Change Communication Slides Used At The October 2010 International Summit W...
BCBS Webinar_Engaging_Members_Final With notes
1. Using MI to Engage Members in Case Management
Using Motivational
Interviewing to Drive
Member Engagement 2013
Katherine Galasso, member of MINT, CIF,
CMT, Conducting Training, Communication
and Change Management Programs at
Blue Cross Blue Shield of Massachusetts
2. Using MI to Engage Members in Case Management
Engagement Components
• Data Feeds –
Synchronized standards
for triggers and outcome
measures
• Program Design – When,
why, and how calls are
made to members
• Collaboration Strategies –
With accounts, providers,
and other programs
• Conversation – Develop
skills rather than scripts
to be prepared to handle
most situations
3. Using MI to Engage Members in Case Management
At Issue
•Nurses are not trained in sales
•Telephone case management is not the same as nursing
•Nurses often feel they are bothering members
•Common lack of confidence in the engagement effort
•Using the assessment tool as a script
•Have difficulty handling rejection
•Trained in the righting reflex
•Have difficulty switching styles
3
4. Using MI to Engage Members in Case Management
Program Difficulties
• Program expectations
• May not match member’s need (too long/too short)
• Mixed measurement of calls made vs. reached rate
• Cold calls without sound leads or triggers
• Staff makes calls between 8:00 – 5:00
• Not everyone needs case management
• Competing programs calling the same member
• Prepares scripts rather than develops skills
And our case managers are still able to engage members!
5. Using MI to Engage Members in Case Management
What Encourages Change?
• You would think that:
– Having heart failure, not being able to breathe;
loss of eyesight or digits; or blackouts when you
lose time
– Would be enough to stop smoking, drinking,
eating less nutritious foods or failing to exercise
• And yet it is not enough to change behavior
6. Using MI to Engage Members in Case Management
Myths about Change
• Making a person feel bad will lead to change
• Pointing out a person’s mistakes will lead to a
modification or learning
• Information will make a person comply
• Change takes a long time
• Star Trek Syndrome: The experts will give
information to “make it so”
7. Using MI to Engage Members in Case Management
Truths about Change
• When people feel unacceptable as they are – they
become paralyzed
• The answers are hidden inside each of us
• Individuals are the experts on themselves
• When people feel heard and believed they are more
likely to change
• When people talk about the past they stay the same
• When people talk about their hopes and dreams of
the future they are more likely to change
8. Using MI to Engage Members in Case Management
Why Motivational Interviewing?
Headlines – Change is Everywhere
9. Using MI to Engage Members in Case Management
Why Motivational Interviewing?
• Evidence (data) – science
• Anecdotal (stories) – values
• Your own experience – skill sets
– Case manager; Utilization manager; Leader
– Parent - family member
• Values + Goals/Outcomes = Effective Relationships
• The spirit of MI synchronized with values
10. Using MI to Engage Members in Case Management 10
-10
0
10
20
30
40
50
60
OEQ CEQ REF AFF
Team A
Team B
Team C
Motivational InterviewingEarly Indicators
Using MI
Percentage of Change in
MI use from June – August
11. Using MI to Engage Members in Case Management 11
Motivational InterviewingEarly Indicators
-40
-20
0
20
40
60
80
100
Sum AD w/P Emp AD
wo/P
Team A
Team B
Team C
Percentage of Change in MI
use from June – August
12. Using MI to Engage Members in Case Management 12
Motivational InterviewingEarly Indicators
Engagement Rates
0
10
20
30
40
50
60
70
80
90
100
June July August
Team A
Team B
Control
Percentage of Reached
Engagement Rate for 2
Study Groups vs. Control
Group
13. Using MI to Engage Members in Case Management
Using Motivational Interviewing
Dr. Jeffery Simmons, Director
(Presented for Katherine Galasso)
Blue Cross Blue Shield of Massachusetts
1992 – First published (substance abuse, social work)
1997 – Motivational Interviewing Network of Trainers, MINT
2002 – Second edition (health care)
2012 – Third edition (corrections, military)
2012 – MINTies = 1,200 in the world in 44 countries
MITI – Scoring process to measure proficiency (MI Fidelity)
Dr. William R. Miller & Dr. Stephen Rollnick
MI Continues to Evolve
14. Using MI to Engage Members in Case Management
Program Design Strategy
The conversation is determined by Program Design:
• Collaborate with sales / accounts / provider groups
• CM as part of the wellness effort as an opt-out rather than
opt-in construct
• Account assistance to communicate program internally and
provide members’ accurate contact information
• Maximize CM insurance skills; BCBS CM vs. provider CM is the
ability to navigate medical and insurance expertise—That is
the differentiator
15. Using MI to Engage Members in Case Management
Engagement Strategy
• Offer a brief reason for the call; set the agenda
• Get the member to talk right away
• Understand the added value as a clinician
• Develop rapport quickly
• Help the member with something
• Listen to members’ needs then connect to case management
offering
• Deliver with skilled vocal techniques
– Tone / Energy / Attitude
• Learn conversation with MI proficiency rather than a script
16. Using MI to Engage Members in Case Management
Key Components of Engagement
16
• Engaging others requires the ability to:
– Demonstrate genuine interest in answers to questions
– Avoid giving unsolicited information, advice or feedback
– Offer genuine empathy
– Explore ambivalence
– Apply the right techniques to members’:
– Stage of change
– Sustain talk; discord; and change talk
17. Using MI to Engage Members in Case Management
Techniques: Master Your Tone
Professionals must consistently sound:
– Upbeat to indicate enthusiasm
– Warm to indicate you care
– Controlled to indicate your confidence
– Clear to indicate your knowledge
• Four Components of tone:
– Speed / Volume
– Modulation / Articulation
18. Using MI to Engage Members in Case Management
Techniques: Word Choice
• Words that Cause Resistance
– Ma’am or sir
– Contractions (can’t, don’t,
won’t)
– Directive words: You should,
you need to, have you thought
about?
