Motivational Interviewing Across the HIV Care Continuum Skills - - PDF document

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Motivational Interviewing Across the HIV Care Continuum Skills Building for Care Teams Committed to Ending the Epidemic

Debbie Cestaro-Seifer, MS, RN, NC-BC, CTP University of Florida, Division of Internal Medicine North Florida AIDS Education and Training Center 1

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Disclosures

§ The activity planners and speaker do not have any financial relationships with commercial entities to disclose. § The speaker will not discuss any off-label use or investigational product during the program.

This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.

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Motivational Interviewing to Support Linkage and Engagement in HIV Care

At the conclusion of Session 2 participants will be able to:

§ Recall the four components of the “spirit of motivational interviewing” and describe how healthcare professionals operationalize each component. § Discuss the term ambivalence and give examples of statements that indicate a person is ambivalent. § Identify and demonstrate MI strategies and corresponding communication skills that are used when a patient is ambivalent about starting antiretroviral (ARV) treatment. § Discuss and demonstrate strategies to identify, accept and discuss a patient’s current stage of change and motivation to consider a new health behavior. § Describe and demonstrate core MI communication techniques that health professionals can use to improve HIV/HCV testing and PrEP acceptance rates in their clinical settings. § Give examples of how MI serves as a “bridge” to patient empowerment, engagement, activation and self-management.

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Welcome

Learning Collaborative § Welcome § HIV Care Continuum Journey using MI § Learning styles § Active Participation § MI is a powerful counseling technique

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Polling Question Word Cloud

Identify an MI principle or skill you consciously tried to use since our first session together 2 weeks ago.

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MI: Am I Doing This Right?

www.centerfor ebp.case.edu

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Motivational Interviewing (MI)

§ 1. Overall Spirit of MI § 2. OARS: Client-Centered Communication Skills § 3. Recognizing Sustained Talk and Change § 4. Eliciting and Strengthening Change Talk § 5. Rolling with Sustained Talk and Resistance § 6. Developing a Change Action Plan § 7. Consolidating Commitment § 8. Transition and Blending with Other Coaching Approaches

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Module 2 Quiz

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Motivational Interviewing

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Welcome! How Can We Care for You Today?

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The Spirit of Motivational Interviewing

Nonjudgmental

• Acceptance

Collaborative

• Partnership

Evocative

• Resources and

motivation for change reside within client

Honoring Patient Autonomy

• Affirms client’s right

and capacity for self-direction

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The MI Spirit

§ Compassion § Acceptance § Partnership § Evocation

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What’s the Difference?

14 Apathy Sympathy Empathy Compassion

Image accessed on 9/6/2020 at https://brianpagan.net/2014/hierarchy-of-spiritual-intelligence/

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Apathy, Sympathy, Empathy and Compassion

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Apathy: I don’t care. (Lack of interest, enthusiasm or concern) Sympathy: I see you and feel sorry for you. (Acknowledgement. Show concern) Empathy: I feel with you. I feel your pain and I understand it. Compassion: I feel with you and act skillfully to work with you to relieve your suffering 15

Empathy

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IS ABOUT FEELINGS INVOLVES LISTENING NO JUDGEMENT FUELS CONNECTION BETWEEN PEOPLE

Image accessed on 9.6.2020 at https://www.bhavanalearninggroup.com/distinguishing-compassion-from- sympathy-and-empathy/

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Empathy Supports the Spirit of MI

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Compassion is Empathy Plus Collaboration

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Compassion

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RECOGNIZING THE ME IN YOU I FEEL YOUR PAIN. HOW DO YOU NEED ME TO HELP?

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Hearing the Difference

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Apathy: “So what’s the big deal?” Sympathy: “Oh you poor thing. Bless your heart.” Empathy: “I understand your feelings of

• distress. This must be unbelievably hard

for you right now.” Compassion: “I want to listen and help.”

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Listening Actively Builds Empathy and Compassion

Active Listening

Greater Listening Fuels Connections Fuels Better Understanding

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Talk in Groups of Four for 10 Minutes

• 1. Describe your self-inventory observations.
• 2. What are some ways for a “following style” to improve?
• 3. What are some ways for a “directing style” to improve?

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Activity #1

• 1. Think of someone you work with who has recently been

linked to care at your clinic who is very concerned about confidentiality and HIV stigma. Pt. Initials AS

• 2. Think about a patient you work with who has recently

experienced homelessness. Pt. Initials SC

• 3. Think about a patient you work with who does not show

for their scheduled telehealth or in-person clinic visits.

