Melanie Bunn, RN, MS

1. Train the Trainer:Home CareChronic Disease Prevention for CNAsA collaboration of Duke University, Division of Community Health and University of South Carolina School of Medicine Melanie Bunn, RN, MS

2. Objectives • Identify potential impact of home care aides on client outcomes • Demonstrate motivational interviewing strategies • Discuss use of adult learning principles, multiple intelligences and experiential learning model • Describe strategies for integrating curriculum into current systems of care and training

3. Purpose of the program • Increase home care aides understanding of common chronic diseases • Introduce motivational interviewing as a strategy to improve client compliance with lifestyle choices • Improve personal lifestyle choices of home care aides

4. Nine 1.5 to 2 hour sessions: Health and Illness Motivational Interviewing End of Life Chronic disease modules Myocardial Infarction Chronic Obstructive Pulmonary Disease Diabetes Hypertension Congestive Heart Failure Cerebral Vascular Accident Structure

5. Outcomes of pilot program 2 NC cohorts 4 SC cohorts 60 first day participants 42 completers 100% female 63% African American, Black, African 33% White 3.6% Other 29.8% with chronic health problems • 41 first day • 34 completers • 78% female • 94% Africa American, Black, African • 3% White • 3% Other • 48.5% with chronic health problems

6. Outcomes of pilot • Improvement in disease management knowledge • Improvement in communication between CNAs and patients • Increased belief in the importance of self-care and lifestyle choices • For patients and self

7. Subjective responses • Listening better to their patients • Being more empathetic • Talking with patients about healthy eating and encouraging them to take their medications • “This has really changed my life. I have been a CNA for almost 30 years. This class is different from any other I have been to because it not only teaches you how to take care of the patient, it teaches you how to take care of yourself.”

8. Impact of Home Care Aides Objective 1 Content from Module 1 Health and Illness

9. What’s the role? • Focus is on their potential contributions in the situation of dealing with changes in home clients • Reinforced throughout each module

10. Managing change • The home care aide may be the first person to notice changes in the client • Their responses may make the difference between: • Hospitalization and home management • Suffering or comfort • Life or death

11. 4 steps to dealing with changes • Step 1: Watch for changes • Step 2: Gather information • Step 3: Report what you’ve found • Step 4: Document your findings

12. Step 1: Watch for changes • Small changes may mean big problems. • Older people and people with several health problems have more trouble recovering from illness. • SO…they get sicker faster • AND…take longer to recover • The sooner we notice something wrong- • The sooner we can start to fix it… • The more likely we are to get a better recovery.

13. Atypical symptoms and signs • Often older people don’t respond to being sick the way younger people do. • First sign of a problem might be confusion or behavioral changes • Vital signs might not change • They might not complain of symptoms • The symptoms they do tell you about might be vague (“worn out”)

14. Kinds of changes to look for: • Anything that is different for this client • Anything out of normal limits • Physical • Functional abilities • Routine changes • Thinking problems • Emotions • Behaviors

15. STEP 2: Gather information • When, where, how long, how often, how bad • Use your senses • Look • Listen • Touch • Smell • Instincts

16. Trust your instincts If you think or feel something is wrong, but just can’t put your finger on it, ask for help!

17. Step 3: Report what you’ve found • Be specific • What do you see, hear, feel or smell? • Describe - don’t label the problem • Explain why you’re concerned • How is this different from normal? • Behave professionally • Treat people like you want to be treated • Try to understand other people’s situations

18. Step 4: Record what you found and what you did • Symptoms • What did the person say? • Signs • What did you see/hear/feel/smell? • Who did you tell? • What did you do? • What was the response?

19. Let’s try it!!!

20. Motivational Interviewing“So, you want to help people change from unhealthy to healthy lifestyle choices” Objective 2 From Module 2: Motivational Interviewing

21. What health behaviors do people say they want to change? • Stop smoking • Get more exercise, physical activity • Improve their diets, nutrition • Lose weight • Stop/reduce alcohol use • Take medications correctly

22. Why do people change their health behaviors? • Fear of consequences • Fear of loss • Finances • Relationships • Health

23. Why do people not change? • Fear of failure • Lack of support • Lack of knowledge about why change is important • Lack of confidence in ability to change

24. Opening the discussion • How can we help our clients not only change… but change because they want to change, not because someone else wants them to change?