– Contradictory words: But,
should, try
– Triggers such as jargon, slang, or
clichés
• Words that Positively Reach
Others
– Person’s name
– Ask others for their opinions:
“What are your thoughts about”
– “What I can do for you is..”
– Words tested positive for
engaging others: You, Discover,
Easy, New, Results, Proven
19. Using MI to Engage Members in Case Management
Stages of Change
• Pre-contemplative – don’t need to change
• Contemplative – ambivalent about change
• Planning – spending time planning (thinking)
• Action – participating in new behavior (3-6 months)
• Maintenance – participating in new behavior (6-12
months)
• Relapse – starting over
Drs. Prochaska and DiClemente
Members are either in action or
ambivalence
20. Using MI to Engage Members in Case Management
Changing Nurses’ Approach to
Increase Engagement
• Master Motivational Interviewing integrated with assessment
• Understand stages of change to meet the member
• Reframe approach; inviting members to case management
• Explore to gain holistic view of the member
• Start a conversation rather than a sales pitch
• For a minimum, use MI for first and last 5 minutes of the call
(before and after the assessment) to maximize the members’
experience
21. Using MI to Engage Members in Case Management
Where to start - OARS
• Open-ended questions
• Affirmations
• Reflections
• Summaries
22. Using MI to Engage Members in Case Management
Example: Start the Conversation and
Set the Agenda with OEQ
• “I’m calling to invite you to our case management
program ”
• “I’m calling to reach out to you after your recent
medical event (activity) to see how you are doing.”
• “I’m calling to welcome you to case management”
23. Using MI to Engage Members in Case Management
Example: Make it Easy for the Member
• “It is part of your benefit”
• “It is a free program to support your health”
• “Case management is an added resource to
manage and support your health”
• “Our program gives you additional tools to
help you navigate the health care system”
24. Using MI to Engage Members in Case Management
Techniques: Open the Door - “O”ARS
• “What is going well with your recovery and what is not going
so well?”
• “What has it been like for you since your hospitalization?”
• “Tell me about your current circumstances regarding your
health.”
• “How did you explain your medical story to your family?”
• “How is your recovery process at this point?”
• “What are your particular health needs right now?”
• “If you could change one thing about your health what would
it be?”
25. Using MI to Engage Members in Case Management
Techniques/Examples: Affirmations –
O“A”RS
• Affirmations identify the strength or effort someone
brings to the process. For example:
– “You are facing some difficult issues and still working hard to
follow your treatment plan.”
– “You are dedicated to getting better with your commitment
to these changes.”
– “Your dedication to getting better is so clear as you work to
follow your doctor’s recommendations.”
26. Using MI to Engage Members in Case Management
Techniques: Reflections – OA“R”S
• Some reflections are more effective than no
reflections
• Pauses are more effective than fillers
• Use reflections and summaries to keep the call
focused, transition to new topics and control the
long talkers
• Master reflective listening to demonstrate
compassion over the telephone
27. Using MI to Engage Members in Case Management
Techniques: Summaries – OAR“S”
• As if you are picking flowers for a bouquet
• Minimum of 4 items
• Lasts about 30 seconds in length
• Follow with a confirmation
• “Did I capture that correctly?”
• “Did I get that all right?”
• Collect material that has been offered
28. Using MI to Engage Members in Case Management
Summary Examples
Offer a recap: “So far you’ve expressed concern about your sugar
levels, you can give yourself the shot, your levels spike at
times and you would like more information about diet
options. What else is on your mind?”
Offer a Link: “That sounds a bit like what you told me about the
lonely feeling you get.”
Provide a transition: “Before I ask you the questions I mentioned
earlier, let me summarize what you’ve told me so far and see
if I’ve missed anything important. You said that you are
feeling sick and it scares you…you are… it is difficult for you
to…”
29. Using MI to Engage Members in Case Management
Techniques: Empathy
• Evidence indicates the level of empathy will
determine the ability to influence
• Examples: “It must be difficult to be in recovery while
taking care of your parents.”
• “It is not easy to work full time and take time to go to
treatments.”
• “You are enjoying the process of being a parent.”
• “It is important to you to understand your
symptoms.”
