1/8/2021 1 Tools to Maximize Virtual and Live Patient Learning and Behavior Change and Provider Communications 12-22-20 DSMES Learning Series Mary Ann Hodorowicz RDN, MBA, CDCES, CEC (Certified Endocrinology Coder) Mary Ann Hodorowicz, RDN, MBA, CDCES CEC, is a registered dietitian nutritionist and certified diabetes educator and earned her MBA with a concentration in marketing. She is also a certified endocrinology coder and owns a private practice specializing in corporate clients in Palos Heights, IL. She is a consultant, professional speaker, trainer, and author for the health, food, and pharmaceutical industries in nutrition, wellness, diabetes, and Medicare and private insurance reimbursement. Her clients include healthcare entities, professional membership associations, pharmacies, government agencies, food and pharmaceutical companies, academia, and employer groups. Mary Ann is on the faculty of the LifeScan Diabetes Institute. She served on the Board of Directors of the Association of Diabetes Care and Education Specialists from 2013 – 2015, was the Chair of the Advanced Practice Community of Interest in 2016 and was nominated for the Award in Excellent Practice of the Weight Management Practice Group of the Academy of Nutrition and Dietetics (AND) 2016. She has served on numerous committees and work groups of ADCES and AND. Mary Ann Hodorowicz Consulting, LLC [email protected]708-359-3864 www.maryannhodorowicz.com Twitter: @mahodorowicz I have no financial relationships to disclose. Learning Objectives 1. Explain the key differences between compliance counseling and motivational interviewing. 2. Name at least 6 of the 24 motivational interviewing tools to maximize patient behavior change that are summarized in the word “A.D.O.P.T.E.E.S.” 3. Name the K.I.I.S.S.S.S.S.S.S. tools to enhance patient learning and retention. 4. Define the 7 “P’s” of a marketing plan for a service…including DSMES services. 5. List the 2 primary goals of promoting/communicating with providers relative to DSMES programs. 6. Give examples of promotions/communications to increase provider referrals to DSMES program. 7. Name the 6 types of outcome measures to be monitored in DSMES programs and explain the order in which patients may achieve them (domino effect). 8. Explain the relationship between positive patient outcomes and the value of the DSMES services from the perspective of referring providers. 9. State what the “3 S” format is for making a recommendation to referring providers on the patient progress report and explain why this can increase referrals.
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1/8/2021
1
Tools to Maximize
Virtual and Live
Patient Learning
and Behavior Change
and Provider
Communications
12-22-20
DSMES Learning Series
Mary Ann Hodorowicz
RDN, MBA,
CDCES, CEC
(Certified
Endocrinology
Coder)
Mary Ann Hodorowicz, RDN, MBA, CDCES CEC, is a registered dietitian nutritionist and certified diabetes educator and earned her MBA with a concentration in marketing. She is also a certified endocrinology coder and owns a private practice specializing in corporate clients in Palos Heights, IL. She is a consultant, professional speaker, trainer, and author for the health, food, and pharmaceutical industries in nutrition, wellness, diabetes, and Medicare and private insurance reimbursement. Her clients include healthcare entities, professional membership associations, pharmacies, government agencies, food and pharmaceutical companies, academia, and employer groups. Mary Ann is on the faculty of the LifeScan Diabetes Institute. She served on the Board of Directors of the Association of Diabetes Care and Education Specialists from 2013 – 2015, was the Chair of the Advanced Practice Community of Interest in 2016 and was nominated for the Award in Excellent Practice of the Weight Management Practice Group of the Academy of Nutrition and Dietetics (AND) 2016. She has served on numerous committees and work groups of ADCES and AND.
1. Explain the key differences between compliance counseling and motivational interviewing.
2. Name at least 6 of the 24 motivational interviewing tools to maximize patient behavior change that are summarized in the word “A.D.O.P.T.E.E.S.”