25. A new way of helping…motivational interviewing! • First • NEVER give medical advice • Then • Be a role model by making healthy choices yourself • And remember • All information is confidential/based on agency requirements

26. Motivational Interviewing • Client centered, directive method to help people become motivated to change • FIRST: Find out what is important to the client • THEN: Use this to motivate the client to change • A method to help people change for themselves

27. General points • Start by establishing rapport and trust • Promote motivation by asking open ended questions that allow the client to: • Discover for themselves the reasons for their habits • Discover what is important to them • Give suggestions only when asked and as infrequently as possible

28. General points • Avoid arguing, even when you strongly disagree with a client’s reason for having a habit • Realize that clients will be at different stages of being ready to change– accept the client’s level of readiness for making a change this time—”Go WITH the resistance!” • Avoid being judgmental – accept the clients reasons for not making a change in their habits • People change because they want to – NOT because you want them to

29. Motivation to change • Knowledge alone does not usually lead to change • People also need to become motivated to change

30. Getting started • The first step is to create a partnership • Trustful partnerships are created by: • Listening • Asking questions

31. Listening • What makes a good listener? • Body language • Sit forward • Nod • Do not do other activities at the same time • Make eye contact • Do not interrupt • Do not judge

32. How to listen Clarify  “ could you explain that more” Restate “what you are saying is….” Remain neutral  nod, “uh- huh..” Reflect  “it sounds like….” Summarize  “if I understand correctly..” Adapted from HIP, CHA training, 2005

33. Two kinds of questions • Closed ended questions • Open ended questions • A key to effective MI is getting the client to think more deeply about the effects of their health behaviors. • This can be done by asking open ended questions.

34. Questions not to ask • Why don’t you want to change? • How can you think you don’t have a problem? • What makes you think you are not at risk? • WHY are these “bad” questions?

35. Willing Able Ready Stages of change

36. Willing • Do you want to change? Why? • What do you want to change? • How important is it to you to change? • Are you happy where you are? OR • Are you torn between wanting to change and staying the same (“on the fence”)? OR • Is your desire to change strong enough for you to start taking action?

37. Able • Do you have what it takes to change? • Ability? • Confidence? • Can you overcome the barriers and setbacks that can make it difficult to change?

38. Ready • If you are willing and able: • How will you do it? Do you have a plan? • Can you “troubleshoot” as your plan unfolds? • Are you prepared with alternate plans if barriers and obstacles arise that can cause setbacks? • Are you prepared to monitor your progress?

39. Willing – How motivated are you to change? • This exercise helps you more clearly define all the reasons you have for: • Not changing – your resistance to change; and • Changing – your motivation to change • In this exercise you will answer some questions that will help you fill out a chart called a Decision Balance Chart

40. Decision Balance Chart • Look at your “Decision Balance” handout • On the left side, you’ll answer questions that will help you become more aware of the reasons you have for not changing. • On the right side, you’ll answer questions that will help you become more aware of the reasons you have for changing.

41. Decision Balance Chart • Write down one of the health behaviors you wrote down at the beginning of the class • Your answers on the Decision Balance chart will inform you on how motivated you are to achieve this goal • Or stated another way: • The balance between the left side and the right side will tell you how WILLING (motivated) you are to change.

42. How WILLING Am I to Make the Change Needed to Achieve My Goal? Behavior:

43. How WILLING are You to Change? • Consider the importance you give to your reasons for not changing and to your reasons for changing • Compare these and use the “Ruler of Change” to score how important making a change is to you. • On a scale of 0 to 10, how important is it to you to make a change?

44. Are you WILLING? • Three possibilities: • 1. No, score 0-3 • 2. On the fence, 4-6 • 3. YES, score 7-10

45. Are your reasons for staying the samestronger than your reasons for changing? • If so (score 0-3), you’re not quite willing to change. • How can you help someone who is not thinking about change? • Help them increase their motivation and/or decrease their resistance so they start thinking more about making a change • Ask, • What would it take to reduce your reasons for staying the same? • What would it take for you to increase your reasons for changing?

46. Are your reasons for staying the sameabout the same asyour reasons for changing? • If so (score 4-6), you are thinking about change but are split between taking action and staying the same • When you’re “on the fence” like this, its hard to take action • How can you help someone who “on the fence”? • Ask questions to help them increase their motivation and/or decrease their resistance so they can get over the fence to the side of taking action

47. Are your reasons for changing greater than your reasons for staying the same ? • If so (score 7-10), you are not only thinking about making a change but you are willing to prepare and take some action to make a change. • How can you help someone who is ready to take action? • Help the client make a good plan so they are more likely to achieve their goal • The plan should be Specific, Measurable, Action oriented, Realistic, and has a Time frame for completion.

48. ABLE - Assessing your confidence and ability to achieve your goal • Understanding your confidence and ability can help you: • Redefine your goals if your sense of confidence and ability is low (such as, start with smaller goals) • Start thinking about what it would take to increase your confidence or your ability to change.

49. ABLE: Confidence and Ability • Score your confidence, from 1 to 10, to make a change • Score your ability to make change.

50. Increasing your confidence and ability to change • Increase your success by asking questions – evoking change talk: • Ask yourself, • “What would it take to increase my confidence to make this change (the change being eating smarter, moving more, stop smoking, etc)?” • Ask yourself, • “What would it take to increase my ability to make this change?”