Featuring Valley Medical Group
This is one in a series of stories about strategies primary care practices are using to increase patient engagement. MHQP is in a unique position to learn about structural programs and innovative practices that help empower patients to be active in their own care, as we have recently completed a first-of-its-kind statewide study of patient engagement activities in primary care practices in Massachusetts with the support of CRICO.
One of the promising ideas that emerged is using Motivational Interviewing (MI) techniques in primary care.
Primary care practices are “in the business” of behavior change – helping patients identify goals and overcome their ambivalence to achieving them. MI is a focused and goal-directed approach, so it is ideally suited for engaging patients in primary care. By bringing MI into primary care, providers can more effectively engage the intrinsic motivation within the client to change his or her unhealthy behavior.
The techniques can be transformative in the primary care setting and are relatively easy to learn and spread throughout the practice. Generally speaking, a practice will designate an internal MI expert who becomes trained in the techniques and then trains others in the practice. The practice establishes a process for training new staff members and periodically offers a refresher course for those already trained.
One practice that has deployed Motivational Interviewing techniques extensively is Valley Medical Group, a four-site practice based in central Massachusetts. We interviewed John Novo, MEd, LMFT, CADC II, LADC I, who leads the MI training. Here are his thoughts about using MI in primary care:
Q: Can you first provide some perspective of what patient engagement means in your practice?
Patient engagement for us involves developing a collaborative relationship with patients, getting them to be active participants in their own care. We want them to be not just happy with their experience, not just treated respectfully and civilly. That’s part of it and that’s foundational, but that’s not the same as having patients actively engaged in shared decision-making and taking on an active role, recognizing that what they do at home is crucial to their health outcome. Very little of what happens in the office leads to behavior change outside the office. Most of what we do involves chronic care, chronic conditions, COPD, reducing smoking, increasing exercise, things that impact health and wellness. And so, it involves helping patients set goals for themselves, resolve their ambivalence about making changes, and it involves more than just telling patients what they should do. We have all kinds of ideas about what is health and what is healthy, and they are sound ideas, but it’s a big step to go from giving someone information to actually helping them make and sustain changes in their behavior.
Q: How does Motivational Interviewing help to create these behavior changes?
In healthcare, we need to give information. Typically, we say, now that we’ve told you what the problem is, here are the things you should do – you need to test your blood, you need to exercise, you need to take your medicine regularly, it’s helpful to get some good sleep, etc. People’s eyes glaze over and they leave and too often do none of it. The provider hasn’t really engaged with them on what they’re willing to do, what they’re able to do, and what’s most important to them. But with Motivational Interviewing, we provide information in a particular way that evokes more engagement. You ask a patient what their concerns are, what they’re worried about, you talk about their health or whatever they want to talk about, and you provide some information, but then you say, “Well, what do you make of that?” or “What do you think?” And you elicit from them their reaction, how they’re taking the information in, and then do that in cycles.
The focus of MI is helping people resolve their ambivalence about pursuing some behavior change. The behavior change might involve thinking differently or exercising more or drinking less, but it also might involve disruptive patterns, negative thoughts or cognitive sorts of things as well. It assumes the patients have the ability to make changes; it values their own opinion about what’s best for them; it respects patient autonomy; it involves compassion and a particular kind of spirit; and it’s collaborative. The basic assumption is everybody has trouble making difficult behavior changes; that there’s not a population of motivated patients and a population of unmotivated patients. Everybody’s motivated to do something, even if they’re not motivated to do the thing that’s in their best interest at the moment. MI has a focus, trying to find a way to help people search their own experience and figure out what they’re concerned about, what’s working for them, what’s not working for them, and help them take in information and make it their own and decide what it is – if anything – that they’re going to do.
Q: MI is a counselling technique. How have you used it in primary care?