• Pt. Initials MJ

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Self Inventory

Mark the box that occurred most often in past month relating to this patient.

• Pt. AS
• Pt. SC
• Pt. MJ

I seem indifferent to the patient’s wishes and choices. I recognize and honor the patient’s choices, including not to change. I struggle with the patient’s choices and/or press the patient to change.

• Pt. AS
• Pt. SC
• Pt. MJ

We meet, but not much is happening. We are working in partnership. We are working against each other.

• Pt. AS
• Pt. SC
• Pt. MJ

I let the session go wherever the patient takes it. I am drawing out the patient’s own views on change. I am presenting the reasons for change. Total Marks _____ Total Marks _____ Total Marks _____

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25 Conversation Style Continuum Following Guiding Directing 1 2 3 4 5 6 7 8 9

Talking

• Pt. talks

& I listen

• Pt. talks &

I speak very little; I mostly listen

• Pt. talks

& I speak some, but I mostly listen

• Pt. talks & I

guide minimally

• Pt. talks & I

guide moderately

• Pt. talks & I

guide frequently Client talks & I talk equally Client talks less than me Client talks much less than me Conversation feels like therapy Conversati

• n seems

very one- sided Conversa- tion seems

• ne-sided

Conversati

• n seems

natural Conversation seems very natural Conversa- tion seems natural Disagreement may occur

• ccasionally

Power struggle may happen

• Pt. may

shut down

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Polling Question: Conversation Style Continuum

Use your own Self Inventory data and your group discussion to help you choose a number on the Conversation Style Continuum where you believe you are currently performing. _________________________________ 1 2 3 4 5 6 7 8 9

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Techniques to Guide and Partner

Follow Guide Direct _ Listen Draw out Teach Understand Encourage Instruct Go along with Motivate Lead

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Empathy, Sympathy, Compassion and the Goldilocks Zone

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Guiding

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First Step: Develop Rapport (LURE)

§ Listen § Understand (and check back) § Resist the urge to correct the patient § Empower your patient

Reference: All Motivational Interviewing All the Time: Pocket Guide for Health Coaches January 2014; Mountain Plains AETC

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Empowerment

“The empowerment of a person or group of people is the process of giving them power and status (recognition) in a particular situation.”

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Strengths Resiliency Knowledge Goals Skills Leadership Lessons learned

Source: Modified from the Collins Dictionary accessed pm 8/24/2020

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Activity #2 MI Spirit: Talk in Groups of Four for 5 Minutes

Use your CAPE notes and work as group to discuss the rating you would give the Counselor for establishing the spirit of MI into the prevention counseling session. Use the MI Spirit Meter below to give a number rating to the Counselor for each component of the Spirit of MI: Compassion, Acceptance, Partnership and Evocation. _________________________________________ 0 1 2 3 4 5 6 7 8 9 10

No Abundant MI Spirit

MI Spirit Meter

MI Spirit

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Activity #2 Spirit of MI Video Activity Groups of Four

33 Aspects of the MI Spirit MI Spirit Rating List ways the counselor demonstrated this aspect

Compassion Acceptance and

autonomy

Partnership and

collaboration

Evocation

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Activity #2 Video Review for MI Spirit

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35 Conversation Style Continuum Following Guiding Directing 1 2 3 4 5 6 7 8 9

Talking

• Pt. talks

& I listen

• Pt. talks &

I speak very little; I mostly listen

• Pt. talks

& I speak some, but I mostly listen

• Pt. talks & I

guide minimally

• Pt. talks & I

guide moderately

• Pt. talks & I

guide frequently Client talks & I talk equally Client talks less than me Client talks much less than me Conversation feels like therapy Conversati

• n seems

very one- sided Conversa- tion seems

• ne-sided

Conversati

• n seems

natural Conversation seems very natural Conversa- tion seems natural Disagreement may occur

• ccasionally

Power struggle may happen

• Pt. may

shut down

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Activity #2 Video Polling Question Conversation Style Continuum

Choose a number rating on the Conversation Style Continuum below to identify the Counselor’s overall Conversation Style. _________________________________ 1 2 3 4 5 6 7 8 9

Conversation Style Continuum

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Motivational Interviewing

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OARS: Core Communication Skills

