Self- Management: Our

Roles as SLPs

Amy Hersh MA CCC-SLP

OSLHA Presentation March 2016

Objectives for this Presentation

• 1. Reviewers will be able to define what “self-management” means and how

it applies to the field of Speech Language Pathology.

• 2. Reviewers/participants will be able to define motivational interviewing

and list at least two principles

• 3. Reviewers will be able to define OARS and explain how OARS is used in

the self-management process

Changes and Trends in Healthcare- Scary Facts

• Recent estimates in the United States show that about one in six, or about 15%, of children aged 3 through 17 years have a one or more developmental disabilities, such as:

• •ADHD,

• •autism spectrum disorder ( 1 in 68 children),

• •cerebral palsy,

• •hearing loss,

• •intellectual disability,

• •learning disability,

• •vision impairment,

• •and other developmental delays

• References from CDC

• Developmental Disabilities: Delivery of Medical Care for Children and Adults. I. Leslie Rubin and Allen C. Crocker. Philadelphia, Pa, Lea & Febiger, 1989.

• 2.Boyle CA, Boulet S, Schieve L, Cohen RA, Blumberg SJ, Yeargin-Allsopp M, Visser S, Kogan MD. Trends in the Prevalence of Developmental Disabilities in US Children, 1997–2008. Pediatrics. 2011; 27: 1034-1042.

•

Additional Information ( www.ohsu.edu) Condition

National

prevalenc

e

Oregon

prevalen

ce Data source

Alzheimer's

disease 4,500,000 72,000

National Institute of

Neurological Disorders

and Stroke

ALS

(amyotrophic

lateral sclerosis)

30,000 500 Amyotrophic Lateral

Sclerosis Association

Anorexia,

bulemia and

binge disorders

5,241,600 78,600 National Institute of

Mental Health

Anxiety disorders 19,100,00

0 286,500

National Institute of

Mental Health

Ataxia 150,000 2,300 National Ataxia

Foundation

ADHD

(attention deficit

and hyperactivity

disorder)

17,400,00

0 261,000

Children’s Disease

Center/ National

Institute of Mental

Health

Autism 4,600,000 7,000 National Institute of

Mental Health

Bipolar disorder 23,000,00

0 345,000

National Institute of

Mental Health

Blephoraspasm 80,000 1,200 National Organization

for Rare Disorders

Blindness and

visual

impairments

10,

000,000 150,000

American Foundation

for the Blind

Interesting…….

• “In a review of the literature, Christensen found that rates of nonadherence to treatment recommendations are 20% to 40% for acute illness, 30%-60% for chronic illness and 80% for prevention. Often the result is reduced treatment effectiveness and poor health outcomes, as well as increased financial and social costs.” Levensky, E.R, Forcehimes, A, O’Donohue, W.T, and Beitz, K, 2007. Motivational Interviewing: An evidence-based approach to counseling helps patients follow treatment recommendations. AJN, vol 107, No. 10, pp 50-58

NIH- Fact Sheet For Self-management (2010)

• Chronic Disease:

“ Almost one in every two (133 million) adults has at least one chronic disease.

These diseases result in limitations in daily living for about one fourth of those

living with them. Although chronic diseases are among the most common and

costly heath problems, self-management research has improved our ability to

maintain a high quality of life even with these conditions”

We can’t do it alone!

• Self-management helps everyone but what is it, and how does it make an impact?

• Literature of Self-Management falls back into the 60’s as a tool used to help with children with asthma*. It is now prevalent in many chronic care conditions ( addiction, diabetes, autism etc)

• Self-management is easily applied into all aspects of health care and falls easily into the scope of practice for the SLP. It can be applied to children, adults and caregivers.

*Creer, T. Renne C, Christian W: Behavioral contributions to rehabilitation and childhood asthma. Rehabilitation Literature. 1976, 37:226-232, 247

What is Self-Management?

Yesterday -NIH Fact Sheet 2010

• Yesterday:

• The utility and effectiveness of self-management practices were not well studied or

accepted.

• There few medications, therapies and treatments that patients could use at home.

• Patients were often expected to follow prescribed medication and treatment

regiments with little understanding or knowledge of their use of purpose

• Little or no capacity for tele-monitoring

Today- NIH Fact Sheet

• “Research demonstrates that self-management strategies improve patient outcomes by empowering patients to understand their conditions and take responsibility for their health.”

• Think about it. If we consider the time we spend with our patients – lets say one hour per week over the course of 168 hours per week- our direct encounter figures to be .000595238% of that weeks time.

How Can We Define Self-Management?

• We start by recognizing the core self-management skills. These include:

• Problem Solving- people are taught how to problem solve effectively- not just given solutions

• Decision Making-providing families with key information they can use to make decisions

• Resource Utilization- not just telling families about resources but showing them how to access ( ie “speakingofspeec.com” website- families need to be shown how to navigate)

• Facilitation of patient and health care provider partnerships-families need to be taught what to recognize as improvements or problems so they can be accurate reporters and decision partners

• Development of action plans with confirmed implementation that is achievable- carrying out a new ( changed) behavior that is tailored to the patient and/or the family

• Lorig K, Holman H: Self Management Education: History, Definition, Outcomes, and Mechanisms. Ann Behavioral Medicine. 2003, 26 (1): (1-7)

But how can we help families develop these

skills for themselves?

