BCBS Webinar_Engaging_Members_Final With notes

Using MI to Engage Members in Case Management

Using Motivational Interviewing to Drive

Member Engagement 2013Katherine Galasso, member of MINT,

CIF, CMT, Conducting Training, Communication and Change

Management Programs atBlue Cross Blue Shield of

Massachusetts


Engagement Components• Data Feeds –

Synchronized standards for triggers and outcome measures

• Program Design – When, why, and how calls are made to members

• Collaboration Strategies – With accounts, providers, and other programs

• Conversation – Develop skills rather than scripts to be prepared to handle most situations


At Issue

• Nurses are not trained in sales• Telephone case management is not the same as nursing• Nurses often feel they are bothering members• Common lack of confidence in the engagement effort• Using the assessment tool as a script• Have difficulty handling rejection• Trained in the righting reflex • Have difficulty switching styles

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Program Difficulties• Program expectations • May not match member’s need (too long/too short)• Mixed measurement of calls made vs. reached rate• Cold calls without sound leads or triggers• Staff makes calls between 8:00 – 5:00 • Not everyone needs case management• Competing programs calling the same member• Prepares scripts rather than develops skills And our case managers are still able to engage members!


What Encourages Change?• You would think that:

– Having heart failure, not being able to breathe; loss of eyesight or digits; or blackouts when you lose time

– Would be enough to stop smoking, drinking, eating less nutritious foods or failing to exercise

• And yet it is not enough to change behavior


Myths about Change• Making a person feel bad will lead to change• Pointing out a person’s mistakes will lead to a

modification or learning• Information will make a person comply• Change takes a long time• Star Trek Syndrome: The experts will give

information to “make it so”


Truths about Change• When people feel unacceptable as they are – they

become paralyzed• The answers are hidden inside each of us• Individuals are the experts on themselves• When people feel heard and believed they are more

likely to change• When people talk about the past they stay the same• When people talk about their hopes and dreams of

the future they are more likely to change


Why Motivational Interviewing?Headlines – Change is Everywhere


Why Motivational Interviewing?• Evidence (data) – science• Anecdotal (stories) – values • Your own experience – skill sets

– Case manager; Utilization manager; Leader – Parent - family member

• Values + Goals/Outcomes = Effective Relationships • The spirit of MI synchronized with values

Using MI to Engage Members in Case Management 10

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OEQ CEQ REF AFF

Team A

Team B

Team C

Motivational Interviewing Early Indicators Using MI

Percentage of Change in MI use from June – August


Motivational Interviewing Early Indicators

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Sum AD w/P Emp ADwo/P

Team ATeam BTeam C

Percentage of Change in MI use from June – August


Motivational Interviewing Early Indicators Engagement Rates

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Team ATeam BControl

Percentage of Reached Engagement Rate for 2 Study Groups vs. Control Group


Using Motivational Interviewing

Dr. Jeffery Simmons, Director (Presented for Katherine Galasso)Blue Cross Blue Shield of Massachusetts

1992 – First published (substance abuse, social work)1997 – Motivational Interviewing Network of Trainers, MINT 2002 – Second edition (health care)2012 – Third edition (corrections, military) 2012 – MINTies = 1,200 in the world in 44 countriesMITI – Scoring process to measure proficiency (MI Fidelity)

Dr. William R. Miller & Dr. Stephen Rollnick

MI Continues to Evolve


Program Design StrategyThe conversation is determined by Program Design:• Collaborate with sales / accounts / provider groups • CM as part of the wellness effort as an opt-out rather than

opt-in construct• Account assistance to communicate program internally and

provide members’ accurate contact information • Maximize CM insurance skills; BCBS CM vs. provider CM is the

ability to navigate medical and insurance expertise—That is the differentiator


Engagement Strategy• Offer a brief reason for the call; set the agenda• Get the member to talk right away• Understand the added value as a clinician • Develop rapport quickly• Help the member with something • Listen to members’ needs then connect to case management

offering• Deliver with skilled vocal techniques

– Tone / Energy / Attitude• Learn conversation with MI proficiency rather than a script


Key Components of Engagement

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• Engaging others requires the ability to: – Demonstrate genuine interest in answers to questions – Avoid giving unsolicited information, advice or feedback – Offer genuine empathy– Explore ambivalence– Apply the right techniques to members’:

– Stage of change– Sustain talk; discord; and change talk


Techniques: Master Your ToneProfessionals must consistently sound:

– Upbeat to indicate enthusiasm– Warm to indicate you care– Controlled to indicate your confidence– Clear to indicate your knowledge

• Four Components of tone: – Speed / Volume – Modulation / Articulation


Techniques: Word Choice• Words that Cause Resistance

– Ma’am or sir– Contractions (can’t, don’t,

won’t)– Directive words: You should,

you need to, have you thought about?