§ Open-ended questions § Affirmations § Reflections § Summaries

Open- ended Questions Affirmations Reflections Summaries

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Four Principles of MI

Empathy

Express

Discrepancy

Develop

with Sustained Talk

Sway

Self-efficacy

Support

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MI Process

• f Guiding

Engaging Focusing Evoking Planning

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USING MI IN HIV PREVENTION

HIV Testing and PrEP Offers

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HIV Prevention: Testing Offers & PrEP

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Sources: Acquired Immune Deficiency Syndrome Volume 82, Number 2, October 1, 2019 and Baseline characteristics and PrEP use among adults and youth June 3, 2019 accessed on 8/21/2020; HIV testing images accessed from the CDC.gov website

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Reasons Participants Did Not Want to Accept PrEP Offer

§ 65% were concerned about drug-drug interactions with hormone therapy § 47% concerned about side effects § 41% did not want to take a daily PrEP pill § Lack of financial resources to access PrEP and to obtain gender-affirming legal documentation

Sources: Acquired Immune Deficiency Syndrome Volume 82, Number 2, October 1, 2019 and Baseline characteristics and PrEP use among adults and youth June 3, 2019 accessed on 8/21/2020; HIV testing images accessed from the CDC.gov website

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Why People Refuse HIV Test Offers?

Survey says people refuse HIV test offers because:

• 1. Confidentiality concerns
• 2. Cost concerns
• 3. They do not believe they can cope with knowing they have HIV.
• 4. They have probably been tested before.
• 5. They don’t feel sick, so they don’t need to be tested.
• 6. They use condoms almost all the time.
• 7. They haven’t had sex recently and they don’t use needles.
• 8. Their partner gets tested regularly and is negative.

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Source: modified from https://www.avert.org accessed on 8/24/2020

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Motivational Interviewing

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12 Strategies of MI

Ask

Permission Open Question Closed Question

Listen

Appreciate Reflect Summarize

Tell

Inform Give Feedback Advise

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Communication Strategies

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ASKING LISTENING INFORMING

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Ask

48 Ask a question that will prompt change talk as the answer Ask for pros and cons of changing and staying the same Ask about the positives and negatives of the target behavior When the patient expresses change talk, ask for more details

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Open vs. Closed Questions

Example 1: “How did you feel when you found out you had an STI today?” A more open-ended question?

“What was it like for you to learn that you tested positive for an STI today?”

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More About Asking

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Pros and Cons

• “What is good about

the status quo”

• “What is not-so-good?”

Key Questions: What next?

• “So what are you

thinking about right now about using PrEP?”

• “What would be a first

step for you?” Using hypotheticals

• “How would you feel if

a person you wanted to have sex with told you they were using PrEP?”

• “What could/would

make PrEP more of a possibility for you?”

• “Suppose you did

decide to use PrEP…?” 50

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Communication Strategies

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ASKING LISTENING INFORMING

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Listening

§ Core of relationship building § When providers listen, patients feel you have spent longer with them than the actual time allotted § Is non-threatening § Fosters change § Opens the door § Focuses on non-verbal cues

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Activity #3

§ Triplet work § Roles: Patient, Counselor, Observer § Patient chooses one simple topic below to talk about § What I liked/disliked most about high school § One thing I would like to do more/less of. § Patient is the only one speaking (no “ums” or “ahhs” permitted by Counselor or Observer) § 2 minutes each and switch; each person will play all three roles; observer is the time-keeper and keeps track of the number of times the Counselor utters a work or sound and any nonverbal communication that is observed (see activity sheet)

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Polling Question: Multiple Choice

Self-reported listening difficulty level. Choose one answer.

• a. Very difficult
• b. Difficult
• c. Not too difficult
• d. Not difficult at all

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Polling Question: Short Answer

When you were the Patient how did it feel to talk and not receive any verbal feedback from the Counselor for 2 minutes?

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Polling Question: Short Answer

What was the most important thing you learned from being the Observer?

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Reflective Listening

§ Deepens the conversation § Helps patient understand themselves § Tests hypotheses about the patient and their motivations § Helps you understand the patient’s situation and perspective § Not a question; voice intonation goes down at the end of the sentence

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Reflective Listening

§ Listen, express interest in, & understand what the patient said from their perspective § Repeat back to the patient a summary of your understanding

§ “So, you are saying….” § “It sounds like….”

