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The Role of Motivational Interviewing inCommunity-Based, RN-led Care Management:

The King County Care Partners Experience

Daniel Lessler, M.D., M.H.A.

Medical Director, King County Care Partners

Professor of Medicine

University of Washington

Objectives

• Describe King County Care Partners (KCCP) and its care model

• Review key concepts of Motivational Interviewing (MI)

• Describe how KCCP has embraced MI as a core element of its clinical approach

• Share an illustrative case-study

• Briefly summarize results

Acknowledgements

• Aging and Disability Services of Seattle and King County leadership– Rosemary Cunningham, Terra McCafree, Mary Pat O’Leary Pamela Piering,

Andrea Yip

• KCCP clinical team– Caroline Bacon, Jeanette Choate, Tia Hallberg, Flor Alarcon Medrano, Lara

Flores-Patacsil, Samantha Santor

• Partnering organizations– Harborview Medical Center, Neighborcare Community Health Centers,

Healthpoint Community Health Centers, Sea Mar Community Health Centers

• Washington State Department of Social and Health Services– Health and Recovery Services Administration

• Center for Health Care Strategies• Center for Healthcare Improvement for Addictions, Mental Illness and

Medically Vulnerable Populations (CHAMMP) at Harborview Medical Center

KCCP brings together organizations that serve medically vulnerable SSI-eligible Medicaid clients to improve clinical outcomes and decrease unnecessary utilization by providing community-based, RN-led, multidisciplinary care management that empowers patients and enhances coordination, communication and integration of services across safety-net providers.

King County Care Partners

KCCP Care Model

• Informed engagement• In-person assessment• Goal setting• Coaching

– Self-advocacy– Self-management (disease specific knowledge and skills)– System access and navigation

• Modeling (joint visits to PCPs and specialists)• Ongoing support• Coordination and communication

– Primary, Specialty and Mental Health Care

• Referring and connecting with community resources– Housing, transportation, social support, etc

• Safety-net engagement and systems building

Community Resources

and Systems

Communicate and

Coordinate

Outcome

Functional and Clinical

Clinical

Systems

Assess

Model

Connect

Primary Care

Specialty Care

Mental Health Care

Addictions Treatment

Coach

Family and Social Systems

Acknowledge

Client

King County Care Partners Care Model: Community-based RN-led Care Management

Housing

Nutrition

Transportation

Interpreter services

KCCP Care Model: The Role of Motivational Interviewing

• Motivational Interviewing (MI)– “Motivational interviewing is a collaborative,

person-centered form of guiding to elicit and strengthen motivation for change.”

– Miller and Rollnick. Behavioral and Cognitive Psychotherapy 2009;37:129-140.

• KCCP’s approach to client interaction and care management is grounded in the spirit and the method of MI)

• MI is not easy

KCCP: Motivational Interviewing Training

• Partnership committed at outset in 2007 to MI

– Tapped expertise at Harborview Medical Center to provide introductory trainings in MI

• With funding from CHCS, in August 2009 implemented intensive training program over 12 months

• Conducted by an MI expert trainer

– Susan Butterworth, Qconsult, Portland, OR

KCCP: Motivational Interviewing Training

• 8 participants, including KCCP core clinical team and 1 delegate from each of the partnering safety-net clinic systems

• Initial 2-day intensive MI workshop• Monthly case conferences with MI coach• Monthly 1:1 mentoring with MI coach for each

participant• Mid-year ½-day workshop focused on using MI in

working with mentally ill• Participants submit taped interactions with actual

clients for review and feedback by MI coach

Systems Building: The Role of MI

• Individuals from all of the partnering systems participated in the MI training

• Familiarity and use of MI across systems:– Promotes consistent, client-centered experience across

safety-net providers– Provides a common language and shared experience that

enhances communication and systems-building

• Sustainable effort– ARNP from HMC with previous experience in MI who

participated in MI-training, and received additional coaching, will become local MI coach for KCCP

KCCP clinical team and MI: In Their Own Words

– “It helps us to know what their agenda is. Our agenda might not be their agenda, and so when you’re using MI and you’re actively listening, a lot of times, without even talking, you can find out what’s important to them, and so through that, I’m able to know where to go with them. I’m not going to spin my wheels working with them here because it’s not important to them. They just said, X, Y, and Z is important to them so instead I’ll put my energy working there.”

» From M Cristofalo et al, Chronic care management intervention: A qualitative analysis of key informant accounts. Report prepared for the Washington State Department of Social and Health Services, Health and Recovery Services Administration, June 2010.

In Their Own Words: Collected Comments from Weekly Case Conferences

• “I’m not hear to change you, or make you do anything you don’t want to do”

• “I will walk beside you…”

• “Affirm and suspicion melts away…”

• “No wrestling allowed…”

An MI Case Study: As Described in Weekly Case Conference

• A.G., 38-year-old Native American man with generalized anxiety disorder and alcohol dependence

– Initial meeting with the RN care manager, A.G. begins by saying, “People have told me what to do; I don’t want you telling me what to do…”

– RN care manager response: “I’m not going to tell you what to do; I’m going to walk beside you regardless of the path you take…”

– On 3rd meeting, A.G. states: “I’m thinking about making a change…but I’m not ready today, and I’m not sure I will be in 2 days or 2 weeks…”

– In subsequent meetings, reflections on ambivalence; affirmations for thinking about change; and ultimately problem-solving

– Patient now in 30-day inpatient CD treatment (after 6 months of engagement)

KCCP: Highlights of Client Survey Results

• Interviews with 286 of 406 clients randomized to KCCP intervention between February and March 2009

• 61 clients could not be directly interviewed; adjusted response rate of 83%– 98% said they had a good, trusting relationship with the RN or MSW– 92% said the healthcare goals they developed with their RN included

their most important healthcare needs– 91% said the program helped them feel they could take charge of their

health– 90% were able to reach at least one of the healthcare goals they

developed with their RN

– From: T. Krupski, et al. Client Perspective on the Rethinking Care Program: Report of a Telephone Survey. Final report prepared for the Washington State Department of Social and Health Services, Health and Recovery Services Administration, June 2010.

Questions?

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