3. Name the K.I.I.S.S.S.S.S.S.S. tools to enhance patient learning and retention.
4. Define the 7 “P’s” of a marketing plan for a service…including DSMES services.
5. List the 2 primary goals of promoting/communicating with providers relative to DSMES programs.
6. Give examples of promotions/communications to increase provider referrals to DSMES program.
7. Name the 6 types of outcome measures to be monitored in DSMES programs and explain the order in which patients may achieve them (domino effect).
8. Explain the relationship between positive patient outcomes and the value of the DSMES services from the perspective of referring providers.
9. State what the “3 S” format is for making a recommendation to referring providers on the patient progress report and explain why this can increase referrals.
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1) Tools to Maximize
Virtual and Live
Patient Learning
and
Behavior Change
To Maximize Virtual and Live Patient Learning, Use
Motivational Interviewing Tools.
They Spell
A.D.O.P.T.E.E.S.
5
• WHY do we want to make our patients our A.D.O.P.T.E.E.S. ?
o 2 BIG Reasons:
Patient’s chronic disease will CHANGE
Patient’s “I.V.’s”…Issues and Variables… will CHANGE
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The one constant in life is change!
#1 Reason Patients NOT Empowered to Change Behaviors
Use of less effective, inpatient acute care
COMPLIANCE COUNSELING TOOLS
to try to get pts to behavior.
In direct contrast to use of
effective outpatient chronic care
MOTIVATIONAL INTERVIEWING TOOLS
for changing behaviors!
Motivational Interviewing Tools…
Do NOT promote wrestling with
your patient as an opponent….
this increases resistance to change
Do lead to dancing with your patient
as a partner…this reduces resistance
to change and helps build a strong
patient-clinician relationship
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COMPLIANCE COUNSELING MOTIVATIONAL INTERVIEWING
Coach Is sage on the stage.
Acts as parent, boss, expert.
Is guide on the side.
Acts as partner, facilitator, negotiator.
Topics Coach selects, per agenda Patient selects, per needTalking & Listening Coach does most of talking Coach does most of listening
Decisions and
Goal Setting
Coach makes all decisions
and sets goals for patient
Patient makes own decisions and
sets own goals
Coach Mindset Pessimistic Optimistic
Coach Emphasizes What’s wrong.
What has NOT been achieved.
What’s right.
What HAS been achieved.
Motivational Interviewing….
Do NOT ask:
“What is the matter with my patient?”
Do ask: “What matters most to my
patient?”
Let’s start the tools in MI Tools that Spell “A.D.O.P.T.E.E.S.”
A = Act as a partner and negotiator,
and never as the expert or boss!
Never look down on anyone unless you will help them up!
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A = Allow time at each visit for patient to select own topics, needs,
problems to discuss (what matters to the patient!)
Why? Increases motivation to change!
I know me best,
Especially my needs.
So today’s topic to discuss,
May I select it, please?
Give patients a fun list of diabetes topics!
• GROUP class, tell patients:
o First half: dedicated to topics HCP needs to review….but whole group will
contribute
o Second half: totally dedicated to what PATIENTS WANT TO TALK ABOUT!
Say to patients before break:
Just write down the questions you’d like answered today
on these sticky notes during our break.
A = Allow patients to be the FIRST to:
• Answer
• Act
• Analyze
• Add their own information
• Agree or disagree
• Arrive at their own behavior goal
• Aid in developing their own treatment plan
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Example: Conversation between Mark and HCP:
Mark: Why does everyone keep telling me that I have to test my blood sugar with this meter?
HCP: Why do YOU think they are telling you this?
Mark: I really don’t know…no one explains it to me.
HCP: How do you feel about using the test results to better control your sugar on a daily basis?
Mark: Yeh, I would think about that, if it would help.
HCP: If you don’t mind, can you share with me your thoughts on how you might use a test result
before dinner to better control your after‐dinner blood sugar?
A = Abide by the 80—20 talking rule
20% of
Timethe
HCP Talks!
80% of
Time
the
Patient
Talks!
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Sweetest sound to patients:
Their own VOICE
Sweetest word to patients:
Their own NAME
Sweetest topic to patients:
Their own STORY
80--20 Talking Rule:
HCP Talks Only 20% of Time!
