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Motivational Interviewing for Medication Adherence

Learning Objectives
1. Explain how a nurse and a clinical pharmacist used motivational interviewing to improve medication adherence, including how their own role in the care team uniquely positioned them to have discussions with patients
2. Describe collaborative communication strategies and key phrases for use in conversations with patients about medication adherence
3. Discuss how motivational interviewing could be used for medication adherence in a specific patient case study
1 Credit CME

Motivational Interviewing for Medication Adherence

The Million Hearts Learning Lab is a bi-monthly learning series focused on cardiovascular disease prevention and management topics. The series is open to clinicians, quality improvement, and other interested staff across the country, but with a focus on community health centers. Clinicians may earn 1.0 CME credit per session through the American Medical Association's Ed Hub.

This project aims to utilize a mixed-method learning model to host bi-monthly “events”. Please watch the videos below, then select “Take Quiz” to earn CME.

Video 1
Medication Adherence

Linda Murakami, Senior Program Manager for Quality Improvement at the AMA, discusses patient related, therapy related, and condition related causes for non-adherence, collaborative communication, and team-based approaches to addressing non-adherence.

Video 2
Motivational Interviewing for Medication Adherence

Jasmine Mencia, a Clinical Pharmacist at Berks Community Health Center, and Dr Mencia and Sonia Deal, from Affinia Healthcare, discuss communication strategies and key elements of workflows involving motivational interviewing, including ways to address medication adherence.

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Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

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Video 1 Transcript

Speaker 1: [00:00] Welcome, Linda. Thank you. Take it away.

Linda Murakami: [00:01] Thanks, guys. Thanks, guys. We'll go ahead and get started. It's maybe 10 minutes, so let's go. 50%, 50% is what we're working with when we talk about the average adherence rate for all medications for long term therapy. And when patients actually take their medications, they're doing it incorrectly also about 50% of the time. So medication adherence, we need it to be at about 80% for meds to work effectively, for them to be able to work. Next slide, please.

[00:31] And what happens when we, you know, don't have adherence? We have increased number of ER visits, we have increasing number of hospitalizations, worsening patient health impacts patient outcomes negatively and can cause patient harm. So need to talk about what we can do. Next slide.

[00:49] So here's just a breakdown of the common factors, I'm going to talk about these. And remember when we talk about, you know, reasons for non-adherence, you have to keep in mind that some of these are intentional, but some of them are unintentional by the patient. Next slide.

[01:06] So, patients, you know, we talked about patient related, therapy related, condition related, they might have trouble with vision or hearing or swallowing, dexterity to pick up the pills—all of these like unintentional, right? There's nothing they can really do, we have to adapt with them. And it really can impact that adherence for them. Patients who don't believe they have an illness, they're not going to take any medications. We know hypertension and increasing cholesterol or LDL levels don't tend to have symptoms. So you know, they don't feel anything, why should I take any medication? Patients are less adherent when they do take their medications, and they don't feel they're working. So I'm taking my blood pressure medication every day, but my blood pressure is still high. What's the point? Right, patients will say that. We saw polypharmacy, right? The polypharmacy dilemma with the issues of multiple medications, they're taking them several times a day. This one's twice a day, this one four times a day, and over and over. And that can be confusing to the patient. Some meds you can't take them with so many hours of the other kind of medication—again, creates confusion. So and always, whether perceived or true, or real—side effects are a problem. If they think they're going to have side effects, or if they do have side effects, patients tend to not take their medications. Next slide, please.

[02:30] So American Heart Association's scientific statement on med adherence states that uninsured adults do not show improvement in hypertension, like privately and publicly insured adults. And the same was true for the treatment of cholesterol...or control of cholesterol. So health insurance makes a difference here with non, with adherence. And there's a lot of patients that they can't directly control, like the cost of medications or how far their pharmacy is from where they live, or, you know, limited hours of operations of pharmacies like in rural areas are open 9 to 5, but you know, you work 9 to 5. So, you know, how can we access that pharmacy? Is there mail order, is there delivery programs with their services, are their couriers where they live that can help deliver?

[03:19] A lot of patients go to the doctor, but they don't trust their providers and their doctors. And so it's a building of that trust—that is a time taking effort, but something that we need to understand. You know, they're good about going, but they're not good about following plans. And, as always, you know, there's issues finding time to teach patients about their medications. We know schedules are tight, and so we always have to try and find places we can insert some of this info. Next slide.

[03:51] So just hold this here for a second. Well, you know, what do we need to remember is—I had no place to put this info—is we want to talk about patients and help them get in control of their health. So it's a process, it takes time, might take several conversations to talk about the medications before we see improvement. We always want to remember: use plain language and try and keep things real, right? You know, not taking your medications may harm you in this way. And you know, make sure we include our patients in all of these decisions. And it might not be one thing that will fix it, we might be selecting two, three, four things in combination to help us get our patients to be more adherent. Next slide, please.

