Home Care Chronic Disease Prevention Program

1. Home Care Chronic DiseasePrevention Program Melanie S. Bunn RN,MS A collaboration of Duke University, Division of Community Health and University of South Carolina, School of Medicine

2. Homework review • What did you do? • What happened as you did that? • Why do you think that happened? • Here’s what might have happened. • How does this impact the next time you try this?

3. Chronic Disease Management Module 1:Health/Illness, Vital Signs, Exercise, Nutrition Module 2: Motivational Interviewing Module 3: End of Life Module 4: Heart Attack Module 5: COPD Module 6: Stroke Module 7: Hypertension Module 8: Diabetes Module 9: Congestive Heart Failure

4. Module 2:Motivational InterviewingOr…“So, you want to help people change from unhealthy to healthy lifestyle choices?”

5. Objectives Discuss health behaviors people would like to change why change is difficult Demonstrate active listening techniques Describe components of motivational interviewing why to use it List the components of a SMART goal

6. 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

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

8. 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

9. Group exercise: Pre-Practice Write down three behaviors that effect your health that you would like to change Pair up; choose “a” and “b” “a” will choose a behavior off of “b’s” list and tell “b” how to change…what to do to be healthier Change roles: “b” will choose a behavior off of “a’s” list and tell “a” how to change…what to do to be healthier Adapted from HIP CHA training, 2005

10. Debrief • What happened when you were being helped? • How did you feel? • Will you change? • What happened when you were helping? • Do we sometimes try to help our patients this way? How do they respond? • Are you willing to try something different?

11. 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?

12. 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

13. Motivational Interviewing (MI) • 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

14. MI 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 it important to them • Give suggestions only when asked and as infrequently as possible

15. MI 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

16. MI general points • People change because they want to – NOT because you want them to

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

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

19. Activity • Find a new partner, decide on “a” and “b” • “a” will talk to “b” about a really challenging client situation while “b” ignores “a” and pretends to complete paperwork, look through handouts, check voicemail etc • Reverse roles and repeat

20. 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

21. How to listen • Clarify • Restate • Maintain neutrality • Reflect • Summarize Adapted from HIP, CHA training, 2005

22. 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

23. 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.

24. What is an open ended question? • Question that allows many responses • Invites a story/explanation • There is no “one – word” answer (which would be closed-ended) • Encourages people to talk

25. What is an open ended question? • Examples – which is open and which closed?: Tell me why you want to change? _____ Do you want to change? ___________ Why is this difficult for you? _______ Will it be hard to change? ________

26. Practice question skills • Did you smoke this week? • Don’t you want to lose weight? • Will it be hard to take your medications like the doctor ordered? • Don’t you know you’re not supposed to eat all that salt? • Did you do your exercises? • Do you want to get sick and die?

27. 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?

28. Willing Able Ready Stages of change

29. 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 and have no interest in change? 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?

30. 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?

31. 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?

32. 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

33. 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.

34. 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.

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

36. 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?

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

38. 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?

39. 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

40. 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.

41. 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.

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

43. 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?”

44. Optimism about change • The client has high confidence and a high sense of their ability to make the change • He/she is more likely to make the change!!! • Positive external supports can help increase confidence and/or ability. • Ask questions that can uncover these supports. Adapted from Miller and Rollnick, Motivational Interviewing, 2002

45. Optimism about change • Questions that help you define the supports most important to your client. • What encourages you to believe that you can change? • What else would help you change? • Who else would help you change? • You are one of the most important supports • You can give the client a higher sense of confidence and ability and encourage their optimism.

46. Ready • Setting goals and making plans for action • Being prepared for dealing with setbacks • Monitoring progress

47. Set and plan a goal – SMART method • If you are Willing and Able, you are Ready to take the actions needed to make your goal. • But to create success, help your client to define their goal in a way that is Specific, can be Measured, is Action oriented, is Realistic, and is set in a specific Time frame.

48. Set and plan a goal – SMART method • If you use the SMART method to set your goals, it will increase the chances that you will achieve them . • Specific • Measurable • Action oriented • Realistic • Timely

49. Set and plan a goal – SMART Method – Some examples • A goal that is not SMART will probably fail. • “I want to start walking” is not specific, measurable, nor has a time frame when the goal will be done. • “I’m going to walk 2 hours a day” is not realistic when starting out.

50. Set and plan a goal – SMART Method – Some examples • A SMART goal would be, • “I will walk leisurely Monday, Wednesday, and Friday from 5 pm to 5:30 pm at my local park [or at the mall or around the block].” • “When I achieve this in two months, I will start to walk a little faster or I will walk more days of the week or I will walk longer each time.”