• OPEN ENDED QUESTIONS
• TELLING….but ask permission FIRST
• ANSWERING pt’s questions….but only if pt cannot
• SUMMARIZING what pt said about every 10 minutes
• ASKING pt to summarize back to you important info
• PLANNING topics, needs, concerns for next visit
Sign over clock in HCP’s counseling office:
Why Am I Talking?
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A = Always remember what it means to be human….
• It means we are not rational in our decision making
• It means that rational approaches to problems can NOT always be expected to work
• BUT: do we often use rational approach to get patients to change behaviors? Ugh!
How is this working for you? Likely not so much!
Irrational Behaviors!
Swim with sharks?Coffee by computer?
Rational?
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A = Accept patient’s ambivalence toward behavior change….and work
with it
….to be human is to be ambivalent
Should I or shouldn’t I
get off the fence?
Our job is to help patients slowly motivate themselves off the fence in direction of change, but only when they’re ready, willing and able.
A = Always roll with resistance
Resistance often reflects disturbance…a good thing!!
Disturbance often is patient’s way of saying:
“I need to understand this better.”
How HCP Can Better Roll with Resistance…
1. Try to understand what is behind pt’s resistance
2. Invite patient to openly discuss his/her resistance
• Create free, friendly, safe environment for talking
• No matter what pt says…good, bad, ugly…always:
o Be gracious, non‐judgmental, accepting
o Be very careful about your body language when patient says something you find a bit “off”
3. Reinforce patient’s role as a problem‐solver
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A = Assist patient in “SAYING” the key, core message(s) via open‐ended
questions (OEQs)
Example:
“I’m sure that my high A1c and 10 pound weight gain is related to the 6
plus carb servings I eat at nearly every meal.”
• Use “Strike 3 Rule” so you’re not there all day to accomplish this!
Strike 3 Rule:
Ask patient 3 different types of OEQs
to get him to say the key, core message(s).
If not successful, then TELL patient,
but only if you ask permission.
Why ask permission?
Open‐Ended Questions (OEQs)
• In today’s visit, what topic would you like to discuss?
• From this checklist on topic, what would you like to discuss?
• Tell me what you have heard or read about weight and blood pressure?
• What will you lose if you reduce salty foods?
• What will you gain?
• What have you tried before to reduce salt and salty foods?
• Tell me what you feel about testing your blood sugar more regularly? What do you think the benefitsmight be?
• What would you like to eat in the café that would be tasty and yet lower in fat and cholesterol?
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A = Always use the K.I.I.S.S.S.S.S.S.S. tools to enhance patient learning and retention
Keep It
Interactive…so patients are “doing” which increases learning; do use:
● Wuzzles (word-picture puzzles)
• Group discussion with “Let’s Just Talk” Handout
• Games (Diabetes Bingo)
• Story telling
Short: 30-60 minutes only for individual visits and <2 hour group visits
Spotlighted on only 1 key message at a time; no fire hosing!
th
Sensory: use fun, 3-Dimensional (3D) teaching aids
Supplied with “graphic/picture-centric” handouts instead of printed word
Supplied with memory aids (acronyms and mnemonics)
Self-created by patients (Square Care Plans)
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Because Adults Learn and Retain:
20% of what they HEAR
30% of what they SEE
50% of what they SEE and HEAR
70% of what they personally explain or SAY
90% of what they SAY and DO
LEARNING by
DOING and SAYING is key!
Remember:
Learning/Knowledge Outcome precedes all other patient
outcomes in a “chain reaction”.
What I hear,
I forget;
What I see,
I remember;
but what I do,
I understand.~ Confucius, 451 B.C
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UseSquare Care Plans
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Keep It
Interactive…so patients are “doing” which increases learning; do use:
● Wuzzles (word and picture puzzles)
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fats that came from
A __ __ M __ __ S
fats that came from
V __ __ G __ __ __ __ __ S
E __ __ R __ __ __ E
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Keep It
Interactive…so patients are “doing” which increases learning; do use:
● Group discussion with “Let’s Just Talk” Handout
Let’s Just
TALK
with Our Patients
to Find Out What
MATTERS TO THEM!