[04:34] So we talk about communicating. We know that some people are better at talking to patients than others, right? So we always need to work on our communication skills. It takes practice. We want to make sure our patients are comfortable. We want to make sure we remain...non, nonjudgmental, and when we do that, we have to remember our facial expressions, as well. So be sure that when we're talking to patients, show some understanding. Their issues for nonadherence could be embarrassing to them, and so understand that anytime they're talking to you, is probably taking a lot of effort and courage to do that, to admit what they're, where they're failing. We also talk about avoiding, yes/no questions, using open ended questions can help elicit better responses. Next slide, please.

[05:25] So we want to talk to patients and listen to what they're saying, but also to what they're not saying. So if we can find red flags, and you know, look for things where they're, you know, having busy things at work or stressors at home, anything that might affect this. We always want to respond positively thank them for you know, talking about their, their behaviors. And when we talk to patients or explaining to them, you know, consider using teach back, if you don't already. It's a very helpful tool. After you talk about the how, when, and why of the medications, you know, ask them, you know, "When you go home, explain to me how you're going to take your medications tonight, or when you get up in the morning." And, you know, ask them, you know, do they remember, you know, do you remember how the medication is going to help you? So just try and get them to describe that. And always make sure the patient understands, you know, that we need them to take their medications, you know, how we are preventing harm and, and helping control their blood pressure or their cholesterol LDLs. Next slide, please.

[06:31] You go to the next slide, we're going to talk about some team-based solutions. I got some for each of these activities for med adherence and how you know, our members of the health care team can participate. Next slide. So, there are so many people who can help with patient education counseling. I think I've pretty much got the entire team listed on the top of that slide. But the hard part is trying to build that education time. Is there a point in the rooming process or as you move the patient through, you know, is there a way to build time during that visit? We know clinic time is very busy. I know of some places that may set up separate visits for this, short visits for medication counseling, phone calls. There's evidence that use of pharmacist increases adherence. Not in my slide is an article I just read on pharmacy time, somebody posted on LinkedIn stating exactly this. I know there's clinics that have pharmacist call patients one to two days after a med change or a new med's been added. Also some clinics have pharmacists in clinics. So when there's BP med changes, the pharmacist actually makes the med change and counsels the patient at the visit, so after they see the provider, they see the pharmacist. And medical assistants—try and use them during that med reconciliation portion of the visit. Ask them you know hey, how are you managing your meds? You know, if they see any troubles they can then notify the provider or the physician and then they can pick it up during the visit time. Next slide.

[08:11] So physicians, providers, and pharmacists, you guys can review the patient medications and look for opportunities to DC meds—discontinue them—or change them looking for single pull combinations. Work with the patients to align when their refills are due, when their meds are running out. You know, if the patient's on five, eight meds, it's hard if they're getting a med that's running out every week, and it's another visit to the pharmacy. So those are just a few ideas on the slide or the next one. So I've already mentioned, you know, contacting the patients after the med is changed or there's a new one, you know, pharmacists, nurses, they can do that. There is e-prescribing software out there that actually tracks when prescriptions are filled or refilled. I worked with a physician in our hypertension work early on, she would call pharmacies for patients where she knew there was going to be potential problems to see if they fill their med or if they're getting their refills. Looking at you know visit info pre-huddle, pre-visit huddles, and if you're having cholesterol panels or if they had high BPS, you know all of that you can then bring that into the visit and have that conversation during that time. Next slide. Okay, financial incentives that can help get rid of those out of pocket costs. We're encouraging health care organizations to improve their formularies to include lower cost meds and adding those single pill combination drugs to the list. We talked about using online discounts, the good RX, the cost plus, and getting med delivery services and things like that, like I mentioned before, can all help improve adherence. Next slide.

[10:03] So this is just a table out of the scientific statement. It shows who the key stakeholders are and how they can have an impact on the strategies that are listed in the lefthand column. I'll let you guys look at that so we can keep going. And that's my last slide. So here's just a list of a few resources that may help you guys as you work to improve adherence of medications with your patients. That's it for me on this. Thanks, everyone.

Video 2 Transcript

Elizabeth Breitenbach: [00:00] As I promised, let's go ahead and get started. So good afternoon and hello everyone. Welcome to today's event, Million Hearts Learning Lab Session 3, Motivational Interviewing for Medication Adherence sponsored by the National Association of Community Health Centers. My name is Elizabeth Breitenbach and I'm meeting and events specialist based in the Clinical Affairs Division here at NACHC. And I'm pleased to bring you this event along with my division colleagues from the Million Hearts team.

[00:23] Before we get started, let's review a few housekeeping announcements. You have joined this online event by either physically calling in or using computer audio. Both options completely fine, as long as you can hear my voice, you're completely connected fully. The duration of this live event is approximately 45 minutes, including a very brief presentation. And of course, Q&A. Q&A is located in the Q&A box. You may have to take your cursor over to the zoom at the bottom of your screen, or maybe it's at the top toggle of your screen. Simply click that Q&A box; you can type your comments, questions, or concerns into this box at any time. You can also submit questions anonymously. And you also upvote comments that lets us know what you think is a priority for us to answer. So again, feel free to type your comments, questions, or concerns into the Q&A box at any time for the duration of this event. The chat box, which I think a lot of people know about zoom that has been disabled. So the only way that you'll be able to pose questions to us is using the Q&A function. Let us remind you that today's event is being recorded and will be available for playback at a later time. At this turn...at this moment, I'd like to turn things over to Judy, who is going to be introducing and setting the stage for us, Judy, the floor is yours.

