Last week Dr. Jan Kavookjian, co-founder of the Auburn University Motivational Interviewing Training Institute, made the case why case management and motivational interviewing (MI) are a good fit for achieving best-case outcomes. Today Kavookjian discusses how to begin to implement an MI program within a department.

(Ed. Note: On Wednesday, August 18, Case In Point will host a training session on MI, which will feature Dr. Kavookjian as a faculty member. To read more about the MI Training Institute, click here.)

CIP Weekly: What are the top ways for case managers (or departments) to begin an MI implementation?

Jan Kavookjian: This is a challenging question. We often have “lone wolf” case managers come through our training who will be going back to an atmosphere where an MI culture is not the prevalent way of being, and they ask this question in looking for solutions about how to approach management for bringing it on board more fully, and for how to develop a core mass of colleagues who will also embrace MI and reinforce through their interactions the skills they got in the training.

We also have organizations which have plunged into the training and 1) consistently send all of their new hires through and 2) have MI working groups which continue to practice skills development in a structured way when back at the workplace. We have also had a couple of health plans bring us onsite to train 50-80 case managers all at once, with self-administered continuous skills development reinforcements later.

For development of an MI culture at a case management site, regardless of which of the above applies, my first recommendation is to use MI to help your colleagues decide to make changes. Sometimes that involves simply starting a conversation using an open-ended question like, "Hey, what do you know/what have you heard about motivational interviewing as an evidence-based way of talking with patients that helps achieve better outcomes?"

The next response is to ask permission to fill in the blanks: "May I share with you some of the things I've learned from the literature?" There are lists out there that include many of the published MI studies; I have a PhD student who has been generating and updating a list of randomized controlled trials (and reviews and meta-analyses) of rigorous studies of MI interventions for chronic disease management and other target behaviors I'm interested in. If anybody would like to have it, e-mail me and I'll be happy to send it to you.

Going into that conversation with management and/or colleagues with an eight-page list of well-conducted studies in hand is helpful in referring to the evidence and not just your opinion. My second recommendation is to get good training and get as many trained as you can in order to develop a culture of MI in your case management workplace. Even if you can get at least one other person to come with you to help reinforce skills development in the work setting after the training, this is helpful.

Regardless, getting good training is important. Be sure it is an evidence-based training that is based on adult-learning theory. One important thing we have learned is that training health careproviders (HCPs) in MI is very different than training mental health professionals. Most HCPs don't have training in psycho/social and behavioral issues that contribute to or pose barriers to health behavior change. Most HCPs haven't been trained to respond empathically, and most have been highly rewarded for communicating in a clinical interrogation mode. For most, this mode feels successful because it feels efficient and it feels like something is being accomplished when the patient agrees to follow our advice.

Unfortunately, that agreement is often short-lived because this type of interviewing produces short-term external motivation. Awareness-raising about the problems this type of communication produces in patients is a key foundational piece to helping HCPs decide to change their way of talking with patients.

Our training is an intensive two-and-a-half days of progressively complex exercises—these are structured around comprehensive disease management cases, with co-morbid conditions and clinical indicators. The trainees are guided through exercises intended to first develop the cognitive aspects of MI before we expect them to apply the skills in role playing.

We then use an active feedback process to reinforce the learning of all in the small groups we use for the skills development applications. I really worry about training that lasts less than a day and puts people into role-playing too early, before they are ready. This sets them up for failure and can reduce self-efficacy and the likelihood of using MI in their future practice lives.