– Contradictory words: But, should, try

– Triggers such as jargon, slang, or clichés

• Words that Positively Reach Others– Person’s name – Ask others for their opinions:

“What are your thoughts about”– “What I can do for you is..”– Words tested positive for

engaging others: You, Discover, Easy, New, Results, Proven


Stages of Change• Pre-contemplative – don’t need to change • Contemplative – ambivalent about change • Planning – spending time planning (thinking)• Action – participating in new behavior (3-6 months) • Maintenance – participating in new behavior (6-12

months) • Relapse – starting over Drs. Prochaska and DiClemente Members are either in action or

ambivalence


Changing Nurses’ Approach to Increase Engagement

• Master Motivational Interviewing integrated with assessment • Understand stages of change to meet the member • Reframe approach; inviting members to case management • Explore to gain holistic view of the member• Start a conversation rather than a sales pitch• For a minimum, use MI for first and last 5 minutes of the call

(before and after the assessment) to maximize the members’ experience


Where to start - OARS• Open-ended questions

• Affirmations

• Reflections

• Summaries


Example: Start the Conversation and Set the Agenda with OEQ

• “I’m calling to invite you to our case management program ”

• “I’m calling to reach out to you after your recent medical event (activity) to see how you are doing.”

• “I’m calling to welcome you to case management”


Example: Make it Easy for the Member• “It is part of your benefit”• “It is a free program to support your health”• “Case management is an added resource to manage and support your health”• “Our program gives you additional tools to help you navigate the health care system”


Techniques: Open the Door - “O”ARS• “What is going well with your recovery and what is not going

so well?”• “What has it been like for you since your hospitalization?”• “Tell me about your current circumstances regarding your

health.”• “How did you explain your medical story to your family?”• “How is your recovery process at this point?”• “What are your particular health needs right now?”• “If you could change one thing about your health what would

it be?”


Techniques/Examples: Affirmations – O“A”RS

• Affirmations identify the strength or effort someone brings to the process. For example: – “You are facing some difficult issues and still working hard to

follow your treatment plan.” – “You are dedicated to getting better with your commitment

to these changes.” – “Your dedication to getting better is so clear as you work to

follow your doctor’s recommendations.”


Techniques: Reflections – OA“R”S• Some reflections are more effective than no

reflections• Pauses are more effective than fillers• Use reflections and summaries to keep the call

focused, transition to new topics and control the long talkers

• Master reflective listening to demonstrate compassion over the telephone


Techniques: Summaries – OAR“S”• As if you are picking flowers for a bouquet• Minimum of 4 items• Lasts about 30 seconds in length • Follow with a confirmation

• “Did I capture that correctly?”• “Did I get that all right?”

• Collect material that has been offered


Summary ExamplesOffer a recap: “So far you’ve expressed concern about your sugar

levels, you can give yourself the shot, your levels spike at times and you would like more information about diet options. What else is on your mind?”

Offer a Link: “That sounds a bit like what you told me about the lonely feeling you get.”

Provide a transition: “Before I ask you the questions I mentioned earlier, let me summarize what you’ve told me so far and see if I’ve missed anything important. You said that you are feeling sick and it scares you…you are… it is difficult for you to…”


Techniques: Empathy• Evidence indicates the level of empathy will

determine the ability to influence• Examples: “It must be difficult to be in recovery while

taking care of your parents.”• “It is not easy to work full time and take time to go to

treatments.”• “You are enjoying the process of being a parent.”• “It is important to you to understand your

symptoms.”