Judy Hannon: [01:31] Thank you so much, Elizabeth. I'm Judy Han and the Senior Advisor for the Million Hearts Initiative. And sorry if you're hearing an echo; we are in a conference room. (pause)

I think that probably got fixed. Sorry about that. And on behalf of Million Hearts, I just want to thank you for spending your time today. I'm looking forward to this session. As you well know, the Million Hearts Initiative is dedicated to preventing a million heart attacks and strokes and other cardiovascular events over a five-year period. We know one of the solutions is intensifying medication to get, especially those with uncontrolled hypertension, to control and I'm looking forward to today's session for us to learn a little bit more about how to use the tool of motivational interviewing to get at that outcome. And with that, I'll pass it over to Leanne. Thanks.

Leanne White: [02:24] Thank you so much. Well, greetings and good afternoon to all of the participants on the call today. My name is Leanne White and I am a Public Health Integration and Innovation Fellow within the Clinical Affairs Division at the National Association of Community Health Centers. It is my absolute pleasure to welcome you all to the Million Hearts learning lab today. We are extremely excited that so many of you...many of you are joining us today. We have had over 370 registrants from across the country and from many different organizations. We're delighted to bring you a session on motivational interviewing for medication adherence, a topic that we all hope that will feel very relevant to your practice and addresses everyday situations to your care team's experience with patients.

[03:11] I'd like to take a brief moment just to provide a review of how our Million Hearts learning labs are structured. The total time for the learning lab is 60 minutes. So the same as a traditional webinar, however packaged into three pieces. We have a 12-minute pre-work video recording, which we will discuss later on during the learning lab, followed by a pre-work survey to share your questions in advance of today's live event and then our live event today, which will be 45 minutes. We will also share how you can apply for CME credits at the end of today's session. Next slide please.

[03:47] Alright, wonderful. We have three learning objectives for today's live session. We will define what motivational interviewing is to anchor everyone and why we are discussing this important skill. Then we will move on to our first objective, which is to describe how a nurse and a clinical pharmacist have used motivational interviewing skills during their discussions with patients on how to improve medication adherence. Next we will describe some collaborative communication strategies and key phrases that can be used during patient conversations. And then lastly, we will discuss a patient case study and how motivational interviewing skills can be used to improve medication adherence. Next slide please.

[04:18] Alright, so I'm very pleased to introduce today's panelist, Dr Jasmine Mencia and Sonia Deal. Jasmine is a clinical pharmacist from Berks Community Health Center in Redding, Pennsylvania. Sonia is the Vice President of Community Health and engagement at Affinia Health Care in St Louis, Missouri. So, welcome to Jasmine and Sonia. Thank you for being here today. Jasmine will start with a short presentation on how motivational interviewing approaches are used to improve medication adherence Then we'll follow her presentation by taking a few minutes to discuss the pre-work case study. Then both Jasmine and Sonia will answer some of the many excellent questions that we have received that you submitted in advance. And we'll also be taking those questions posed in the Q&A box. So please feel free to add your questions in that Q&A box. So at this time, I'd like to turn it over to Jasmine. Jasmine?

Jasmine Mencia: [05:25] Thank you, Leanne. So good afternoon, everyone. The purpose of today's presentation is to learn how motivational interviewing can be used by a variety of care team members to improve medication adherence, understand collaborative communication strategies and key phrases for use in conversations with patients about medication adherence, and identify different approaches and strategies specific to common medication adherence barriers. So let's just start by answering the question, what is motivational interviewing? Motivational interviewing is a counseling approach designed to help people find the motivation to make a positive behavior change. As I'm sure many of you have experienced yourselves, it's possible to have conflicting desires when it comes to change. In other words, you may want to change your behavior, but at the same time, you may think you're not ready to change your behavior. This is where motivational interviewing comes in handy. It is a client-centered approach that helps resolve this ambivalence and can increase a person's motivation to change.

[06:30] Next slide. So who exactly can conduct a motivational interview? The simple answer is any member of the health care team. Basically anyone who has time to have a conversation with the patient about their overall health, and specifically their medication use. What I have found as a pharmacist is patients are willing to tell you the truth about how they use their medications. You just have to be willing to listen. In order to do that appropriately, you'll want to keep the four basic motivational interviewing strategies in mind.

