skill to demonstrate understanding and caring for others. • It is important to remember that empathy be nonjudgmental even when the patient is engaged in a behavior that is clearly detrimental to health.

  19. Empathetic Listening and Responding “NOT” • Ordering, directing, commanding • Warning or threatening • Giving advice, suggestions, solutions • Persuading or lecturing • Moralizing, preaching fixing, healing, and converting) • Disagreeing, judging, criticizing, or blaming • Agreeing, approving, or praising • Shaming, ridiculing, or labeling • Reassuring, sympathizing, or consoling • Questioning or probing

  20. Developing Discrepancy Techniques: I. Ask the patient what is good (positive) about a particular behavior (e.g., not taking medications as prescribed) and what is bad about the same behavior. By repeating back the positives and negatives put forward by the patient, with examination of each in detail, discrepancy and dissonance will emerge. II. Question the patient about their goals in taking a particular medication. What this does is reinforce, in the patient’s mind, the need for taking the medication on a regular basis. When reviewed in the context of past adherence behavior, reinforcement can be a stimulator of discrepancy and dissonance.

  21. Staying in Tune with the Patient Supports self-efficacy If the patient mentions a positive intention (needed to improve adherence), it is important to recognize this and help move the patient towards the desired behavior. Patient: “I really need to be doing my blood sugar checks more regularly.” Response that supports self-efficacy “I am glad you are concerned about your health”. Follow up immediately by eliciting “Can we take a few minutes to explore some things that might be helpful with doing your sugar checks?”

  22. Get in the Habit of Celebrating Success with Your Patients and Make a Positive Behavioral Change that Melts the Iceberg.

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