LET’S JUST TALK! Instructor’s HEALTHY EATING Questions to
Patients to Start the Conversation
Patients,
Jot Down Your Thoughts Here
1 ReasonHow does healthy eating affect blood glucose?
How does it affect the complications of diabetes?
2 DescriptionWhat does healthy eating consist of?
3 FrequencyHow often should a healthy meal plan be followed?
4 Sharing ExperiencesWhat are some tips to make healthy eating easier?
5 Getting StartedWhat would you like to do as a first step to eating healthy?
6 BarriersWhat barriers, if any, will make it challenging to get started with this first step? What are some ways to reduce them?
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Keep It
Interactive…so patients are “doing” which increases learning; do use:
Turn Key Materials for ADCES DSMES Program Accreditation•DSMES Program Policy & Procedure Manual Consistent with NSDSMES (72 pages)•Medicare, Medicaid and Private Payer Reimbursement•Electronic and Copy‐Ready/Modifiable Forms & Handouts•Fun 3D Teaching Aids for ADCES7 Self‐Care Topics•Complete Business Plan
3‐D DSMES and Diabetes MNT Teaching Aids ‘How‐To‐Make’ Kit•Kit of 24 monographs describing how to make Mary Ann’s separate 3‐D teaching aids plus fun teaching points, evidence‐based guidelines and references
This information is intended for educational and reference purposes only. It does not constitute legal, financial, medical or other professional advice. The information does not necessarily reflect opinions, policies and/or official positions of the Center for Medicare and Medicaid Services, private healthcare insurance companies, or other professional associations. Information contained herein is subject to change by these and other organizations at any moment, and is subject to interpretation by its legal representatives, end users and recipients. Readers/users should seek professional counsel for legal, ethical and business concerns. The information is not a replacement for the Academy of Nutrition and Dietetics’ Nutrition Practice Guidelines, the American Diabetes Association’s Standards of Medical Care in Diabetes, guidelines published by the Association of Diabetes Care and Education Specialists nor any other related guidelines. As always, the reader’s/user’s clinical judgment and expertise must be applied to all information in this document.
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REFERENCES
1. Ellen R. Glovsky, PhD, RD, LD, Gary Rose, PhD, Motivational Interviewing — A Unique Approach to Behavior Change Counseling, Today’s Dietitian Vol. 9 No. 5 P. 50, May 2007
2. Miller WR, Rollnick SR. Motivational Interviewing: Helping People Change, 2nd edition. New York: Guilford Press; 2002
3. Miller WR, Rollnick SR. Motivational Interviewing, Third Edition: Helping People Change (Applications of Motivational Interviewing), , 3rd
edition. New York: Guilford Press; 2013
4. Rose GS, Rollnick SR, Lane C. What’s Your Style? A model for helping practitioners to learn about communication and motivational
interviewing. MINUET. 2004;11:2‐4
5. Hersen M, Eisler RM, Miller PM (ed). Progress in Behavior Modification. Belmont, Calif.: Wadsworth; 1994
6. Marc Steinberg, MD, FAAP, Clinical Perspectives on Motivational Interviewing in Diabetes Care, Diabetes Spectrum, August 2011, vol. 24 no. 3, 179‐181
7. Rollnick SR, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners. London: Churchill Livingstone; 1999
8. Nutrition Practice Guideline for Diabetes Mellitus Type 1/Type 2 and Hypertension, and Disorders of Lipid Metabolism Toolkit,www.andevidencelibrary.com, Academy of Nutrition and Dietetics; accessed 1‐5‐13
9. Suzanne E. Mitchell, MD, MS, Motivational Interviewing in the Management of Type 2 Diabetes: An Expert Interview With Faculty and Disclosures, CME Released: 02/07/2012, Medscape Education Diabetes & Endocrinology