[07:04] Next slide. So while there are multiple mnemonics available that have been developed to help keep focused on MI techniques, for today's session, we will be reviewing the mnemonic rule, which will help us remember the four guiding principles, which are: R - resist the righting reflex, U - understand the patient's motivations, L- listen with empathy, and E - empower the patient. So let's dive a little further into this. What exactly does the righting reflex mean? Sorry, same slide. So what does the righting reflex mean? It means try not to immediately fix the problem. Don't tell the patient what they should be doing or scold them for what they're not doing. As health care professionals, we definitely have a tendency of doing this. And that behavior, although good intentioned, can instantly kill the conversation, or the patient's willingness to be open with you.

[08:02] So what should you do instead? We need to understand the patient, their personal motivations and where they are coming from. Basically try to understand where's the disconnect for them. A good rule of thumb for MI is seek first to understand rather than to be understood, listen with connection and empathy. Ask the patient how they feel. Invite them to tell you more, let them vent, admit and share, and expect that the conversation might get comfortable and be uncomfortable and be okay with that. When we do this, we are more likely to create a safe space for the patient sharing information with us.

[08:36] Next slide. In order to bring the RULE mnemonic to life, keep these strategies in mind when interviewing the patient. Arrange the conversation so that the patients talk themselves into change. Remember, outcomes are more likely when the patient is the one who came up with a solution. Next, keep the client's best interests in mind. So again, resist the righting reflex. What you might believe is the best solution for the patient might not be what the patient believes is the best solution for the patient. So let them guide the conversation and put aside your own desires and feelings. Use open-ended questions, obviously so that you can get more information out of the patient, work collaboratively with the patient and assess their willingness to change. As mentioned earlier, people often do want to change but sometimes conflicting feelings prevent them from acting. So kind of gauging where they are in the process will help you come up with a better plan together.

Mencia: [09:40] Next slide. When assessing medication adherence, which is the focus of today, I cannot stress enough how important it is to use open-ended questions. The amount of information you can get from a patient by asking some of these questions is sometimes mind blowing. For example, when I'm doing a medication reconciliation, which is where I have the patient bring in all of their medication bottles, and we go through them one by one, I find that it's very important to never assume things. So even though I have the physical bottle in my hand, and it says take one tablet twice a day, I don't assume that they're taking it twice a day, I simply just ask, "How are you taking this medication?" And, again, you'll be surprised how open people are willing to be. I often get the answer, "I know that it says take it twice a day, but I'm only taking it in the morning because at night I forget, when I get home from work, I just get caught up doing other things." Or they'll tell me "That medicine makes my stomach hurt...I don't want to feel sick all day. But I know it's important for me, so I only take it in the morning," or whatever it may be. So again, by asking open-ended questions, you might be able to pull that information from them better.

[10:54] Next slide. So to kind of help you guys, of course, all patients have reasons for why they don't take their medicine as prescribed. So here on this slide, I've kind of listed, the top six reasons or common medication adherence issues that are typically identified during a motivational interview. Oh, sorry, my light turned off. Okay. So common side effects, common adherence issues are side effects, lack of understanding or denial of their medical condition altogether, the cost of medications, feeling like they're taking too many medications, or they forget to take it, transportation issues, and administration issues. We're going to kind of dive into each one and look at them a little more closely. So that you can kind of offer solutions to the patient, and then let them decide what they feel is the best path to get them adherent with their regimen.

[11:58] So, next slide. Let's start with side effects or fear to have side effects. So of course, all medications have the ability to have secondary effects that are unpleasant to the person. So you can ask them, "Would you be willing to take a medication that is completely different and doesn't have the side effects associated with it?" Or maybe the side effect is happening because they're not taking it correctly. For example, the medication should be taken with food. So same thing, you can offer them the solution, "Oh, it sounds like you might be having, you know, a stomach ache because you're taking it on an empty stomach, would you be willing to try taking it with food for a week and see if that helps?" Administration time can also be a reason for side effects or them not wanting to take it. So for example, medications that cause drowsiness, sometimes people are taking it during the day or during working hours. And then they start taking it because they say, "Oh, I keep falling asleep at work" or "I need to be alert." So counseling them and offering them to take it at night is also a solution.

[13:07] And sometimes just providing education. And this one goes more for the fear side effects portion. So often I hear patients say, "You know, I read the side effects, and it says it could damage my kidney or my liver. And I don't want that problem. So I'm not taking this medicine." Just simply educating them on...sometimes just their disease state. So for example, hypertension, you know, "Hey, if you leave your blood pressure uncontrolled, uncontrolled blood pressure can also lead to kidney damage," or, you know, whatever the fear is. So providing that information and helping them understand the severity of the disease we're trying to treat, sometimes will help them be more open to taking it. But again, you always have some people who are very adamant and resistant. So offering them a completely different alternative might be the best choice.

Mencia: [14:00] Next slide. The next common side effects would be lack of understanding or denial of the medical condition altogether. So again, from the perspective of hypertension, you know, people don't have symptoms. It's an asymptomatic disease until it's too late and you end up with heart attack or stroke. So providing that education on what kind of secondary effects could happen if you leave the condition uncontrolled, that might make them understand why it's important to take their medicine, even if they don't feel any different on it. Sometimes people just have so many medicines that they honestly don't know why they're taking these medicines. So helping them organize their medications and letting them know, "Hey, these six bottles are super important because these three are for your blood pressure, these three are for your diabetes, like if you're not going to take medicine, I don't care about those 10 other bottles, but definitely make sure you take these six bottles." Sometimes that helps them.

