Motivating change

CareSupport brings behavioral health techniques to physical health care management

When you’ve been trained to give advice, it seems slow, indirect and even passive to wait for people to decide on their own to make needed changes.

But that may be the most effective prescription for change. And it is a prescription that CareOregon’s CareSupport Program is taking, and taking seriously. Every member of the team is being trained in motivational interviewing.

“Motivational interviewing has been around a long time in behavioral health,” says Buck Clarke, CareSupport Behavioral Health Coordinator and a certified addiction counselor. The change is in applying the techniques to care for physical ailments and in training everyone in them.

“Everybody is involved,” he says. “The nurses, the health care guides and the supervisors. In the last six months, we’ve had a half-day and two full-day training sessions. We have coaching calls once a month individually. We also meet as a group once a month for an hour to work on motivational interviewing.”

What is motivational interviewing?

Some describe it as patient-centered therapy, Buck says. Another description says it’s more like a spirit of “being with” the patient.

“Empathy is a huge part of this,” Buck says. “What we try to do is find out the member’s story, find out where they are. You have to start where the person is.”

In a conversation, the person giving information is likely to fail if the hearer is really not ready to listen. In therapy, the therapist is not likely to be successful if the patient is not ready or willing to change.

Motivational interviewing theory considers that people weigh the pros and cons of change. If they fail to find enough immediate payback to outweigh the costs, they’ll be ambivalent to change and less likely to make it. The therapist helps people explore both sides of their ambivalence and find on their own good and sufficient reasons for making the change.

Perhaps a clinic will call about a patient who is a CareOregon member. She’s a single mother, mid 40s, with three children. She has diabetes, obesity and depression, and the doctor has been working with her for two years without progress.

“The doctor is frustrated because the patient hasn’t changed anything,” Buck says. “He doesn’t understand when it’s clear to him she is putting herself at high risk.

CareSupport will call the member and use the tools of motivational interviewing to examine ambivalence, resolve it and move toward making the changes that the doctor prescribed.

From the nurses’ viewpoint

Sheryl Sherman, RN, knows well the usual approach followed by doctors and nurses.

“Usually, we come up with a plan for our patient or member as to how we can best treat the condition,” Sheryl says. “We come up with a plan that has worked previously with the diagnosis. Then we tell them, ‘This is what you need to do.’”

For Buck’s hypothetical patient, the directive might include checking her blood sugar four times a day, and working for results below 120 mg/dl.

“With motivational interviewing, instead of telling her what I want her to do, I would ask what she is doing right now,” Sheryl says. “I try to find out why she tests twice a day instead of four times. Ask her if she’s willing to change. Ask her what she would see the change being.”

It’s important to adapt your approach, she says.

“You get more positive outcomes if you base it on the individual, their ability, their schedule,” Sheryl says.

Perhaps the best that this patient can ever hope to do is get that blood glucose down from 400 to 180. That should be considered an accomplishment to acknowledge.

“You also need to look at what they are interested in changing,” Sheryl says. “When people have more than one issue to deal with, each issue has an impact on all the others. There is a high probability of a positive outcome if you start where the member wants to start, identify what they want to change, then coach and encourage them along the way.”

Peggy Loveless, CareSupport Team Supervisor, describes CareSupport’s approach to serving members with complex care needs as holistic, patient centered, strength based, proactive and population focused.

“Employing motivational interviewing fits well as it is also a client-centered and goal-oriented approach to preparing people for change,” she says.

Entire team benefits

Including in the training not only staff members who deal directly with members but also managers, supervisors and medical directors is a major cultural change, says Rebecca Ramsay, RN, MPH, CareSupport Program Manager.

“We are changing not only the way we talk to our members about lifestyle habits and self-management issues, we are also changing the way we talk about our members,” she says. “The ‘non-compliant, resistant member’ that has us so frustrated is now a ‘member who is ambivalent about making this change’ but has identified the pros and cons for change and is setting her own agenda.

“I cannot think of a more powerful approach to take, given our unique relationship with our members and the challenges and opportunities they face,” Rebecca says. “I have to commend my staff for being so committed to our members that they are willing to learn a skill that is extremely foreign to them, and that takes a lot of patience and practice to perform.”

Motivational interviewing in chronic illness care

To Rebecca Ramsay, MPH, CareSupport Program Manager, it seemed natural to use motivational interviewing in care management for medical patients.

“I was introduced to motivational interviewing while in graduate school,” Rebecca says. “When I began working with the CareSupport teams and learning about the needs of the population we serve, behavior change theories came flooding back to me.”

Rebecca Ramsay

“I was introduced to motivational interviewing while in graduate school,” Rebecca says. “When I began working with the CareSupport teams and learning about the needs of the population we serve, behavior change theories came flooding back to me.”

The theories were reinforced at every chronic disease conference, where a common topic of discussion was helping patients improve self-management skills through motivational interviewing.

“A recent study highlighted that the provision of perfect medical care contributes a 10 percent reduction in premature death, while optimal patient health behaviors contributes a 40 percent reduction in premature death,” Rebecca says.

“If you think about this, it makes a lot of sense. There are a growing number of evidence-based guidelines that practitioners can follow for the treatment of chronic illness, for example, using a specific type and dose of medication for a patient with congestive heart failure,” she says.

“But if that patient does not take the medication as directed and also smokes and eats salty foods, that evidence-based medical advice has no effect on mortality.”

And that is frustrating to providers.

Can we help?

If you have a CareOregon member who has difficulty understanding his or her CareOregon health plan benefits, following the treatment plan you've developed, or making it to medical appointments, CareSupport may be able to help.

CareSupport's team includes nurses, social workers, pharmacists and others who can work with you and your patient. We can help if your patient has a chronic condition such as asthma or diabete, behavioral issues or social problems, such as poverty or homelessness, that makes it hard for them to follow your treatment plan.

CareSupport services are available whether the member is enrolled with CareOregon Advantage, or with CareOregon via the Oregon Health Plan.

To reach CareSupport, call Tareyn Tamez at 503-416-5753 or send her an e–mail.

For more information about the CareSupport Program, you may download an informational brochure, or review an in-depth article on the program model.