to mi or not to mi - ucla health...to mi or not to mi wendy slusser, md, ms hs clinical professor...

To MI or Not to MI

Wendy Slusser, MD, MS HS Clinical Professor UCLA Schools of Medicine and Public Health Associate Vice Provost UCLA Healthy Campus Initiative

Objectives

• Describe strategies to improve the quality and consistency of pediatric counseling • Identify and describe two strategies to enhance

the practices in the prevention and management of childhood obesity

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Learning Preferences for the “Net Generation”

•  Learning and working together in teams Socially Centered

•  Structure with achievement-oriented goals Digitally literate

•  Engagement and learning about things that they feel matter to them

Constantly connected to others

•  Visual and kinesthetic educational modalities and environments

Experiential learners

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From: Chu LF et al… 2012

In order to Educate Well To Communicate Well, We: •  To nurture future Leaders in our community. Work in teams

•  And participate in quality improvement activities Set goals

•  In self directed independent projects Engage

•  Community and clinical projects Experience

•  Body, mind and spirit to support the health of residents Integrate

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Organizations & Institutions

Media Law

Popular Culture

Professional Education

Public Education

Public Parks

Community/Neighborhood

Home Visitation

Child Care

Employer

Lactation Specialists

Hospitals

Health Care

Providers

Insurers

Parent, Infant, Child

Friends/Family

Fathers

Friends

Family

Neighbors

Coworkers

To whom does the physician communicate?

Physician Communication and Counseling Skill Building Strategies ▫ Motivational Interviewing ! “... method of communication rather than a set

of techniques. It is not a bag of tricks for getting people to do what they don’t want to do; rather, it is a fundamental way of being with & for people - a facilitative approach to communication that evokes change.”

From: Miller & Rollnick 2002

▫ Asset Mapping and Mobilization From: www.abcdinstitute.org

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Fit for LA project* • Multi-component 3 year project, started 2011 •  Training UCLA residents who have continuity

clinic at Venice Family Clinic • Venice Family Clinic Simms Mann Center

population: primarily low-income, Latino, uninsured

*Funded by UniHealth Foundation

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Intervention

• Pediatric residents receive training, mentorship from faculty and other experts • Build Motivational Interviewing skills • Complete Quality Improvement projects

to enhance clinical care related to obesity prevention and management. • Asset Mapping and Mobilization

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Overweight or obesity defined as:

•  To calculate: BMI = weight / height / height x 703

•  Children •  Obese BMI for age ≥ 95th percentile •  Overweight BMI of 85th – 94th percentile

•  Adult BMI Below 18.5: underweight 18.5 – 24.9: normal weight 25.0 – 29.9: overweight 30.0 and above: obese

From: Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics, 2007.

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From: www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/module1/text/page10b.htm

BMI for Age Chart

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Overweight* Children in the U.S. (*BMI > 95th percentiles)

Source: NICHQ;JAMA. 2010;303(3):242-249; JAMA. 2012;307(5):483-490

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Why????

A. Larger Portions B. Less family meals C. No Fat child left behind D.  Lack of services for obesity prevention and management F. All of the above

COFFEE

20 Years Ago

Coffee (with whole milk and sugar)

Today Mocha Coffee

(with steamed whole milk and mocha syrup)

Calorie Difference:

COFFEE

20 Years Ago

Coffee (with whole milk and sugar)

Today Mocha Coffee

(with steamed whole milk and mocha syrup)

45 calories 8 ounces

350 calories 16 ounces

Calorie Difference: 305 calories

How long will you have to walk in order to burn those extra 305 calories?

• 83 minutes of walking • 45 minutes of cycling • 34 minutes of jogging • 25 minutes of swimming

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Stages of Obesity Treatment •  Stage 1: Prevention Plus •  Stage 2: Structured Weight Management •  Stage 3: Comprehensive Multidisciplinary Intervention •  Stage 4: Tertiary Care Intervention

From:Barlow, S Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics, 2007.

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Stage 1: Prevention Plus • Once Overweight or obesity is diagnosed. •  Focus is on basic healthy lifestyle eating and activity habits. • Goal is improved habits and as a result improved habitus

(BMI Status). •  Frequent Monitoring. From: Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report.

Pediatrics, 2007.

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Focus is on basic healthy lifestyle eating and activity habits

•  Minimize Sugar-sweetened beverages with a goal of 0**.