[15:00] As a provider, if you're sending in prescriptions and you know your patient has many conditions, sometimes just including the indication in the safe text will also help prevent that confusion and maybe motivate them to take their medicine if they understand the severity of the disease. So...really all these go hand-in-hand with just explain, explain, explain. Try to get them to understand why it's important. And that might help them be compliant.

[15:31] Next slide. Cost, as we know, is also a big reason why some people do not pick up their medicines on time or take their medicines, because they might be on a fixed income. So although you may want to prescribe a medication because it's your go- to drug, sometimes, for a given patient, that might not be the best option. So again, consider an alternate agent, especially if like you're prescribing a brand product, maybe there's a generic available. So consider generic options first, if you know your patient's on the fixed income, or sometimes there's combination tablets available. So patients might be taking multiple medicines that are actually available as a combo tablet, and that'll save them a copay each month or every 90 days.

[16:22] For the brand name products, see if a coupon card is available, or some kind of trial sample, especially the newer drugs, usually, you can find some kind of discount copay card on the manufacturer's website, which can offer them, like free 12 months or something to help with the costs. Or if you have samples in the office, you can provide that. Work with the pharmacy or the insurance to figure out what is the preferred agent. So, of course, for all disease states, there are multiple agents available. And again, you might have your go-to drug that you'd like to prescribe. But that might not work for all people. So work with the insurance company and the pharmacy, and then consider writing a 30-day supply versus a 90-day supply. Because obviously, then they only have to pay like a smaller amount per month, versus having to put out so much money at the forefront.

[17:17] Next slide. Another common reason why people say they don't want to take their medicine is they feel they have too many medicines, or are taking too many pills per day. So consider if you can minimize pill burden. And what I mean by that is, often I find patients are taking medicines two or three times a day. And there are other medications in the same exact drug class that do the same exact thing that they only have to take once a day. So it really starts to add up, especially when they have multiple conditions. So if you can change the formulation to something that's once-daily dosing, sometimes that will help the patient. Again, consider combination therapy, because if you can put multiple pills into just one pill that might motivate them to take it and be compliant with it. Determine if any agents can be eliminated. We have this tendency of just always wanting to add, add, add, oh, you have this problem, you have this problem. Maybe look at the bigger picture, and maybe something's causing a secondary side effect that now you're treating with another medication. And maybe if you eliminate both of those things, now that's two less drugs the patient has to take per day. And then offer organization solutions. So pill boxes, or blister packs, because then maybe that helps them feel like they don't have to do so much work to take their 20 bottles per day.

Mencia: [18:41] Next slide. Transportation can also be a reason why patients are not adherent to their medicine. So a couple things to think about or consider. Number one, do you guys have an in-house pharmacy? If an in-house pharmacy is available, I'm sure there's a way to coordinate...with the patient's visits or whatever, to make sure that they can get their medications on time. Most pharmacies offer delivery or shipping options. So again, work with your neighborhood pharmacist to figure out how this patient can be set up for those things. And if there's a charge associated with it—sometimes there is sometimes there isn't—so just find out how that particular pharmacy operates. Work with patients, see if they have someone who can help them get their medicines, so a caregiver or a friend who can pick it up. And in this case, a 90-day supply is probably better than a 30-day supply, so they don't have to come to the pharmacy so frequently. And so they only have to worry about getting there four times a year versus 12 times a year.

[19:45] Next slide. Administration issues. So this can go many ways. For example, like maybe a patient tells you that a pill is too big to swallow so that's why they only take it every other day or when they feel like it because it gets stuck in their throat. Or if it's an injectable, maybe they tell you that they're just so tired of poking themselves. So offering them an alternative solution. For example, I put here Crestor vs Lipitor, so that's a cholesterol agent. Lipitor is actually a pretty big pill to swallow. Crestor is just as effective. If anything, it's more effective, it's more potent, and it's much smaller. So if you're looking for similar effects, you know, same thing, I don't expect you guys to know the pill size off the top of your head, but you can easily call the pharmacist, I'm sure they'd be more than willing to help and offer solutions if a patient's having administration issues. Considering an alternate delivery method. So again, like I said, if they don't want to inject themselves, maybe there's an oral agent available that we can substitute it with, and then counseling the patient on appropriate administration. So again, if they're not taking it because they're saying it's making them sick or nauseous, just counseling them to take it with food. And again, the admin time changes. Next slide. And that is the end of my presentation. So we will address things during the Q&A. Thank you.