30. Using MI to Engage Members in Case Management
Developing Focus
• Focus on members’ needs and
wants
• Listen for hinge point
• Look for the fit
• Remember the value you bring
• Ask more than tell
• Resist the “righting reflex”
• Implement Tricks of the Trade
CM
Resources
Hinge
Point
Member’s
Needs
31. Using MI to Engage Members in Case Management
The Righting Reflex
• Fix it
• Make it better
• I know what you need
• I’m the expert
• If you do as I say you will be better
• I had a similar situation… so I know
32. Using MI to Engage Members in Case Management
Roadblocks
Thomas Gordon Outlined 12 responses that are not listening:
1. Ordering, directing, or commanding
2. Warning, cautioning, or threatening
3. Giving advice, making suggestions, or providing solutions
4. Persuading with logic, arguing, or lecturing
5. Telling people what they should do; moralizing
6. Disagreeing, judging, criticizing, or blaming
7. Agreeing, approving, or praising
8. Shaming, ridiculing, or labeling
9. Interpreting or analyzing
10. Reassuring, sympathizing, or consoling
11. Questioning or probing
12. Withdrawing, distracting, humoring, or changing the subject
http://www.unodc.org
33. Using MI to Engage Members in Case Management
3333
The Spirit of MI
Collaboration
AcceptanceCompassion
MI Spirit
Evocation
34. Using MI to Engage Members in Case Management
The Spirit of MI
• Collaboration – partners
• Evocation – drawing forth
• Acceptance – you are okay as you are
(autonomy, you make the choice)
• Compassion – empathy
35. Using MI to Engage Members in Case Management
Empathic Listening
• Is an accurate understanding of others’ worlds
as seen from their insides rather than yours
• Occurs when the person feels heard and
believed
• Communicates acceptances without judgment
• Opens the door
36. Using MI to Engage Members in Case Management
Listening Skills Requires you to…
• Be present when you listen
– Suspend assumptions, status, judgment
– Suspend unsolicited advice or information
• Be interested – offer your undivided attention
– Quiet the “monkey mind”
– Care about the answer to each question
• Be curious - listen for understanding
– Listen for what is meant, rather than what is said
– If a question comes forward in you mind, answer it, then state it as an
empathic reflection
• Honor silence - relax into it
• Accept the person and listen with Delight!
37. Using MI to Engage Members in Case Management
Wisdom
“One of the hardest things we must do sometimes is to
be present to another person’s pain without trying to
fix it; to simply stand respectfully at the edge of that
person’s mystery and misery. Standing there we feel
useless and powerless, which is exactly how the
person feels – and our own unconscious need to
reassure ourselves that we are not like the soul
before us.” - Parker Palmer
38. Using MI to Engage Members in Case Management
Define Listening
• Focus your purpose, attention, and energy on understanding
what the person’s message means to him or her rather than
to you
• Focus: What the person is saying?
Simple Reflection
• Focus: What does the person mean?
Complex Reflection
• Listening means you are present, interested, and curious
39. Using MI to Engage Members in Case Management
Ambivalence
• It is normal!
• It is necessary
• It is a step toward change
• It is a block to change
• It is the key to unlock change
The goal of MI
is to explore
ambivalence
and increase
commitment
language
40. Using MI to Engage Members in Case Management
Getting Permission
• Simply ask: “May I share some information with
you?”
• Answer a question
• Cluster technique: “Would you be interested in what
some of my other members have found helpful?”
• Menu technique: “There are a number of things we
can talk about. We can discuss ___, ___, or ___.
Which would be most helpful for you?”
41. Using MI to Engage Members in Case Management
Menu Technique - Bubbles
Sugar Levels
Testing
Buying
Supplies
Physical
Activity
Food
What to
Watch for
Fluids
Eating Out
Symptoms
Diabetes
Pick 4-5
topics about
diabetes to
set the
agenda
from a
menu
42. Using MI to Engage Members in Case Management
Agenda Setting - EPE
• Elicit the member’s agenda
– Share what the member has revealed so far in a thorough summary.
– Then ask: “You mentioned some changes you have been thinking
about. Would it be okay with you if I shared some information and
then get your thoughts about it?”
– Wait for a sincere “yes”
• Provide information
– “Your blood levels are at x and the goal is between y and z.”
• Elicit by asking permission or for the member’s opinion
– “and I’m wondering what you think?” or “What do you make of
that?”
43. Using MI to Engage Members in Case Management
Change Agents
• When you think about people in your life who
motivated you to change…
• Who were they?
• How did they motivate you?
• What characteristics did they bring?
• Across multiple countries most report that it was the
compassion rather than the information that made
the difference.
44. Using MI to Engage Members in Case Management
Studies Indicate what Works
• Simple reflections work for understanding the
meaning
• Complex reflections are needed to move the
conversation forward
• Talk about history = status quo
• Talk about hopes for the future = change
45. Using MI to Engage Members in Case Management
4545
Principles
• Express Empathy – acceptance, understanding
• Develop Discrepancy – perceived conflict
between present behavior and desired goals
• Avoid arguments – “righting reflex”…
– No unsolicited advice, direction, feedback
• Roll with resistance – empathetic reflection
• Support Self-efficiency – empower, autonomy
46. Using MI to Engage Members in Case Management
4646
Listen for Types of Talk
• Change Talk – Possible change (s)
• Sustain Talk – Staying the same
• Dissonance (Resistance) – Upset at the process
The response to each of these is different and
makes or breaks the engagement process.
47. Using MI to Engage Members in Case Management
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Change Talk
• Types of Change Talk: “Prep”
• DARN
– Desire: I want to…
– Ability: I can…
– Reasons: There are good reasons to…
– Need: I really need to… I have to
48. Using MI to Engage Members in Case Management
4848
Commitment Language
• Types of Change Talk: “Mobilizing”
• CAT
– Commitment Talk: I’m going to…, I intend to… I
will… I plan to…
– Activation: willing, ready, preparing
– Taking Steps: I started…
49. Using MI to Engage Members in Case Management
MI Skills / Strengths
•Listen for Change Talk and reply with
–Elaboration
–Affirmation
–Reflection (complex)
–Summary (30 seconds)
50. Using MI to Engage Members in Case Management
5050
• Defending
• Arguing/Squaring
Off/Power Struggle
• Interrupting
• Disengagement
• #1 form of resistance is
compliance
Sustain Talk and Discord
51. Using MI to Engage Members in Case Management
5151
• Desire for status quo
• Inability to change
• Reasons for sustaining status quo
• Need for status quo
• Commitment to status quo
Sustain Talk and Discord
52. Using MI to Engage Members in Case Management
5252
• About the process
• Behavior
• Interpersonal (takes 2 to resist)
• A signal of relationship
deterioration
• Highly responsive to helper
style
Discord
53. Using MI to Engage Members in Case Management
5353
• Discord in Engaging occurs the member’s filters
trigger a response:
– Prior experience or expectations
– Feel judged, shamed, criticized, praised, labeled, blamed…any of the
roadblocks
• When these occur the engagement ends or is
interrupted and the CM must begin again to
reconnect
Discord When Engaging
54. Using MI to Engage Members in Case Management
5454
• Emphasizing autonomy
• Reframing
• Agreeing with a twist
• Running head start
(pros and cons)
• Coming alongside
Responding to Sustain Talk
55. Using MI to Engage Members in Case Management
5555
• Reflective
listening
• Apologizing
• Affirming
• Shifting Focus
Responding to Discord
56. Using MI to Engage Members in Case Management
5656
Engaging
• Person-centered style
– Listen
– OARS
– Learn this first - EMPATHY!