• Consider Practicing and Implementing Motivational Interviewing In Your Sessions…..

• Guided by these principles:

• Motivational Interviewing must be an expression of empathy via reflective listening- showing that you are accepting of the situation

• Motivational Interviewing is clinician guided questioning that helps the patient recognize a discrepancy between an identified goal and current behaviors that would impede that goal attainment ( ie he refuses to eat a variety of foods, but I only buy him the things he will eat).

• Clinicians need to meet resistance to change and roll with it. They need to understand that change is hard and is often met with resistance and that motivational interviewing emphasizes autonomy with an emphasis on supported problem solving.

• The clinician supports self-efficacy- the patient or caregiver must be confident that a change can be made and the SLP MUST BE CONFIDENT IN THE PATIENT/CAREGIVER

• McFarlane, L.(2012). Motivational Interviewing: Practical Strategies for Speech-Language Pathologists and Audiologists. Canadian Journal of Speech –Language Pathology and Audiology,36, page 11.

Motivational Interviewing Uses OARS…

• O- open questions- “ If Bobby’s behavior doesn’t improve, what might happen with his friendships over time?”

• A- Affirmations ( genuine statements of appreciation/recognition of skills that are factual) –”By telling us about Bobby’s behavior, we can tell how seriously you are considering this challenge and it’s potential outcomes”

• R- Reflections-convey that the family has been heard, and that you have a relationship with them- ‘You’re concerned about Bobby’s behavior but don’t want to label him because he might grow out of it’

• S- Summaries-consolidated informative statements- positively highlighting strengths and linking ideas towards a change.

• McFarlane, L.(2012). Motivational Interviewing: Practical Strategies for Speech-Language Pathologists and Audiologists. Canadian Journal of Speech –Language Pathology and Audiology,36, pages 12-13.

Motivational Interviewing

So What Can Motivational Interviewing Look

Like?

Summary of What We Saw…. OARS!

• Open ended questions-an opportunity for the patient or family member to set the stage

• Affirmations-genuine statements of appreciation

• Reflections- expressions of empathy-” on the one hand and on the other”

• Summaries- consolidating the information so that the clinician communicates that information is understood and that there is an agreed upon goal.

• MI is an “integrated, goal oriented approach and guiders skillful, strategic us of communication techniques to achieve specific therapeutic outcomes” McFarland, L. (2012). Motivational Interviewing: Practical Strategies for Speech –Language Pathologists and Audiologists. Canadian Journal of Speech- Language Pathology and Audiology, 36, 11

What We Also Saw…

• A visual support- to help build understanding of rote facts

• The use of a confidence rater- scales that range from 1-0 are often used to help a patient express how strongly they feel about accomplishing a goal, task or skill – how confident they feel about making a small change in their daily life that could impact their outcome.

• Language that was encouraging but not judgmental or authoritative- we saw three important communication skills- ASKING, LISTENING, and INFORMING- These skills are used in eliciting “CHANGE TALK”

• Body language and facial expression that was not assertive or dismissive

What we did not see…

• We did not see any effort to “trick” the patient into what she did not want to

do. “Motivational Interviewing is a skillful clinical style for eliciting from

patients their own good motivations for making behavior changes in the

interest of their own health” or the health of the loved one they care for.

• Rollnick, S., Miller, W.R.& Butler, C (2008) Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press

Application to SLPs and Audiologists

• Although there are no studies of MI use in pediatric practice in these disciplines, there have been reports and studies from other health care providers. MI has been used in programs providing support and education to parents of children with health and psychosocial needs”

• Gance-Cleveland, B. (2007) Motivational interviewing: Improving patient education. Journal of Pediatric Health Care, 21, 81-88

• “Sindelar, Abrantes, Hart, Lewantder and Spirito (2004) also reviewed MI use in pediatric settings and concluded that MI supported current patient –centered approaches to healthcare and was an appropriate method for use by pediatricians and other health providers.”

• McFarlane, L.( 2012) Motivational Interviewing: Practical strategies for Speech –Language Pathologists and Audiologists. Canadian Journal of Speech –Language Pathology and Audiology – Vol. 36, No.1 Spring 2012 page 10

Hypothetical Scenario….

• A family has a little boy diagnosed with ASD. He is four years old. He is non-verbal and needs a communication system and a visual schedule to help with his behaviors. The child has seen multiple providers, all recommending the same supports and communication strategies. The family is resisting using a visual schedule in the home as the family does not feel that their son understands the point of the schedule and they are convinced that using a schedule in the sessions has contributed to the behaviors impeding his progress. The family has recently started therapy with a new team, a speech pathologist and an occupational therapist. The first session was spent deciding what was a priority for the family- what would success look like. It was decided that success would be a reduction in behaviors around transitions. A “first- then” and instructions were given to the family after the first session. Instructions with respect how to use the first –then board were given and demonstration was provided. The second session began like this…..