White: [21:16] Thank you, Jasmine really excellent information and truly highlights the importance of how impactful and important these skills are when exploring a patient's own reasons for change. So thank you so much for that presentation. So now we're excited to be able to take a few minutes to apply the concepts in your presentation to the roleplay case study that we shared in the pre-work. For those who could not watch the video vignette, it showed a conversation between a nurse and a patient who had many barriers to medication adherence to treat hypertension. The dialogue used some motivational interviewing skills well, but there are also some areas where techniques could have been applied a little better. So I'd love to hear from our speakers, Jasmine and Sonia, on what they thought worked well and what didn't. And for those who viewed it, please feel free to share your questions with the panelists about what you felt worked well. And what could have been better through our Q&A feature. Jasmine, Sonia...we'll start with what you thought worked really well in the video vignette.

Sonia Deal: [22:23] Thank you. Yes. So what we felt or what I felt worked really well is the conversation between the nurse and the patient. We had one of our lovely community health workers, Tracy Times, acting as the patient but actually telling the patient story, and having that conversation with the patient that they had once had. So I believe that the nurse definitely shared a lot of information and asked those open ended questions for the patient to then respond and provide feedback to the nurse and the community health worker in regards to the things that were barriers for their care.

Mencia: [23:14] And I mean, I will just piggyback off Sonia. So yes, I believe that the nurse and the patient, there was a lot of good information exchanged between the two. Definitely different ways that you can work with that information to arrive at a plan on how to improve this patient's care. But overall, just addressing the purpose of her being there, or why she was being referred, and then asking what kind of issue she's having and her sharing that information. There was a lot of content there that definitely could be worked with.

White: [23:54] Absolutely. So what I'm hearing is there was a lot of asking and affirmation and the nurse was definitely seeking to understand those challenges that was [sic] coming through on the patient's...from the patient's side of their perspective and working with the patient to explore that a bit more. So for the skills that you felt could be improved upon in the video vignette, what are your thoughts?

Deal: [24:19] So I do know that cost was one of the concerns that was brought up with the patient in this roleplay and one of the things that we did not have the luxury of time, of course, to be able to share all of the different incentives and the different services that we provide here at Affinia. But that was something that was brought up during the roleplay. And there was a comment in regards to the cost being addressed or not being addressed. And Affinia does have the benefit of having a Pharmacy Benefits representative, and that individual actually goes out, talks with the different manufacturers of medications, and is able to assist the patient with signing up for scholarships to receive those medications that either decrease the cost or completely bring the balance to a zero, bring it to a zero balance. So that was something that was not displayed or not discussed in the roleplay. But that is one of the services that Affinia Healthcare provides for our patients.

Mencia: [25:39] And I mean, just overall, honestly, you know, the roleplay had bits and pieces of motivational interviewing. But a good takeaway overall is this is actually probably what happens normally in a day-to-day basis or on a day-to-day basis in the health care setting. So we have to find a way to move away from that, and try to empower the patient a little more, and let them lead the discussion on their health care and where they would like us to...help them. I preface a lot of my interactions with "I can't help you unless you want to be helped. So how can I do that for you?" Or "Where do you see me fitting in on getting you to this goal that you have?" Or what have you. So again, it's hard. It's definitely a skill that you need to train yourself to do. And you will catch yourself doing the opposite often. So all I can encourage everyone to do is continue to practice. And just remember, open-ended questions is probably the most inviting way to get information that you were not even looking for.

White: [26:56] Those are great answers and great insights to that video vignette. Thank you so much for sharing. I would like to move into the Q&A portion of our learning lab now, we have several coming through the chat so we will get to those. I'd like to first start off by asking both Jasmine and Sonia. So we all know that time is highly valuable, especially when office visits themselves are very short and limited. And so is the time, correct? So how can health care team members incorporate motivational interviewing skills in their conversations with their patients about medication adherence in that short, limited timeframe?

Mencia: [27:38] So I'll start. Yes, time is definitely a big factor when considering motivational interviewing. So what I would suggest is, some people are very complicated patients. So honestly, you probably cannot address everything in one visit. Unless you specifically carved out time to do that. So I would say identify basically what is the purpose of today's visit and focus on that particular disease state for that day. So for example, if a patient came into the clinic for a blood pressure check with the nurse, the nurse can ask a basic open-ended question like what issues or concerns do you have regarding your blood pressure medications? And let the patient answer and go from there. Or if time permits, most people, I mean, hopefully, 5 to 6 max medications for blood pressure. So if the nurse has time, she can review them one- by-one. And try to keep in mind those open-ended questions. "How are you taking your amlodipine?" "How are you taking your lisinopril?" "What side effects are you experiencing from these medicines?" "How often do you forget to take these medications in a week?" You know, all those questions can lead to answers that might explain why their blood pressure's high today. "Oh, I didn't know that medicine was for my blood pressure" or "I never picked that up from the pharmacy. When did they send that in?" So there's always something and it's honestly probably right there underneath your nose, you've just got to ask the right question.