Developing Focus• Focus on members’ needs and

wants • Listen for hinge point • Look for the fit• Remember the value you bring• Ask more than tell• Resist the “righting reflex”• Implement Tricks of the Trade

CM Resources

Hinge Point

Member’s Needs


The Righting Reflex • Fix it• Make it better• I know what you need• I’m the expert• If you do as I say you will be better• I had a similar situation… so I know


RoadblocksThomas Gordon Outlined 12 responses that are not listening:1. Ordering, directing, or commanding2. Warning, cautioning, or threatening3. Giving advice, making suggestions, or providing solutions4. Persuading with logic, arguing, or lecturing5. Telling people what they should do; moralizing6. Disagreeing, judging, criticizing, or blaming7. Agreeing, approving, or praising8. Shaming, ridiculing, or labeling9. Interpreting or analyzing10. Reassuring, sympathizing, or consoling11. Questioning or probing12. Withdrawing, distracting, humoring, or changing the subject

http://www.unodc.org

http://www.unodc.org/


The Spirit of MI

Collaboration

Acceptance Compassion MI Spirit

Evocation


The Spirit of MI• Collaboration – partners • Evocation – drawing forth• Acceptance – you are okay as you are (autonomy, you make the choice)• Compassion – empathy


Empathic Listening• Is an accurate understanding of others’ worlds as seen from their insides rather than yours• Occurs when the person feels heard and believed • Communicates acceptances without judgment• Opens the door


Listening Skills Requires you to…• Be present when you listen

– Suspend assumptions, status, judgment– Suspend unsolicited advice or information

• Be interested – offer your undivided attention– Quiet the “monkey mind”– Care about the answer to each question

• Be curious - listen for understanding– Listen for what is meant, rather than what is said– If a question comes forward in you mind, answer it, then state it as an

empathic reflection• Honor silence - relax into it• Accept the person and listen with Delight!


Wisdom“One of the hardest things we must do sometimes is to

be present to another person’s pain without trying to fix it; to simply stand respectfully at the edge of that person’s mystery and misery. Standing there we feel useless and powerless, which is exactly how the person feels – and our own unconscious need to reassure ourselves that we are not like the soul before us.” - Parker Palmer


Define Listening• Focus your purpose, attention, and energy on understanding

what the person’s message means to him or her rather than to you

• Focus: What the person is saying? Simple Reflection

• Focus: What does the person mean?Complex Reflection

• Listening means you are present, interested, and curious


AmbivalenceIt is normal! It is necessaryIt is a step toward changeIt is a block to change It is the key to unlock change The goal of MI

is to explore ambivalence and increase commitment

language


Getting Permission• Simply ask: “May I share some information with you?”• Answer a question• Cluster technique: “Would you be interested in what some of my other members have found helpful?”• Menu technique: “There are a number of things we can talk about. We can discuss ___, ___, or ___. Which would be most helpful for you?”


Menu Technique - Bubbles Sugar Levels

Testing

BuyingSupplies

Physical Activity

Food

What to Watch for

Fluids

Eating Out

Symptoms

Diabetes Pick 4-5 topics about diabetes to set the agenda from a menu


Agenda Setting - EPE• Elicit the member’s agenda

– Share what the member has revealed so far in a thorough summary. – Then ask: “You mentioned some changes you have been thinking

about. Would it be okay with you if I shared some information and then get your thoughts about it?”

– Wait for a sincere “yes”• Provide information

– “Your blood levels are at x and the goal is between y and z.”• Elicit by asking permission or for the member’s opinion

– “and I’m wondering what you think?” or “What do you make of that?”


Change Agents• When you think about people in your life who

motivated you to change…• Who were they?• How did they motivate you?• What characteristics did they bring?• Across multiple countries most report that it was the

compassion rather than the information that made the difference.


Studies Indicate what Works• Simple reflections work for understanding the

meaning• Complex reflections are needed to move the

conversation forward• Talk about history = status quo• Talk about hopes for the future = change


PrinciplesExpress Empathy – acceptance, understandingDevelop Discrepancy – perceived conflict between present behavior and desired goalsAvoid arguments – “righting reflex”…

No unsolicited advice, direction, feedbackRoll with resistance – empathetic reflectionSupport Self-efficiency – empower, autonomy


Listen for Types of Talk• Change Talk – Possible change (s)• Sustain Talk – Staying the same • Dissonance (Resistance) – Upset at the process

The response to each of these is different and makes or breaks the engagement process.