• Engaging necessarily comes first
• Engaging skills continue throughout MI
57. Using MI to Engage Members in Case Management
Examples: Handling Resistance
• “Why do I need a case manager, I have one from my
doctor’s office?”
• “How can you help me over the telephone?”
• “I don’t think I need more people involved?”
• Respond with: reflection; then emphasize personal
choice and control or Agree with the Negative
58. Using MI to Engage Members in Case Management
Techniques: Roll with Resistance
• Complex Reflections
– Amplified
– Double-sided
• Coming along side
• Agreeing with a twist
• Reframing
• Emphasizing personal choice and control
• Shifting focus
59. Using MI to Engage Members in Case Management
Motivational Interviewing Goals…
• To create a safe place to explore ambivalence
• To no longer engage in power struggles with the
person
• To give no unsolicited advice, direction and feedback
• To use complex reflections to move the conversation
forward
• To ask for change talk
60. Using MI to Engage Members in Case Management
Construct a Complex Reflection
• Member: “I’m having a difficult time with my children. They do
not listen to me.”
• Simple Reflection: “It is not easy to be a parent.”
• Complex Reflection: (What is the meaning of what is said?)
– What question would you like to ask them?
– Imagine a reply to that question.
• Then put it into a statement (complex reflection)
– “You’re scared for them.”
– “You have some fears about their future.”
– “You’re afraid of not being a good parent.”
61. Using MI to Engage Members in Case Management
Complex Reflections
• Amplification: This behavior does not cause you any
problems
• Double-sided: on the one hand…on the other
• Affective (emotion): You feel that…
• Metaphor: It’s as if…
• Continuing Paragraph: This is important and…(guess)
• Emphasizing Personal Choice: This is your choice…You know
that it is up to you
• Siding with the Negative: You know you cannot do anything
about this…
62. Using MI to Engage Members in Case Management
Measurement: Engagement Study
• Comparing use of specific elements to engagement rates
• Study tools
– Worksheet
– Recorded calls
– Engagement rates
• Parameters
– July – September, 2012
– First 12 minutes of each call
– 28 case managers in a variety of programs
63. Using MI to Engage Members in Case Management
Engagement Worksheet
Subject # ______
Employee Ext _______
MI Skills: Circle one once 3 calls are completed:
Novice * Intermediate * Advanced
Call 1: 0 – 12 Min.
Qty Message Y / N
Verification Y / N
Date _______
Time _______
Length _______
Inbound / Outbound
Comments
Open-ended Questions*
Closed-ended Questions
Reflections**
Affirmations**
Summaries**
64. Using MI to Engage Members in Case Management
Engagement Worksheet
Subject # ______
Employee Ext _______
MI Skills: Circle one once 3 calls are completed:
Novice * Intermediate * Advanced
Call 1: 0 – 12 Min.
Qty Message Y / N
Verification Y / N
Date _______
Time _______
Length _______
Inbound / Outbound
Comments
Advice/Info with Permission**
Advice/Info With Out permission
Empathy
Resistance Response Yes / No
Ye =CARES CRA CRD / No=None
Did this member enroll Y / N
65. Using MI to Engage Members in Case Management
MITI Coding System
• Motivational Interviewing Treatment Integrity 3.1.1
(MITI 3.1.1)
• T.B. Moyers, T. Martin, J.K. Manuel, W.R. Miller, & D.
Ernst
• University of New Mexico
• http://www.motivationalinterview.org/Documents/
miti3_1.pdf
66. Using MI to Engage Members in Case Management
Global Ratings
Evocation 1 2 3 4 5
Low - High
Collaboration 1 2 3 4 5
Low - High
Autonomy/ Support 1 2 3 4 5
Low - High
Direction 1 2 3 4 5
Low - High
Empathy 1 2 3 4 5
Low - High
Giving
Behavior Counts
Giving Information: MI Adherent
Asking permission
affirm, emphasize
control, support
Giving Information: MI Non-adherent
Advise, confront, direct
Questions
Closed Question
Open Question
MITI Coding System
67. Using MI to Engage Members in Case Management
Measurement: Proposed Outcomes
• Compare the number of MI Components used
• Engagement Rates for same time period
• Compare top engagers and low engagers
More to come!
68. Using MI to Engage Members in Case Management
To Change How One Communicates
• Requires effort
• Means working through:
– The Concept: The harder you work for someone else to change – the
less likely he or she will change
– The “awkwardness”
– More energy is spent on avoiding the “Awkward” then on trying
something new
• Effort means being in the awkward, passing through it, to get
to the other side when you acquire new skills as your own
Notas del editor
Thank you Julie. (Julie Pung)
And thank you all for your interest in Engagement.