Deal: [29:18] And I would add...I definitely sometimes we have to be okay with the awkward silence when we ask a question of a patient, especially if it's an open-ended question and we're trying to get that communication, that conversation going. But I would also add, for our teams, splitting up the responsibilities per title or per position. So if the MA is doing medication reconciliation, them asking the patient what medications are they taking? How are they taking it and are they actually taking the medication and then passing that information on to the nurse to then explain to them, or do that education, or do a deeper dive into the questions and answers that that patient has given. I think that that has been helpful for us to not only complete medication reconciliation, but then also to provide education for that patient in regards to their medications.

White: [30:26] Wonderful, thank you both. And I agree that that pause can create some discomfort, but is truly necessary and really important. So it's just getting comfortable with that discomfort. I'm going to grab some questions from the chat. So we have a question. One of our participants does outreach calls to discuss medication adherence, and most of the time they have difficulty getting the patient to admit that they have a problem with adherence, despite having data that they are non-adherent. So how...how did they get more patients to discuss adherence issues without sounding accusatory?

Mencia: [31:07] Alright, Sonia, if you want to go.

Deal: [31:09] Okay, I would say we have a very skilled community health worker that has conversations with the patients and she just makes them feel very comfortable. And the questions sometimes if you ask a question, and you believe that the response is not necessarily the most accurate, you can ask that question a different way, and see if you would get the same response from that patient.

Mencia: [31:44] So yeah, in terms of outreach calls, I used to do this back in my retail days. I guess don't be afraid to use the data. So for example, I would call patients, let's just pretend I'm calling about a hypertension med. "Hi, Mr So-and-So, are you still taking lisinopril 10 milligrams? Yes. Okay. How are you taking it?" "I take it once a day." "Okay, well, we last dispensed it to you on August 1 for 30 days. It is now October 10. And I don't see that we've refilled it. So do you have extra medication on hand? Or what's going on?" And usually, believe it or not, people do have real answers. I've had people say, "Well, I was admitted to the hospital for a month." Okay, that makes perfect sense. Or they say...that they switched insurance, especially during the beginning of year like "Oh, I switched insurances, so I had picked up a bottle in December, and then they refilled it like the first week of January with my new insurance. So I had a surplus of supply." So I think presenting the data after they lie to you, or they didn't lie to you, but after they give you an answer, that doesn't quite make sense. If you put it in that perspective for them, like Well, where are you getting that? Actually, I had someone once told me that their friend...their friend's mom died, and that's one of the medicines she was taking. So he's using up her supply. But okay, I mean, don't recommend it, but at least they gave you an answer that makes sense. So...that's my advice, try to use that data to pull a little more information. And always be friendly like that. So that's like me, I'm like, Oh, well, it's now 45 days later. So where did you get those extra 15 days from? And they'll be more inviting.

White: [33:42] Wonderful. Thank you, Jasmine, Sonia. So we're going to do one more question from the chat. And so we have a participant that's mentioned that they have a hard time getting patients to participate in their care. And so what suggestions or advice would you have to get the motivation for patients to be active participants in their care?

Deal: [34:08] So that is a very good question. Engagement, I believe, especially for FQHC. Sometimes the patients, they come when they want to or when there is a need, not necessarily preventative. And one of the things that we work on is prevention. However, when the patient is in front of us, our team does very well. We have...our hypertension clinic is actually a pharmacist-run clinic but has a hypertension nurse as well as the CHW who works with those hypertensive patients. I would...we have a multitude of things. We send out text messages, the team's reach out to them. But we also utilize the providers. The providers, are the ones who refer the patients to the hypertension clinic. And even with those referrals, sometimes patients will say "I'm not interested" or "I'm not ready to come right now." And I think some of those soft conversations about "do you know why controlling your blood pressure is important?" Having those conversations about family, learning what's important...what is important...to them. So if it's, "I want to be around for my grandchildren," well, you know, your blood pressure is very important. And it's very important to your health. And so let's work on how we can continue to provide you with resources, as well as education, so that you can live a quality, quality life and be around for your grandchildren. So it's really kind of appealing to the softer side of the patient as well.

Mencia: [35:59] Perfect. And then, just to add to that, like I said, earlier, I preface things with "I can't help you, unless you want to help yourself. So...where are you in this process? What can I do for you, to help you better understand why this is so important?" Or...you need to gauge where they are. And I actually have a provider here who...I've heard him be very frank with people, he says, "You don't want to take the blood pressure medicine on prescribing, you don't want to take cholesterol medicine, you want to do everything with diet and exercise, there's nothing I can...you coming to these appointments...there's nothing I can do for you, if you're not going to take the treatment that...we work on or decide on," because diet and exercise where this person particularly was...most likely not going to get her to gold. But I even tried calling her after that conversation she had with him and she said, "In 3 months when I redo my bloodwork, if it's still bad, then I'll consider." And you know what, that's what we have to accept. So again, you just have to gauge where the patient's at, come up with some kind of plan. Maybe if she didn't offer that solution herself, we could offer that like, "Okay, listen, you want to do it your way, no problem. This is...here's diet and exercise information, because that's the route you want to go. What can we do if in 3 months, you come back and nothing has changed? Or it's still dangerously high?" Or what have you. And I think that'll get the patient...again, they have 3 months to decide. And who knows, maybe they'll come back sooner, saying, "You know, I think I'm ready, because I don't feel good," or what have you. So that's my little two cents.