We’ve trained not just the primary care providers, but also the nurses and medical assistants. It’s a major commitment of resources and time, the big expense being pulling providers out of providing care. But we thought it was important enough that if we’re going to hit our targets for quality and outcomes – not just process, but really affect health outcomes with chronic illness – then patients need to be engaged, they have to collaborate, and they have to make changes. And we recognize the importance of trying to improve the way that we talk to patients so that they’re much more likely to be active participants in their own care. Just telling people and giving them psycho-education and letting them know what they should be doing really has not worked well at all for many, many people. Sometimes it’s actually counter-productive. Everybody knows that cigarette smoking is bad for them. They know it causes cancer and all of that. But that knowledge in and of itself is not enough for most people to make a change. The people who have heard that and responded to it quit smoking a long time ago, and what we’re left with are the people for whom it’s a much more difficult behavior change. It serves a function in their life. It requires other changes to address things that they’re ambivalent about.
One of the key concepts in MI is that readiness to change is made up of importance plus confidence. If someone doesn’t think something’s important enough, they’re not going to pursue it. And if they also feel it’s hopeless and they’re not going to be successful or it’s too much of a change, then they’re not going to pursue it. For most people there’s a mix of both. One of the differences in MI is we pay attention to those kinds of things. We have some ways to help people recognize if this is a problem of importance or if it’s a problem of confidence. If you’ve got somebody who you’re talking to about a health issue and they just don’t feel it’s as important as you do, having a conversation about all those things they ought to do and how they ought to pursue it, it’s really not going to be very helpful. But if you’ve got someone who recognizes that they need to make a change and maybe even feels desperate about it, but they don’t know where to start and they don’t feel confidence, that’s a different conversation. MI pays attention to those kinds of things and tries to meet people where they’re at.
Q: Has this led to some sort of a culture change within the practice?
I think it did help providers think differently about how their patients get stuck – why they don’t make changes. Instead of being judgmental, it made people more empathic and they could realize we all have difficulty making behavior changes. Every one of us has something that we would like to change that we don’t change. Part of the culture change, I think, is talking and thinking about how we relate to patients and how we motivate them to make changes, rather than just lamenting the patients who don’t do the things that we think they should do.
Q: How does this relate to goal-setting?
The way MI approaches goal setting is that the goals should come from within the patient. They are hopefully influenced by the medical knowledge and the interaction with the provider, but the goal has to be one that patients think is important enough and they have some confidence in pursuing. And then the focusing part helps determine what those goals will be.
You’re trying to get people to a place where they can take some action, sometimes just a small action. For example, just getting someone to park their car further away from the door when they go to the mall is a way to increase a little bit of exercise. Part of the approach is you build on small changes, if that’s where people are at. Some people are ready to make a bigger leap and you go with that, but it’s determined by the patient. Just getting people unstuck and if they find they can do a few things then their confidence goes up and they become more willing and able to make other more significant lifestyle changes.
Q: Could you talk about the nuts and bolts about how you rolled this out across the practice?
We’ve actually done this several times, the first time was way back in 2006. And there were a few years when we didn’t do much with it and then we had another big effort last year. I divided the training into four 3-hour segments and spread those out so there were a few weeks between sessions. It’s very active training. We try to minimize the didactic talking part and we do roll-playing and exercises that break down some of the skills and practice. The idea is people would take whatever piece of it they thought they could into their practice and work on it between the sessions. For example, somebody might just work on asking open questions to elicit from patients their own perspective – I’m going to give a little bit of information and then I’m going to pause and ask the patient what they make of what I’ve just said. So those kinds of small things.
Q: How has the feedback been from your providers?
The feedback from providers has been very positive. People tell me they struggle much less with their patients and it helps with burnout because they no longer feel the responsibility for making people change. In healthcare, we have taken a lot of responsibility for outcomes – getting people to do things – and much less responsibility for our own behavior in the process. In MI, we don’t take responsibility for the outcome. What we take responsibility for and pay attention to is how we interact with our patients in a way that moves them toward change or farther away from change. Being overly directive, being confrontational, being judgmental, being overly educational, those are behaviors on a provider’s part that are less likely to lead patients to make changes and in fact may push them farther away from making changes. You’re not taking on the responsibility of getting somebody to lower their A1c or whatever, but you are fully taking responsibility for interacting with them in the way that is most likely to be helpful. Plus, it’s collaborative, so if you can engage somebody, then there’s two people working on it, there’s not just one person taking responsibility for the change.”