MI and the reluctant parent…

SLP: “So tell me how it went with the First –Then board this week.”

Parent: “We tried it once but he just shoved it away”. It doesn’t seem like he wants to use it and it just makes him mad.”

SLP: “So sounds like it’s been super challenging for you- especially if he’s pushing it away”. I think it’s great you tried it though.” Would it be ok if I told you a little background information about visual supports how they can help kids with autism?”

Parent: “ I guess so, but I really can’t figure out how these things can help.”

MI and a reluctant parent…

• SLP: So lots of families have told me this before. I can start by saying visual supports for kids with ASD are very common. They are used to help kids understand what to expect – where they are going, when they are going to be rewarded. We look to a calendar to remind us when we are going to be paid too. How would it look if we didn’t have a calendar to plan or remind us when we can expect a reward.

• Parent: yes- but that’s different..

• SLP: Tell me what you mean by “different”.

• Parent: Well I look at it all by myself – he still needs to be guided to it.

• SLP- Can you think of other times that you have to help direct him to finish or complete things?

• Parent: I can’t thing of anything

• SLP: Can I give you an example ?

• Parent: I guess

• SLP: How about getting dressed or putting on his shoes. A First – Then Board would show him first – we get dress then you get iPad time. Once the kids learn the “contract” of “ I do- then I get paid’, it gets a lot easier.. This sort of visual support has a lot of evidence behind it that I can share with you if you want.

MI and the reluctant parent

• Parent: I tell him what we are going to do…I know he understands, he just doesn’t want to do what we are going to do.

• SLP: So you’ve been verbally telling him what to do and where to go for a while now right? But he still has trouble with transitions right?

• Parent: Yeah- that’s all we do…

• SLP: So knowing what we know about visual supports and how they can help with transitions, what do you think might help transition “Bobby” from the house to the car?

MI and the reluctant parent…

• Parent: I don’t know! I guess I could try it again…

• SLP: Well would you mind if I made a couple more suggestions for you to try and you could choose the one that works best for you?

• Parent: sure-

• SLP: You could try having the reward already in the car and available for Bobbly to see. This way when he sees that it’s time for the car, he might be motivated to get in. Or you could give him little parts of a reward as he walks to the car- like bits of the cookie he’s about to get once he gets in his car seat. Do either of these ideas seem helpful to you?

MI and the reluctant parent…

• Parent: I like the idea of him seeing a toy in the car- we keep a travel bag in

the car anyway….

• SLP: So on a scale of 1-10, how easy do you think using the First- Then

Board will be for you this week? Say if we use it three times….

• Parent- Well we gotta try it…I guess

• SLP: Let’s do it! Would you want to try today as we are leaving today?

Concluding thoughts…

• So not all interviews are going to be easy- change is scary and hard for many

people….

• Self-management will look different for each and every patient and success

can be impacted by a host of challenges:

• Education, age, access, finances, transportation, other family members, health issues,

child care, schedule conflicts (school, extra curricular), insurance coverage

Concluding thoughts….

• Keep your focus on goal attainment and removing obstacles by providing

information and resources

• Remember you are developing a healthcare relationship- an alliance that

helps families help themselves.

The Joint Commission

• Effective Communication is….” the successful joint establishment of

meaning wherein healthcare providers exchange information, enabling

patients to participate actively in their care from admission through

discharge, and ensuring that the responsibilities of both patients and

providers are understood. “

The ASHA Leader, March 2016 page 40.

Helpful Resources

• Rosengren, D. (2009). Building Motivational Interviewing Skills: A

Practitioner Workbook. New York: Guilford Press.

• Rollnick, S., Miller, W.R., & Butler, C. (2008) Motivational Interviewing in

Health Care: Helping Patients Change Behavior. New York: Guilford Press.

Articles…

• McFarlane, L: Motivational interviewing: practical strategies for speech-language

pathologists and audiologists. Canadian Journal of Speech-Language Pathology and

Audiology. 2012, Volume 36, No.1.

• Lorig, K. & Holman, H: Self-management education: history, definition, outcomes,

and mechanisms. Annals of Behavioral Medicine. 2003, 26 (1): (1-7)

• Behrman, A. (2006). Facilitating behavioral change in voice therapy: The relevance

of motivational interviewing. American Journal of Speech –Language Pathology,

15, 215-225.

Links/websites

• http://www.ninr.nih.gov/

• www.motivationalinterview.org- their mission is to promote quality training

of MI

• www.asha.org/policy

Special Appreciation….

• A very special thank you to Gina Blume, Karen Rizzo, and Irv Wollman of

CCHMC who were kind enough to share their materials, experiences and

knowledge about this important topic!!