Motivational interviewing is a counseling method that has shown considerable success in helping patients achieve change. The Case Management Society of America, which sponsors the groundbreaking Motivational Interviewing Training Institute at Auburn University, calls the approach “a proven, patient centered counseling method for addressing patient ambivalence and resistance to change.”
On August 18, Case In Point will host an overview and training session on MI, which will feature faculty member Dr. Jan Kavookjian, an associate professor at the Harrison School of Pharmacy at Auburn University, who is a co-founder of the Motivational Interviewing Training Institute there.
Today we sit down with Dr. Kavookjian to find out about MI’s exiting application to case management. (Ed. note: Be sure to check back next week in this space for Dr. Kavookjian’s top tips on implementing MI within a case management department.)
CIP Weekly: In your AU MITI program, you have trained a large number of case managers. Can you talk about the relationship between MI and case management? Why is there a good fit here?
Jan Kavookjian: We've held 12 on-site and two off-site Institutes thus far and I've learned a lot in response to this question. There are several reasons why MI is a good fit with case management. First, we know that case management typically 1) involves comprehensive disease management that includes health behavior changes in addition to treatment adherence; and 2) includes intervention with patients who are high-risk and/or poorly controlled in their illnesses/conditions.
MI is a strategy set that helps address the ambivalence or resistance that a patient likely has had for awhile about making changes—these are the mindsets that got them into high risk/uncontrolled status. We really can't generalize from one patient to another about what the barriers are—one thing we know from an established body of research is that adherence with treatment regimens and health behaviors varies significantly from one patient to another.
Motivations vary as well. This is why a patient-centered approach is so important to helping patients decide for themselves to change and for that change to last. Motivational interviewing is patient-centered and involves a “'dance” with the provider interviewing while the patient leads the movement across the floor via the responses he or she gives. When MI is done well, the interviewing elicits responses from the patient that help him or her 1) get to their own internal motivation; and 2) make the argument for change.
MI training that we've done with case managers has significantly improved not only their case retention rates, but also their patient outcomes. It's exciting and rewarding to see that kind of impact on patients who need it most.
CIPW: What types of outcomes do successful MI initiatives bring about?
JK: Many of those studies have been applied in diverse patient populations and settings. Some are structured lab/clinic studies; others are unstructured and in the natural setting. Target populations included diversity in race, age (including seniors and adolescents), gender, socioeconomic status, urban vs. rural, etc.
Regardless, when the studies are well conducted, including well-conducted MI training and a measure of intervention fidelity for the MI intervention, positive outcomes have included weight loss, dietary changes, engagement in physical activity, medication adherence, smoking cessation, adherence with return appointments, and many other positive benefits.
I collected data among our trainees about the impact of their MI training after our fifth training session and found remarkable outcomes that included not only patient outcomes, but also HCP outcomes. For patients, these included improvements in clinical outcomes and two distinct cases of patents each losing about 100 pounds after their HCP started using MI in the intervention process. The case managers indicated that the process of telephonic encounters was more efficient, more rewarding in that they felt they were making better connections with patients and really seeing/hearing patients make changes, and they felt better equipped to handle unusual cases (e.g., resistant patients). In addition, improved case retention rates were rewarded by management.
CIPW: What do you find most rewarding about MI?
JK: There isn't really one single most rewarding aspect of MI. I have a passion for MI as I have seen it work in the lives of people and relationships in my personal and professional lives. Personally, in the 10 years I've been training HCPs and students in MI, I have learned a lot myself about how to be a better friend, parent, daughter.
I have family members, like we all do, who have chronic disease that requires health behavior changes to manage. Using the old ways of telling them what they should do meant they tuned me out. Using MI, with respect for autonomy and attempts to respond with understanding, has helped them not only make changes, but also has improved the relationships substantially. In my professional life, I use it with patients in my student care teams, with my graduate students in their decision-making about dissertation progress, and with the pharmacy students I mentor through academic recovery in helping them make decisions about how to develop study habits and work on health behaviors that might be detracting from their success (e.g., drinking, lack of sleep).
Seeing outcomes from these encounters is highly rewarding in and of itself, but even in the face of no change, the preservation of the relationship that is at the foundation of MI, goes a long way toward building connections and trust. When that formerly resistant student comes back to me, asking advice because I was the one person in his/her life who didn't use a shaming/blaming approach, I feel great reward in that first step toward change. I also really enjoy training HCPs in MI—the moments of “aha” are exciting, when they 1) realize that previous ways of being with patients haven't been effective and may have done more harm than good; and 2) when they begin to succeed at developing MI skills. I hope many patient lives are impacted through the training their HCPs have gotten with me.