White: [37:44] Yeah, no, and it highlights the importance of every member, the care team having these skills...having everyone practice and refine those skills. But also meeting the patients where they are and listening, those just small steps, but it will eventually lead to bigger steps. So thank you so much. And so I just want to turn to one more question, which is Jasmine, Sonia, if you had one piece of advice that you'd like to provide all of our participants on the call today, as a takeaway from today's learning lab, what would that be?

Mencia: [38:24] I would say the biggest thing is using these skills is one thing, but doing something with the information that you get from it is another. So again, I can't stress enough how many times patients tell me, "I already told this to my doctor, but he didn't listen to me" kind of thing. So if you're going to ask the questions, make sure you're listening. And you make the patient feel heard by acknowledging what they've told you. And, again, offering solutions if they don't have some of their own to offer, and letting them choose which solution works best to resolve that issue. It honestly blows my mind how easy it is to get people to take their medicine, if you just listen. Nobody wants to have a stomachache all day. Nobody wants to feel tired at work. Nobody wants to be choking every time they tried to swallow a big pill. So just taking that information and doing something with it can honestly make a big difference in everyone's health.

Deal: [39:30] And I'm going to piggyback on that with a few things. Helping the patient to create or develop a SMART goal, something that's specific, measurable, action-oriented, realistic—realistic, listening to the patient—and time-oriented. Having them to actually develop their own SMART goal using the motivational interviewing technique is something that is very helpful because it's something that they're developing, they're creating the plan for themselves. And they're also saying, "Well, this is what I can do." And, again, it's going to take listening and questioning, giving them the skills and resources to then act on whatever it is that they...whatever the goal is that they've set. But then also, I would speak to the organizations to definitely take time to be very innovative. We have different departments and different initiatives that we have going on. And I'll take just a brief second. A couple years ago, right before the pandemic hit, we actually did a block party out on...the front lawn of our biggest health center, and it was opened up to the patients. But we also had our vendors there to talk about cooking demonstrations and healthy eating. We had the city there to talk about tobacco cessation. So all of those things that impact heart health, we had several different vendors that were there to provide education information, and then we had Zumba on the front lawn. So [laughter] just taking an opportunity to be innovative, sometimes will help with engagement, as well, as seeing your patient and your patients seeing you doing Zumba on the front lawn, how motivating is that. So I would definitely...those two things, SMART goals and being innovative, are two of the top things that I would say, to make sure you implement into your practices.

White: [41:51] Thank you. I guess innovation is like one of my favorite words. I love that, Sonia. And I just want to...before we move on to the wrap up, I just want to call out a participant message in our chat that I really love is "Leave the welcome mat out. Make sure patients understand that we are here to help with a variety of resources when they're ready." So I just wanted to call that out because I thought that was really great addition. So all right, we're going to move on to our next slide. On this slide, we have listed some helpful resources that are all very practical, offering specific actions and sample phrases that you can incorporate in within your motivational interviewing skills into your discussions with patients on medication adherence and their efforts. And we definitely invite you to check them out. Please note that the links for the last two resources point to our Million Hearts learning lab on our Confluence page where these resources are posted. And rest assured we will also be sending out these resources and slides with the recording here shortly. So at this time, I'm going to hand it over to Rupi Hayer from the American Medical Association. And she will share with you how to claim CME credits and close this out. So Rupi?

Rupi Hayer: [43:01] Thank you, Leanne. Yeah, and thank you to the speakers, it was a very insightful discussion. I love the conversation around empowering the patients. So thank you. So for those of you that are interested in claiming CME credit, here's the information, there's a activity link that you'll need to click on. This will also be shared via email with you guys. And if you have not...if you do not have an Ed Hub account, it will actually direct you to create an account. If you do have one, it'll just direct you to go ahead and sign in. Once you've signed in, there should be a stop button that you click, which will direct you to a quiz. You'll go ahead and complete that quiz and select the appropriate amount of CME to claim. As a reminder...you'll need to claim your credit by March 1. So that's about 45 days from today, and then go to the next slide. This is just some instructions on how to access and download your certificate of participation. So once you've completed that quiz, there should be a transcript button that you select and be able to select certificate next and hit download and you should be good to go.

[44:08] And then next slide. So here is a friendly reminder of two upcoming learning labs. The first one is scheduled for March 15. And that will focus on bidirectional text messaging to engage patients in chronic disease management. Same time, 3pm Eastern time. And then the one after that is scheduled for May 17. And that is focusing on the role of the pharmacist in helping manage hypertension. And again, same time at 3pm. There is a QR code there if you guys want to go ahead and register if you haven't done so already. But you'll also get this in an email. And I think that wraps us up for the day. So thank you all for joining us today. We really appreciate it you guys taking time out of your schedule to take part in this insightful discussion. We hope to see you again soon. Thank you.

White: [44:59] Thank you.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.


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