By Corinne Rogers, Project Manager
To say that integrated care teams are short on bandwidth is an understatement. Doctors, nurses, counselors, physician extenders, pharmacists, patient navigators and all members of the healthcare continuum work hard to help as many patients as they can yet feel like they never have adequate time. Moreover, providers are in the tricky position to treat immediate symptoms while offering preventative education. Over time, some patients may present certain behaviors that lead them to regularly return to be seen by an often overworked and understaffed care team for the same symptoms, stuck in a revolving door of illness and short-term treatment, no matter what they are told or warned. Motivational Interviewing (MI) is one strategy recommended to stop this revolving door by bridging communication gaps and facilitating behavior change that can be implemented at all levels of healthcare organizations.
MI in a Nutshell
Evolving out of addiction treatment, MI is a communication guide that has been shown to be beneficial across different health care professions, driving patient centered treatment decisions, improving health outcomes, and decreasing readmissions. Though called “interviewing,” MI is really a systematic conversation style that aims to elicit and identify change talk by evoking feelings, thoughts, and attitudes via the OARS (Open ended questions, Affirmations, Reflections, and Summaries) skills to craft questions and responses. Confidence and importance rulers are helpful framing devices when utilizing MI to measure ambivalence and facilitate change in a more targeted way. Asking questions should only comprise about ¼ of the overall conversation. MI is most effectively used when patients are already in a state of ambivalence about changing behaviors. Using the OARS principles to direct conversation during appointments can elucidate patients’ beliefs, values, and habits to discover barriers and motivations to change, which is crucial to informing an effective treatment plan.
The MI Spirit
One of the more compelling aspects of MI is its emphasis on sincerely respecting human autonomy with compassion, understanding that patients are the experts on themselves even when they need help. This mindset is known as the MI Spirit and is foundational to its efficacy. Asking open ended questions allows the care team to hear patients’ reasons to sustain behavior, reasons to change, and healthcare goals in their own words according to their own values and beliefs. Affirming can reinforce common ground between patients and caregivers in a way that helps make the patient feel heard and respected. Reflections allow patients to hear their words spoken back to them with an opportunity to make corrections and clarifications. Patient stories can be complex, so summaries allow caregivers to highlight patients’ values, competencies, reasons for change and barriers that can be addressed in a treatment plan, like flowers in a garden full of weeds.
This communication style may feel like opening Pandora’s box, but the OARS tools can help caregivers respectfully keep the conversation on track while targeting patient concerns. The MI Spirit challenges providers to explain when recommendations are important (after asking permission) using call backs from past conversations, linking the patients’ stated desires and values to the treatment decision at hand. The style of MI also allows caregivers to roll with resistance while communicating with combative, defensive, or otherwise difficult patients. Practicing the MI Spirit and OARS skills can be useful at all levels of the care team. Those who are trained in MI can listen for change talk and discern when patients may be entering a state of ambivalence and respond appropriately. OARS skills may also help with de-escalation, burn out prevention, and improved patient experience.
Slow is Fast and Fast is Slow
In healthcare, time is of the essence. Some critiques of MI state that providers do not have the time for such a conversation when addressing serious issues. However, advice and education given by providers are filtered through patients’ personal perceptions and preconceived notions, often lowering the likelihood that patients will share their provider’s urgency. MI skills work with those perceptions when discussing a patient’s health, emphasizing patient centered and trauma informed care. OARS skills work to deliver care and education so that patients may be more receptive to information, reduce readmission, and improve overall timeliness at all branches of the healthcare continuum. When incorporated into a treatment plan, MI can strategically acknowledge barriers faced by revolving door patients to promote treatment adherence. Integrating MI core skills and the MI Spirit of listening for change talk in the patients’ own language can help reinforce that their barriers and values are understood by their caregivers, so they feel more involved in their treatment rather than feeling talked at (or worse, talked down to). With MI, more may get done in a 10-minute conversation than over the course of several doctor visits.
Implementing the MI Spirit in an integrated healthcare setting can begin with using the OARS principles, i.e., focusing on mirroring the patient’s words and values when constructing questions and responses, emphasizing that patients learn better from their care team when caregivers meet them where they are. Combined with other treatment approaches, MI has been shown to be helpful with no adverse consequences. At most, MI helps patients change behaviors that negatively impact their health and quality of life. At least, it is a helpful communication guide that naturally reinforces patient centered care. MI is helpful to learn how to communicate. Effective communication makes care timelier, and timely care makes the difference between change and the revolving door.