Case Management is an effective supplement to our members’ care management. More than ever before our accounts are asking for case management; and a growing number providers are adding case management to their patient care strategies.
Julie Pung, MBA, FAHM
Senior Manager, Center for Clinical Operations
Office of Clinical Affairs
Blue Cross Blue Shield Association
The engagement process has a number of components including:
Data feeds that synchronize standards for triggers and outcome measures.
Program designs that determine when, why, and how members are called.
Collaboration strategies with accounts, providers and competing programs.
And the touch point moments in our case managers’ conversations with our members. That is the focus of our discussion today.
Most people are not trained actors able to make a script sound unscripted. The engagement strategy is to teach communication skills so our case managers can handle most situations rather than memorizing scripts of an if… then.. scenarios.
At Issue regarding engagement is that Nurses are not trained in sales.
There is a transition of skills from bedside nursing to telephonic nursing.
Nurses often feel they are bothering members.
There is a common lack of confidence in the engagement effort.
Some use the assessment tool as a script and have difficulty handling rejection; thought that is part of the engagement process.
Clinicians are trained in the righting reflex and often struggle to switch styles from directive to a collaborative style.
Some program designs set up barriers to engagement.
Some programs expect 20 minute phone calls, with 120 questions about the members’ medical history that has little to do with change and is information that the member already knows. The assessment does not benefit the member as much as it benefits the case management program. And the member knows that.
Collectively we may be using different measurement parameters: For example engagement may be based on calls made or a reached rate? Just because members agree to a second call are they really engaged in the process?
Cold calls without sound leads or triggers means more time calling wrong numbers than case managing members.
Calls made between 8:00 – 5:00 results in talking to answering machines more often than people.
Not everyone needs case management; and who do we let go.
Some members are receiving multiple calls from competing CM programs
Some programs emphasis adherence to a script rather than development of communication skills that enable one to handle any kind of call or situation.
In spite of all that our case managers are still able to engage members! They have a difficult job and need encouragement and opportunities to develop.
What encourages Change?
You would think that:
Having heart failure, not being able to breathe; loss of eyesight or fingers; or blackouts when you lose time
Would be enough to stop smoking, drinking, eating less nutritious foods or failing to exercise.
And yet it is not enough to facilitate behavior change
Some Myths about Change include
- By making a person feel bad about their choices they will change – consider how we talk to teenagers to get them to clean their rooms.
- Pointing out a person’s mistakes will lead to new behavior – What we know is that correcting others results in the person avoiding the person doing the correcting.
- Information will make a person comply – We spend time “educating” members and alone is a condescending approach.
- Change takes a long time
- And there is the Star Trek Syndrome: The experts will pour into the member the right information about their diagnosis and it will work to “make it so”.
Here is what we know about change.
What we know about change is that when people feel unaccepted as they are, they become paralyzed to change.
We know that the answers are hidden inside most of us about what we should and should not do for our health.
Individuals bring expertise about themselves to the process.
When people feel heard and believed they are more likely to change.
When people talk about their past, they will stay the same.
When people talk about their hopes and dreams for their futures, they are more likely to change.
The focus of the assessment tools is more about the past than the future.
So Why Motivational Interviewing?
Change is part of the foundation of health care today. The entire health care paradigm is shifting from how people access care; how people manage their own care to how health care is paid for. Change is all around and there is ambivalence about all of it.
The practitioners of Motivational Interviewing invest in data gathering about what works and what does not work. There are over 200 studies involving MI.
Anyone who has attempted to use even some MI strategies and techniques have found success. Every week a nurse or doctor will share with me a success story about turning a no to a maybe or even a yes, a member offered change talk moving toward change, or a relationship was repaired because they used the MI style in their conversation.
It is working with our UM clinicians to open discussions about levels of care, and average lengths of stay, parents working with their children and leaders with their associates. MI bridges goals and values together for better outcomes.
In 2010, I conducted my own study with Team A and B in the study group and Team C in the control group. By measuring the frequency of use of MI elements in a phone call, I was able to measure the presence of MI in the conversation. The elements across the bottom of the chart include: Open-ended Questions, Closed-ended questions, reflections, affirmations
Summaries, advice with permission, empathy and advice without permission. The graphics here indicate increased use of these MI elements. The control group received no additional training in MI beyond the basic class. The study group received additional MI practice, once a week for 8 weeks. The result for the study group was an increase in use of MI by 20%.
The engagement rates were recorded for each person in both the control and study groups over the same period of time. The data indicates an increase in engagement by 20% for the study groups A and B, while the control group stayed the same.
Our friends in BCBS of MI did a similar study more recently and had improvements of about a 40% increase of MI and engagement rates.
So we know it works and it continues to evolve to meet the changing needs of our members.
The first publication in 1992 was based on substance abuse and social workers as the practitioners. As MI expanded to include more practitioners it also expanded to more applications.
In 1997, the founders created the Motivational Interviewing Network of Trainers, or MINT, to ensure the integrity of how MI was being taught to preserve the style and how it was being adopted.
In 2002, the second edition was published and included more examples taken from the expansion into use in by the health care industry.
In 2012, there were a total number of 1200 MINTies, or members of the training community, spanning 44 countries and 14 languages. MI is now being used in correction facilities and parts of the military.
The scoring system designed to measure the proficiency of MI or the Fidelity of MI is known as the MITI. We will talk about this coding system toward the end of the presentation.