•  Increase meals prepared at home**. •  Education and modification of portion sizes** •  Reduction of inactive time to < 2 hours/day and if

less than 2 years old to 0 time**. •  Increasing active time for children and families to

>=1 hour each day**. •  Involve the whole family in lifestyle changes. •  Cultural sensitivity ** = strong evidence


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Focus is on basic healthy lifestyle eating and activity habits

•  Increasing to 5 fruit and vegetable servings or more per day*. •  Reduction of 100% fruit juices*. •  Consume a healthy breakfast*. •  Reduce foods that are high in energy density *. •  Meal frequency and snacking *. •  Involve the whole family in lifestyle changes. •  Cultural sensitivity


*weaker evidence, but may be important for some individuals

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Stages of Obesity Treatment • Stage 1: Prevention Plus • Stage 2: Structured Weight Management • Stage 3: Comprehensive Multidisciplinary

Intervention • Stage 4: Tertiary Care Intervention

From:Barlow, S Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics, 2007.

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Stage 1: Prevention Plus • Once Overweight or obesity is diagnosed. • Focus is on basic healthy lifestyle eating and

activity habits. • Goal is improved habits and as a result

improved habitus (BMI Status). • Frequent Monitoring. From: Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report.

Pediatrics, 2007.

22 Goal: Improved Habits and in turn

Habitus

After 3-6 months, if child has not made appropriate improvements move to stage 2.

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Stage 2: Structured Weight Management •  Targeted behaviors the same as Prevention Plus, but more support

and structure provided to the child to achieve these behaviors. •  Specific eating and activity goals with: ▫  planned diet, structured daily meals and snacks. ▫  Supervised physical activity. ▫  Monitoring behaviors with logs. ▫  Additional reduction in inactive time ▫  Planned reinforcement


Motivation – it’s complicated!

Motivational Interviewing: A Definition

Motivational interviewing is a person-centered, directive method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

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Cultural Openess Motivational Interviewing

! Strong evidence provider style, the way they talk, influences outcomes (Miller & Rollnick 2002)

! When patients are motivated and express verbal commitments to change, they have better treatment outcomes (Armhein et al 2004)

The Spirit of Motivational Interviewing

•  Collaboration

•  Evocation

•  Autonomy

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High spirit of collaboration • Clinician is not the “expert” • Willing to negotiate with the patient • Open to ideas from the patient • Avoids persuasion • Explores and support what the patient wants to

do • Patient is the “partner” (e.g., dancing)

High spirit of evocation

• Elicits the patients’s ideas about change • “Curious and patient” • Stays focused on whatever behavior change the

patient is willing to do

High Autonomy/Self-efficacy

• Accepts the patients may not choose to change • Are invested in behavior change but does not

push it in order to maintain patient doctor alliance • Reinforces ultimately any behavior change is

within the realm of the patient

How is Spirit of MI different? • Not sympathy • No emphasis on expertise (on the part of the health

provider) • Education of the patient is not considered effective

(not to be confused with Giving Information) • Does not focus on skill-building • Does not analyze unconscious motivations • Not passive

The Dilemma of Change Developing Discrepancy

Ambivalence

Exploring Ambivalence

What are the advantages of things staying just

the way they are now?

What are the advantages of changing?

What are the disadvantages of changing?

What are the disadvantages of things staying just

the way they are now?

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Steps to Meet these recommendations

OARS: The Basic Skills of MI

• Open-ended questions • Affirmations • Reflective listening • Summarize

Open-ended Questions

• “What brings you in today?” • “What can you tell me about that?” • “Tell me more about that.” • “In what ways….?” • “What have you noticed…?”

Questions

• Closed questions: will result in “yes” or “no” response. • Open Question: allows for a wide range of

information from the client.

• Don’t you think it’s time for a change? • What do you think would be better for you –

walking to the grocery store or cutting down on fast food? • What do you like about exercising? • What do you already know about our

program? • Is this an open question?

Open or Closed Questions?

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0 1 2 3 4 5 6 7 8 9 10

Goal 0-10 Importance 0-10 Confidence Minimize Sugar-sweetened beverages with a goal of 0

Increase meals prepared at home

Education and modification of portion sizes

Reduction of inactive time to < 2 hours/day and if less than 2 years old to 0 time

Increasing active time for children and families to >=1 hour each day


How important would you say it is for you to _________? On a scale of 0-10, where 0 is not at all important and 10 is extremely important, where would say you are? Follow-up: And why are you at __ and not zero? How confident would you say it is for you to _________? On a scale of 0-10, where 0 is not at all confident and 10 is extremely confident, where would say you are? Follow-up: And why are you at __ and not zero?