§ Allow time for patient to verify, correct, add or process or enhance

BE CAREFUL NOT TO OVERUSE

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Reflective Listening is NOT

§ Directing § Warning § Advising § Persuading § Moralizing § Agreeing § Reasoning § Disagreeing § Labeling § Interpreting § Reassuring § Questioning § Withdrawing § Approving

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Activity #4 Andre and HIV Prevention

• 1. Work in pairs in your virtual room for 5 minutes.
• 2. Each person take 2 minutes to play Andre or “Andrea”.
• 3. Each person take 2 minutes to be the coach or

counselor.

• 4. Goal: Talk about HIV prevention and get a read on how

Andre/Andrea thinks about HIV prevention strategies. What can they do? What do they say they cannot do?

• 5. Meet back for continuation of the video.

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Activity #4 Video

Background: Andre has been diagnosed with an STD and he agreed to speak with the case manager before leaving the clinic. Watch the 20 second video. You will continue the conversation using role play in pairs.

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Image Source: https://pixabay.com/photos/video-production-video-movie-film-4223885/ accessed on 8/25/20

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Activity #4 Video

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HIV Continuum of Care Goal: Viral Suppression & Improved Health Outcomes

HIV-positive Test Result Linkage to Care

Retention in Treatment & Care Starting Antiretroviral Medication Taking Antiretroviral Medications as Prescribed

Viral Load Suppression

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Did You Know?

§ PWH are most vulnerable to being lost to care in the first 12 months of being diagnosed with HIV § A feeling of connection at the first appointment is key to some patients returning for their next appointment. § Patient experience is the “sum of all the interactions and experiences in the

• rganization that influence the patient’s

perceptions across the continuum of

• care. “

Sources: Accessed on 9/8/2020 Beryl Institute, 2017 and https://pixabay.com/photos/calendar-icons-calendar-icons-month-925109/

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Linkage to HIV Care: Challenges and Opportunities

Establishing persons in HIV care immediately following diagnosis as evidenced by an initial outpatient medical care visit with a provider who has medication-prescribing authority.

§ Linkage to an agency that can provide case management to assist the individual with accessing available community resources § Timely § Individualized

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Image Source: https://pixabay.com/illustrations/puzzle-partnership- corporation-69995

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Best Practices: HIV Linkage to Care

HIV Linkage to Care Coordination § HIV linkage to care specialist § Enhanced case management § Warm and personalized connections to HIV medical care and/or medical case management services

§ Image Source: https://pixabay.com/

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Retention in and Engagement with HIV Care

§ Not a singular event or visit § Process of empowerment, engagement activation and self-management § Unmet needs challenge engagement in care § Engagement is essential to viral suppression and

• ptimal health outcomes

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Image Source: https://pixabay.com/illustrations/ linked-152575_1280.png

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Barriers to Retention/Engagement

, M. (2012) Getting HIV-Infected Patients Into Care: What are the Barriers? Medscape Education Internal Medicine

Types of Barriers Descriptors Individual Level Health, wellness, basic needs Social Level Relationship level with significant other, friends, family Community Level Characteristics Structure, service availability, access Health System Characteristics Structure, service availability, access Health Policies Service availability, access 69

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Activity #5 Reflective Listening Exercise: Linkage and Engagement

1. You will be joining a group of 10-12 participants and one facilitator. 2. The facilitator will play the Patient and make a statement. The Group will work together to formulate a reflection that hypothesizes what the Patient’s statement means to the patient and the Patient will respond. Can the group tell the Patient’s Stage of Change by the statement? 3. There will be a total of 5 Patient statements. Participants should use the Activity #5 worksheet to document reflections used in the exercise. 70

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Activity #5 Reflective Listening Exercise Focused on Linkage and Engagement

Group Reflection Stage of Change § You mean that… § So you are saying that… § It sounds like…. § You mean that… § You are… 71

Group Facilitator I am… I like… I don’t like… I just can’t…

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Polling Question: Short Answer

What was the most helpful take-a-way about MI for you today?

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Polling Question: Word Cloud

What aspect of MI will you set a goal to work on over the next 2 weeks?

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Next Session (Module 3) September 24, 2020

§ Demonstrate the use of a variety of reflections as part of a patient discussion focused on antiretroviral adherence. § Identify and role play MI strategies that are best suited for each stage of change as demonstrated by an individual who is non-adherent to their prescribed ARV regimen. § Discuss the use of U=U as part of a motivational interviewing conversation.

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Question, Comments and “Aha Moments”

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Speaker Contact Information

Debbie Cestaro-Seifer, MS, RN, NC-BC, CTP

Email: deborah.cestaro-seifer@medicine.ufl.edu

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