Program designs can encourage better engagement rates by the collaborations with sales and how they talk about case management, the accounts and how they promote case management internally and by providing accurate member contact information. Collaboration with our provider groups plays a role. Some of our AQC accounts attend MI training along with our nurses and doctors to encourage health behavior change and how we communicate with our members.
Programs designed as part of wellness programs add in case management as an opt-out strategy rather than talking employees into the program.
As more provider groups add case management programs of their own, the biggest differentiator for BCBS is for our case managers to be experts in the insurance side of our business. We can sell our case management programs with the notion that we have the clinical side as well as knowing how to help members navigate through the health care system.
Merging the MI Style to the Engagement process includes the following strategies:
- First offer a brief reason for the call to set the agenda
- Get the member to talk right away rather than sit through a long explanation of the program.
- Remind nurses about the value they bring to members and the power of that. For a nurse to affirm what a care giver is doing for a family member or a member for themselves is meaningful.
- Develop rapport quickly
- Help the member with something if it comes up
- Listen to the members’ needs then connect it to what the case management program has to offer
- Deliver it all with skilled vocal techniques
The case managers’ Tone / Energy / Attitude will make all the difference.
- Learn conversation with MI proficiency rather than a reciting a script – again we are not trained actors to pull off other peoples’ dialogue.
The components of MI that contribute to engagement require the ability to
Demonstrate genuine interest in the answers to the questions that we ask. Get more information by asking fewer questions.
Avoid giving unsolicited information, advice or feedback
Offer genuine empathy
Explore ambivalence
And Apply the right techniques to the members’:
Stage of change and conversation whether they respond with
Sustain talk; discord; or change talk.
The clinicians’ bed-side-manner is delivered in their tone. There is no eye contact or body language to help deliver the message. It must all be done through vocal techniques.
Professionals must consistently sound:
Upbeat to indicate enthusiasm
Warm to indicate you care
Controlled to indicate your confidence, and
Clear to indicate your knowledgeable
The Four Components of tone:
Are Speed / Volume
Modulation / Articulation
If you talk too fast you sound less confident,
If you speak too loudly and you sound uncaring,
If you stay on the same pitch you sound disinterested,
And if you mumble you seem unprofessional. Tone Mattters More than word choice!
Word choice Matters too:
Some words can cause resistance for example:
Using Ma’am or sir-seems inappropriate when discussing personal matters.
Contractions (can’t, don’t, won’t) encourage resistance.
Directive words: You should, you need to, have you thought about? Are all considered condescending and cause roadblocks.
Contradictory words: But, should, try can also cause resistance: You are doing great, but… You know nothing good is coming next.
Triggers such as jargon, slang, or clichés speak down to the others.
Words that Positively Reach Others
The sound of the person’s name, pronounced correctly
Asking for others opinions: “What are your thoughts about”
Framing things to benefit the “You” - “What I can do for you is..”
Some words tested positive for engaging others: You, Discover, Easy, New, Results, Proven
The stages of change matters as taught to use by Drs. Prochaska and DiClemente. If you are asking someone who is pre-contemplative, “So what do you think you are ready for?” you will lose them because they are not ready for that part of the conversation.
If someone shares their ambivalence: “I know I should stop smoking but it helps me manage my stress.” And respond with identifying a goal; you have missed the opportunity to facilitate change.
People in the planning stage are often miss assessed. They have invested time and energy in preparing for change. They researched the best gym; found the perfect outfit; read up about starches turning to sugar and can speak in a way that indicates they know what to do. So clinicians think that they are in action stage; even though they have yet do any thing, they just talk about it. So it requires a conversation to accurately determine which stage someone is in.
If a member has been demonstrating a healthy behavior for 3-6 months they are in action stage and 6-12 months suggests maintenance stage. People can be in action stages for testing their sugar levels and in pre-contemplative for exercise. It means you use different communication techniques for each situation.
Most people are either in action or ambivalence. If they are in action stage they need less MI or case management for that matter. Most people are ambivalent and that’s where MI contributes to successful facilitation of behavior change.
We know that when nurses use MI to engage members there is an integration of MI with the assessment tool.
- Understanding the stages of change helps meet members where they are.
- Reframing the approach to invite or welcome members to case management rather than ask if they are interested.
- Explore ambivalence to gain a holistic view of the member
- Approaching engagement as a conversation rather than a sales pitch
- As a minimum, use MI for the first and last 5 minutes of the call (before and after the assessment) to maximize the members’ experience.
Example: Start the Conversation and Set the Agenda with OEQ
“I’m calling to invite you to our case management program ”
“I’m calling to reach out to you after your recent medical event (activity) to see how you are doing.”
“I’m calling to welcome you to case management”
Example: Make it Easy for the Member to participate.
“It is part of your benefit”
“It is a free program to support your health”
“Case management is an added resource to manage and support your health”
“Our program gives you additional tools to help you navigate the health care system”
Techniques: Open the Door and get the member talking - “O”ARS
“What is going well with your recovery and what is not going so well?”
“What has it been like for you since your hospitalization?”
“Tell me about your current circumstances regarding your health.”
“How did you explain your medical story to your family?”
“How is your recovery process at this point?”
“What are your particular health needs right now?”
“If you could change one thing about your health what would it be?”
Techniques/Examples: Affirmations – O“A”RS
Affirmations identify the strength or effort someone brings to the process. For example:
“You are facing some difficult issues and still working hard to follow your treatment plan.”
“You are dedicated to getting better with your commitment to these changes.”
“Your dedication to getting better is so clear as you work to follow your doctor’s recommendations.”
Techniques: Reflections – OA“R”S is the corner stone of MI.