Cultural Openess Listen carefully with a goal of understanding the dilemma, but give no advice. Ask these three open questions, and listen:

1. What is there about you (strengths, abilities, talents) that would help you do this?

2. How might you go about it, in order to succeed? 3. What have you done successfully in the past that

was like this in some way? Reflect and summarize confidence statements

•  Elicit the patient’s understanding and needs -  What would you most like to know about ____?

-  What do you already know about _____?

•  Provide new information in a neutral manner -  Information only not interpretation

-  Information in a manageable chunk

•  Elicit what the information means to them -  What do you make of that?

-  What do you think of this information?

-  What more would you like to know?

Elicit-Provide-Elicit

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• Work in groups of 3

▫  One patient

▫  One provider

▫  One observer

Exercise #1

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Something about yourself that you...

▫  want to change ▫  need to change ▫  should change ▫  have been thinking about changing

...but you haven’t changed yet (i.e. – something you’re ambivalent about).

Exercise #1: Patient’s Topic

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• Listen carefully with a goal of understanding the dilemma

• Give no advice • Ask as many open-ended questions

• Examples of open-ended questions –  Why would you want to make this change?

–  How might you go about it, in order to succeed?

–  What are the three best reasons to do it?

Exercise #1: Provider

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• Listen carefully to the provider

• Tally the number of open-ended and closed-ended questions the provider asks

•  If possible, write examples of helpful open-ended questions

Exercise #1: Observer

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Go! (10 minutes)

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?How Did the Patient Feel How Did the Provider Feel? What Happened?

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Affirmations

•  Emphasize a strength

•  Notice and appreciate a positive action

•  Should be genuine, not cheerleading

•  Express positive regard and caring

•  Strengthen therapeutic relationship

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Affirmations may include: •  Commenting positively on an attribute ▫  “You’re a strong person, a real survivor.”

•  A statement of appreciation ▫  “I appreciate your openness and honesty today.”

•  Catch the person doing something right ▫  “Thanks for coming in today!”

•  A compliment ▫  “I like the way you said that.”

•  An expression of hope, caring, or support ▫  “I hope this weekend goes well for you!”

Reflective Listening •  It should be a statement, with the inflection turning

down at the end.” ▫ “So, you mean that…” ▫ “It sounds like you…” ▫ “You’re wondering if….” • Are statements rather than questions • Make a guess about the patient’s meaning (rather

than asking) • Yield more information and better understanding • Often a question can be turned into a reflection

•  Collect material that has been offered ▫  “So far you’ve expressed concern about your diabetes and how you

would like to get outdoors more.”

•  Link something just said with something discussed earlier ▫  “That sounds a bit like what you told me early about how

important it is to you to be there for your kids.”

•  Draw together what has happened and transition to a new task ▫  “Before I ask you the questions I mentioned earlier, let me

summarize what you’ve told me so far, and see if I’ve missed anything important. You came in because you were feeling really sick, and it scared you...”

Summaries can:


How important would you say it is for you to _________? On a scale of 0-10, where 0 is not at all important and 10 is extremely important, where would say you are? Follow-up: And why are you at __ and not zero? How confident would you say it is for you to _________? On a scale of 0-10, where 0 is not at all confident and 10 is extremely confident, where would say you are? Follow-up: And why are you at __ and not zero?

Motivational Interviewing Clinical Practice

Set Goals through Quality Improvement and PDSA (Plan, Do, Study, Act) Cycles.

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Quality Improvement Activities Set Structure with achievement-oriented goals and engaged

residents in independent projects

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Lifestyle Log

DATE / / / / / / BMI & %ile

Classification Overweight Obese Overweight Obese Overweight Obese BP & %tile Typical daily diet B:

L: D: Skipped meals: #home-cooked meals/wk: Portion size:

B: L: D: Skipped meals: #home-cooked: Portion size:

B: L: D: Skipped meals: #home-cooked: Portion size:

Vegetables (serve/day) 0 1 2 3 4 5 >5 0 1 2 3 4 5 >5 0 1 2 3 4 5 >5 Fruit (servings/day) 0 1 2 3 4 5 >5 0 1 2 3 4 5 >5 0 1 2 3 4 5 >5 Soda/Juice (cups/day) 0 1 2 3 4 5 >5 0 1 2 3 4 5 >5 0 1 2 3 4 5 >5 Snacks (type and frequency)

