Self-Management Support in the Person
Centered Medical Home
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A person-centered directive method for
motivating change by exploring &
resolving ambivalence.
◦ MI comes into play when a person is painfully aware of
“being stuck in the muck” being conflicted about their
ability to move forward.
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Motivational Interviewing (MI), a counseling
methodology developed over the past 25
years, initially arose in the addiction
treatment field.
The goal of MI is to encourage change-talk
and discourage resistance-talk.
The more a person makes the case for
change, the more likely they are to actually
make changes
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Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self – Efficacy
•These four principles assist a person in gaining
awareness of the thoughts and feelings that are the
foundation for their behaviors.
• By increasing such awareness, MI enables a person to
resolve ambivalence and pursue alternate behaviors.
Empathy is I respect (understand) your pain
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Empathy is the prelude to the work of MI.
Through the respectful and appreciative
understanding of a persons experiences:
 we help expand their awareness
 create openness
facilitate change.
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Awareness of the gap that may exist between
present behavior and important personal goals
and values.
This is the discrepancy between where the
person is now and where they intended to be.
Remember this is GO Ave.
“Connect not Correct”
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Respectfully explore a persons underlying
feelings needs & desires.
Shifts from:
◦ Correction to Connection
◦ Competence to Confidence
Pushing back against resistance can move
people backward in their readiness.
“People do not resist change, they resist being changed”
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By bolstering a persons convictions that
they are able to achieve and maintain their
goals over time it;
◦ Enables a person to become self-confident
learners who can boldly take on and master
challenges.
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Until & unless a person believes they can
achieve their goals;
◦ They will never even attempt to fulfill them
◦ That’s the power of self-efficacy
“Whether you think you can or you can’t, you’re
right”
Open Ended Questions
• What?
• How?
Reflective Listening Statements
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Simple
Amplified
Double-sided
Shifted-focus
Rulers
• Willingness
• Confidence
• Readiness
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OEQ are questions that require multiple words to answer,
rather then one or two.
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More then 50% of all questions in MI should be open
ended questions, what & how.
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OEQ allow a patient to take an active role in the
conversation as they explore both positive and negative
impacts of their behaviors.
Examples:
“What concerns do you have about your current behavior?”
“How might your desired future behavior lead to benefits in
the future?”
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Function like mirrors, enabling patients to see
themselves in new ways & muster the motivation
for change.
MI uses more reflective listening statements than
questions of any type. The ideal ratio of
questions to reflections is 1:2
There are four types of reflections:
Simple, Amplified, Double-Sided & ShiftedFocused
Employed reflective statements will stimulate
change-talk and what feelings and needs may lay
behind a patients words, body language, or tone.
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Simple reflections are like the images we see in a
flat mirror.
Paraphrases and restates what the patient is
saying
Example:
Patient- “I don’t have time to exercise. My friends
and spouse don’t either!”
Simple Reflection- “I hear you saying that you
don’t have time to exercise and that your friends
and spouse don’t either.”
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These reflections are like the images we see in a
convex or concave mirror.
They maximize or minimize what patients say in
order to evoke disagreement from them in the
direction of change-talk.
Example:
Patient- “I don’t have time to exercise. My friends and
spouse don’t either!”
Amplified Reflection- “I hear you saying that you don’t
know anyone who has the time to exercise and that
its impossible for you to fit exercise into your
schedule.”
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These reflections are like the images we see in tri-fold
mirrors
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Revealing multiple perspectives at the same time so that
the person can see and choose how to move forward.
Example:
Patient- “I don’t have time to exercise. My friends and
spouse don’t either!”
Doubled-Sided Reflection- “I hear you saying that you don’t
have time to exercise and that your friends and spouse
don’t either. But I’ve also heard you say that exercise
makes you feel better and that regular exercise would be
good for your energy and health.”
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These reflections are like the images we see in a
periscope.
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They redirect our attention away from a resistanceprovoking the person to focus on another area.
Example:
Patient- “I don’t have time to exercise. My friends and
spouse don’t either!”
Shifted-Focused Reflection- “Since your don’t have
time to exercise, lets talk about the dance class you
started with your partner. You were doing pretty well
with that, I remember you saying that your were
enjoying the classes.”
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MI makes use of scoring rulers to enable clients to think out
loud about their readiness, willingness, and ability to change.
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When patients feel ready, willing, and able, behavior change
is more likely to occur.
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MI utilizes three rulers:
◦ Willingness Ruler
◦ Confidence Ruler
◦ Readiness Ruler
There is growing evidence in increasing
utilization of MI in specialized medical settings:
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ER’s
Trauma Centers
Obesity Treatment Centers
Smoking Cessation
Sedentary Lifestyle
Medication Non-Adherence
Mental Health Issues
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Chronically ill patients
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Self-management of symptoms, treatment and
related changes in patients life
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Increase patient skills and confidence
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Effective with resistant patients
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MI is a powerful tool for Self-Management
Support
Resist the righting reflex
Understand the patient
Listen to the patient
Empower patient
“I want to quit smoking because I don’t want another
heart attack. I want to see my kids grow up.”
Content:
“You see a connection between your smoking and your heart
disease
and you’re ready to take action.”
Feelings:
“You’re scared you might have another heart attack and die
prematurely.”
Meaning:
“Your children mean a lot to you and you want to be there for
them.”
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Patients and families who feel they can manage their
condition, learn needed self-care skills, and adhere
to treatment goals will have greater success.
Practices may use motivational interviewing to
assess patient’s;
◦ Readiness to change
◦ Self-management abilities
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The purpose of assessing self-management abilities
is that the practice can adjust self-management
plans to fit patient/family capabilities and resources.
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The practice provides evidence-based
counseling:
◦ coaching
◦ motivational interviewing with patients for adopting
healthy behaviors associated with disease risk factors:
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Tobacco use
Nutrition
Exercise and activity level
Alcohol use
Example: Rewards to Quit Program
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NCQA PCMH Standard 1 Element G
Factor 5 -Care Team members are trained in
evidence-based approaches to self-management
support, such as patient coaching and motivational
interviewing.
NCQA & DSS are asking for the practice to give a
description of its training process and training
schedule or materials showing how the staff is
trained in each area identified in the factors.
*The ASO Glide Path Training Template must be
completed
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Hold regular biweekly sessions to develop
knowledge and skills needed for chronic
care model;
◦ Sessions can include Diabetes 101, Hypertension
101, Motivational interviewing to support chronic
care management, self-management support of
chronic diseases
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Provide location where sessions are held
Dates the sessions took place
List of staff in attendance
Agenda discussed/minutes
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Schedule monthly meetings to train care team members in
the concept of population management and proactively
addressing needs of patients and families served by this
practice.
Educate staff on evidence based guidelines used for
population management.
Educate team members in evidence-based approaches to
self-management support, such as patient coaching and
motivational interviewing.
Educate staff on effective patient communication for all
segments of the practice’s patient population but
particularly the vulnerable population.
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Motivational interviewing is a method of
communication to support and facilitate
behavior changes in patients.
It can be very useful to achieve behavior
change in your work environment.
Sandi Staley CPTS
Bachelor of Science -Public Health
Specialization in Health Promotion
Certified Wellness Coach
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Wellcoaches Corporation (2009). Coaching
Psychology Manual: Chapter 5 NVC &
Motivational Interviewing in Coaching.
Cole S, Davis C, Cole M, Gutnick D (2011).
Motivational Interviewing and the Patient
Centered Medical Home: A Strategic Approach
to Self- Management Support in Primary Care.