Some reflections are more effective than no reflections
Pauses are more effective than fillers
Use reflections and summaries to keep the call focused, transition to new topics and control the long talkers
Mastering reflective listening is important to demonstrate compassion over the telephone
Reflections will help you gain more information than asking questions – depending on your reflective listening skills.
Techniques: Summaries – OAR“S”
Is described by the image of picking flowers for a bouquet
Minimum of 4 items
Lasts about 30 seconds in length
Follow with a confirmation
“Did I capture that correctly?”
“Did I get that all right?”
Collect material that has been offered by the member
Summary Examples
Offer a recap: “So far you’ve expressed concern about your sugar levels, you can give yourself the insulin shot, your levels spike at times and you would like more information about diet options. What else is on your mind?”
Offer a Link: “That sounds a bit like what you told me about the lonely feeling you get sometimes.”
Provide a transition: “Before I ask you the questions I mentioned earlier, let me summarize what you’ve told me so far and see if I’ve missed anything important. You said that you are feeling sick and it scares you…you are working on more exercise… it is difficult for you…” I would like to go back to something you said earlier.” Then ask an open-ended question to transition to the next topic.
Techniques: Empathy
The MI studies indicate evidence that the level of empathy will determine the ability to influence
Empathy is not: “oh, I’m sorry, that is so difficult.” That is sympathy.
Empathy acknowledges the struggle from the members’ perspective and sounds like this:
“It must be difficult to be in recovery while taking care of your parents.”
“It is not easy to work full time and take time to go to treatments.”
“You are enjoying the process of being a parent.”
“It is important to you to understand your symptoms.”
The engagement process means:
A focus on members’ needs and wants
Listen for hinge point
Look for places where their needs fit your program
Remember the value you bring as a clinician
Ask more than tell – use reflections instead of questions
Resist the “righting reflex”
Implement Tricks of the Trade – for example ½ quarter of water keeps vocal cords moist – when you talk all day you need 3x the amount to fully hydrate your vocal cords.
In my role, I have listened to hundreds of calls over the past 9 years and you can hear the member’s tone change when the case manager starts to tell them what you should do, you need to, have you thought about…in the righting reflex way that many health care practitioners have been raised.
The idea that I know better than you – does more to turn off the very person you are trying to help. It is the same in parenting, leading, and other relationships.
When any of these responses are used, a roadblock goes up.
Ordering, warning, giving advice, persuading, telling people what they should do, disagreeing, or judging, questioning, or analyzing. Even praising and reassuring causes roadblocks.
If your member tells you she went running last week and you say, “Fantastic, Great job, good for you” that is praise. What will you say next week when she didn’t exercise at all? Most say, “Oh, that’s okay, you’ll do better next time.” Now you are reassuring and essentially give them exactly what they want; an out for not doing the new behavior. You set the member up for criticism when you offer praise. Though you may not say, “bad job” in contrast it will feel that way to the member.
I hear this exchange when I listen to the calls and it clearly breaks the engagement process.
The approach is to apply the spirit of MI to Collaborate, show compassion and acceptance, and evoke from within the solutions rather than offering them.
Collaborating means partnering with your member who is an expert on himself or herself
Evoking or drawing forth from within the solutions the member has beneath the surface
Acceptance suggests to the member that you are okay just as you are and do not need to be fixed. And the autonomy that allows them to make their own choices
Compassion is the expressing of empathy in a way that is meaningful for the member.
Empathic listening is an accurate understanding the world as it is seen from their eyes rather than yours
It occurs when the person feels heard and believed.
It communicates acceptances without judgment and opens the door to real change.
Listening requires you to…
Be present when you listen
Suspend assumptions, status, judgment
Suspend unsolicited advice or information
Be interested – offer your undivided attention
Quiet the “monkey mind”
Care about the answer to the questions that you ask
Be curious - listen for understanding
Listen for what is meant, rather than what is said
If a question comes forward in you mind, answer it, then state it as an empathic reflection
Honor silence - relax into it
Accept the person and listen with Delight!
Parker Palmer offers this wisdom:
Skilled listening focuses your purpose, attention, and energy on understanding what the person’s message means to him or her rather than what it means to you.
Focus on what the person is saying using Simple Reflections.
Focus on what the person means by using complex Reflections.
Listening means you are present, interested, and curious
Ambivalence is normal, necessary and a step closer to change.
If it goes unexplored it blocks change –
When you hear it expressed – it is a signal that it is presenting itself for exploration through MI. The goal of MI is to explore ambivalence and increase commitment language toward change.
You can offer information, advice and feedback once you have earned the trust through the engaging process. Only then can you ask permission to offer more. Permission comes in many forms. Here are four.
Ask by saying, “May I share some information with you?”
Answer a question that the member asks
Use the cluster technique. “Would you be interested in what some of my other members have found helpful?”
Use the menu technique. “There are a number of things we can talk about concerning your diabetes. We can talk about your sugar levels, the testing process, foods that help your levels or the role exercise plays in your levels. Which would be most helpful for you?”
To prepare for the menu technique use the bubbles to identify categories for a specific conditions as illustrated here for diabetes. Make a new set for oncology, asthma, COPD, and heart conditions.
Another method for sharing small amounts of information is the EPE technique.
Elicit – Provide – Elicit.
Using the information the member already shared, once you have developed real rapport and earned trust with appropriate empathy and all done with skilled vocal and tone; you may share small amounts of information, advice or feedback.
Reflect or summarize first.
Then ask or elicit: “You mentioned some changes you have been thinking about. Would it be okay with you if I shared some information and then get your thoughts about it?”