Milk (Type) # cups/day

Wh 2% 1% Sk 1 2 3 4 5 >5

Wh 2% 1% Sk 1 2 3 4 5 >5

Wh 2% 1% Sk 1 2 3 4 5 >5

Fast Food/wk 0 1 2 3 4 5 >5 0 1 2 3 4 5 >5 0 1 2 3 4 5 >5 Who Buys Food? Eating Habits TV w/meals

Family meals TV w/meals Family meals

TV w/meals Family meals

Physical Activity/in the past week What: Frequency: Jump rope Y N

What: Frequency: Jump rope Y N

What: Frequency: Jump rope Y N

ROS: HA, OSA sx, joint pain, bullying, mood, depression

School Performance

TV/video games in bedroom? Weekend Weekday

Yes No Hours/day: 0 1 2 3 4 5 >5 0 1 2 3 4 5 >5

Yes No Hours/day: 0 1 2 3 4 5 >5 0 1 2 3 4 5 >5

Yes No Hours/day: 0 1 2 3 4 5 >5 0 1 2 3 4 5 >5

GOALS (I.E. 5 servings F/V 2 hour screen time 1 hour exercise No Soda/Juice Portion Size Change Milk Type Limit Fast Food )

Patient Patient Patient

Parent Parent Parent

Confidence Low Med High Low Med High Low Med High Pro/Cons of Achieving Goal

Interventions (I.E. Referrals, Labs, Meds)

Follow-up Issues for Next Visit

Copyright ® 2009 Venice Family Clinic (reprint only with permission

Family Hx: __DM __HTN __Cholesterol __Obesity __CVD __early death

Asset Mapping Asset Mobilization Advocacy

Teaches residents through experiential learning to: • Work in teams • Engage in meaningful

work

Capacity-Focused Community Development

• Asset mapping is an inventory of the community’s treasure chest rather than looking

at the deficits, you look at the strengths of a community. ▫  In the process of this inventorying, important

relationships are developed.

Capacity-Focused Community Development

•  Mobilizing assets for collective action which requires organizing and harnessing the relationships that exist within the community

•  Often Asset Mapping lends itself to Asset Mobilization

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Available on www.fitprogram.ucla.edu or ttp://bit.ly/QmnRWb

Resource Guide

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Outcomes Measured • Provider knowledge, attitudes and confidence

related to pediatric obesity prevention and management • Patient BMI compared to 6 or 12 months

prior

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Methods

• 52 residents received training and mentorship • 23 completed questionnaire at baseline and

follow-up • Medical charts of all overweight or obese

patients seen in project year 1 and 2 at different time periods • 6 or 12 month BMI extracted retrospectively

Knowledge, Attitudes and Practice Questionnaire Results

Domain

Change from Pre to

Post

P-value *Significant at alpha = .05

General Knowledge (Maximum=39) + 2 0.009*

Attitudes (Maximum= 95) + 9.5 <.001*

Confidence Subdomain

(Maximum=60) + 9 <.001*

QI Knowledge (Maximum= 40) + 3.5 0.0645

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Retrospective Chart Review Outcomes for UCLA Residents at VFC

Percent of appointments where BMI percentile decreased or stabilized

12 months prior 6 months prior2

Year One 71% (n=31) 62.5% (n=8) All 6 mo: 69.4% (n=36)

Year Two 56.8% (n=118) 48.7% (n=39) All 6 mo: 54.0% (n=113)

Percentage of overweight/obese patients assessed for sleepiness within last year (6-12 months)

Simms Mann

Year One 65.6% (n=32)

Year Two 70.3% (n=212)

Blood Pressure: Percentage of hypertensive patients3 whose blood pressure decreased/stabilized (6-12 months)

Simms Mann

Year One 71% (n=7)

Year Two 70.4% (n=27)

In Summary, To Educate Well, We

Work in teams

Set goals

Engage

Inspire

Integrate

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In Conclusion Resident training and mentorship based on Quality Improvement, Motivational Interviewing and asset mapping is an effective pediatric obesity prevention and management strategy

Haiku – by Samuel Bruce, 3rd Grader May 2002

Fruit comes from flowers Fruit is very good to eat I like to eat fruit

to mi or not to mi - ucla health...to mi or not to mi wendy slusser, md, ms hs clinical professor...

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