Wait for a sincere “yes”
Provide the information
“Your blood levels are at x and the goal is to have them fall between y and z.”
Then Elicit by asking the member’s to join you… “and I’m wondering what you think?” or “What do you make of that?”
Think about a change agent in your own life. What characteristics did they bring? How did they motivate you?
There is an exercise we do in class and the results across multiple continents suggest that change agents compassion rather than information makes the difference.
Studies indicate what works to influence health behavior change.
Complex reflections move the conversation forward better than simple reflections.
Talking about medical history results in talking about status quo.
Talking about health hopes and dreams results in change talk.
The basic principles remain the need for empathy, the ability to develop discrepancy between where a member is and would like to be; avoidance of roadblocks and righting reflex which includes no unsolicited advice or information. The ability to roll with resistance rather than confront it or argue with it and the ability to support self efficacy to empower the member’s autonomy.
Listening also means distinguishing between
Change talk – about possible change
Sustain talk – about staying the same
And Dissonance, (what we have been calling resistance) which is pushback on the process or the person.
How you respond to each of these categories is different and will make or break the engagement process.
Change talk is describe in the phrase: DARN CAT – Darn is the desire, ability, reason and need for change.
CAT refers to mobilizing language toward change based on a commitment, action, or steps to get started.
The techniques for responding to change talk is described in the acronym EARS, Elaborating (tell me more about that) affirmations, complex reflections, and summaries.
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The engagement process requires a person-centered style rather than a directive style and is done through listening, OARS and empathy. Engaging must come first before the rest of the case management process can be entered intp and then MI can continue through an integrated process with the assessment tools.
Here are two quick examples of responding with the spirit of MI to engagement resistance.
“Why do I need a case manager, I have one from my doctor’s office?”
It sounds like you have enough support for your health goals already. I’m wondering what would it mean to add another member to your team to help navigate through the health care system?”
“How can you help me over the telephone?”
You’re right it does seem more remote by telephone. Some members find it helpful to talk from the comfort of their home rather than a trip to the office and sometimes they remember something they wanted to talk about only after they left their doctor’s office. We like to provide options. What do you think?
Here is the list of techniques for rolling with resistance that are covered in MI Training. You’ll notice the bottom 5 spell out the acronym CARES to help remember them all.
The goal of MI is to create a safe environment to explore the ambivalence that keeps people from change. To stay out of the power struggle of trying to change people who are not ready with unwelcomed advice and information.
Increase the use of complex reflections and the member will get more out of the case management conversation. When you ask for change you have more of a chance of opening the door to ambivalence than by recording a member’s medical history that many would rather forget than recall.
To generate a complex reflection try this technique. If a member says:
“I’m having a difficult time with my children. They do not listen to me.”
A simple reflection might be: “It is not easy to be a parent.”
A complex Reflection has more depth and reaches for the meaning of what is said?
Think about the question you would like to ask?
Imagine a reply to that question.
Then put it into a statement to create a complex reflection
That might sound like this:
“You’re scared for them.” or
“You have some fears about their future.” or
“You’re afraid of not being a good parent.”
Here are seven types of complex reflections to help move the conversation forward that are taught in MI Training.
And that sets up the process for coding a call for MI adherence or MI Fidelity. In the study I referenced at the beginning of today’s presentation I talked about counting the MI elements. The tools for conducting the study include a worksheet to record those elements, the recorded calls, and the engagement rates for the same case managers and timeframe.
The study I conducted was over a 3 month time frame. Each call included:
the first 12 minutes of the conversation for
28 case managers in both the control and study groups
3 calls for each round scored
And a total of 3 rounds for each case manager
This is part of the worksheet I used to count the MI Elements
Here is another section of that worksheet listening for advice with and without permission, empathy vs. sympathy, and the presence of resistance and the reply.
The data was sorted by subject (or person) for each program with % of difference recorded and complied in aggregate.
The % of increased use of MI was compared to the % of increase in engagement over the same time frame.
The MI community uses a coding system called the MITI, version 3.1.1 and can be found at this web address. There are MINTies who provide scoring for case managers’ calls. The trend is for case managers to have between 3 and 5 calls scored over time to improve their MI Fidelity in conjunction with ongoing practice.
The MITI coding system measures how well the practitioner applies the spirit of MI during a call. The MITI is the state-of-the-art coding system for evidence-based clinical communication. There are variations of the coding system customized to health care.
By comparing the MI Fidelity to the engagement rates you produce evidence of what works and what does not work when engaging our members in case management programs.
The process of changing how a person communications requires:
Effort
Commitment
Practice
And willingness to be vulnerable and make mistakes
I can hear case managers doing all the work; they do all the talking and are exhausted by the end of the day.
When the case manager is doing all the talking, there is no change taking place for the member. The same is true for leaders with associates and parents with children.
The learning process requires the ability to be vulnerable and step into the “awkward”; and return to the status of novice. And that is difficult for so many people who have achieved levels of expertise in their professions. And that is what keeps people from learning MI.
Many people understand the theory. It is the practice they avoid to keep from appearing unskilled. And yet to learn, you must do it often and with feedback. To be in the awkward, take some risks to try some things that may not work. When you get to the other side you have gained a new level of skill.
Learning MI is like learning a language or learning to play an instrument. It takes time. Dr. Miller says that he gets it right about 80% of the time. Others have told me it takes about 10 years to master. It is also true that even using a little bit of MI will result in greater influence for change than if you use none.
And like anything that is hard to attain; it has greater value.
We have time for comments and questions that are on your mind.