Change Talk• Types of Change Talk: “Prep” • DARN

– Desire: I want to… – Ability: I can… – Reasons: There are good reasons to… – Need: I really need to… I have to


Commitment Language • Types of Change Talk: “Mobilizing” • CAT

– Commitment Talk: I’m going to…, I intend to… I will… I plan to…

– Activation: willing, ready, preparing – Taking Steps: I started…


MI Skills / Strengths• Listen for Change Talk and reply with

–Elaboration–Affirmation–Reflection (complex)–Summary (30 seconds)


DefendingArguing/Squaring

Off/Power StruggleInterruptingDisengagement#1 form of resistance is

compliance

Sustain Talk and Discord


Desire for status quoInability to changeReasons for sustaining status quoNeed for status quoCommitment to status quo

Sustain Talk and Discord


About the processBehaviorInterpersonal (takes 2 to resist)A signal of relationship

deteriorationHighly responsive to helper style

Discord


Discord in Engaging occurs the member’s filters trigger a response:

Prior experience or expectationsFeel judged, shamed, criticized, praised, labeled, blamed…any of the

roadblocksWhen these occur the engagement ends or is interrupted and the CM must begin again to reconnect

Discord When Engaging


Emphasizing autonomyReframingAgreeing with a twistRunning head start (pros

and cons)Coming alongside

Responding to Sustain Talk


Reflective listeningApologizingAffirmingShifting Focus

Responding to Discord


Engaging• Person-centered style

– Listen– OARS– Learn this first - EMPATHY!

• Engaging necessarily comes first• Engaging skills continue throughout MI


Examples: Handling Resistance• “Why do I need a case manager, I have one from my doctor’s office?”• “How can you help me over the telephone?”• “I don’t think I need more people involved?”• Respond with: reflection; then emphasize personal choice and control or Agree with the Negative


Techniques: Roll with Resistance• Complex Reflections

– Amplified– Double-sided

• Coming along side• Agreeing with a twist• Reframing• Emphasizing personal choice and control• Shifting focus


Motivational Interviewing Goals…To create a safe place to explore ambivalenceTo no longer engage in power struggles with the

personTo give no unsolicited advice, direction and feedbackTo use complex reflections to move the conversation

forwardTo ask for change talk


Construct a Complex ReflectionMember: “I’m having a difficult time with my children. They do

not listen to me.”Simple Reflection: “It is not easy to be a parent.” Complex Reflection: (What is the meaning of what is said?)

What question would you like to ask them?Imagine a reply to that question.

Then put it into a statement (complex reflection)“You’re scared for them.” “You have some fears about their future.”“You’re afraid of not being a good parent.”


Complex Reflections• Amplification: This behavior does not cause you any

problems• Double-sided: on the one hand…on the other• Affective (emotion): You feel that…• Metaphor: It’s as if…• Continuing Paragraph: This is important and…(guess)• Emphasizing Personal Choice: This is your choice…You know

that it is up to you• Siding with the Negative: You know you cannot do anything

about this…


Measurement: Engagement Study• Comparing use of specific elements to engagement rates• Study tools

– Worksheet– Recorded calls– Engagement rates

• Parameters– July – September, 2012– First 12 minutes of each call – 28 case managers in a variety of programs


Engagement WorksheetSubject # ______Employee Ext _______MI Skills: Circle one once 3 calls are completed: Novice * Intermediate * Advanced

Call 1: 0 – 12 Min.Qty Message Y / NVerification Y / NDate _______Time _______Length _______ Inbound / Outbound

Comments

Open-ended Questions*

Closed-ended Questions

Reflections**

Affirmations**

Summaries**


Engagement WorksheetSubject # ______Employee Ext _______MI Skills: Circle one once 3 calls are completed: Novice * Intermediate * Advanced

Call 1: 0 – 12 Min.Qty Message Y / NVerification Y / NDate _______Time _______Length _______ Inbound / Outbound

Comments

Advice/Info with Permission**

Advice/Info With Out permission

Empathy

Resistance Response Yes / NoYe =CARES CRA CRD / No=NoneDid this member enroll Y / N


MITI Coding System• Motivational Interviewing Treatment Integrity 3.1.1 (MITI 3.1.1)• T.B. Moyers, T. Martin, J.K. Manuel, W.R. Miller, & D. Ernst• University of New Mexico• http://www.motivationalinterview.org/Documents/miti3_1.pdf

http://www.motivationalinterview.org/Documents/miti3_1.pdf


Global RatingsEvocation 1 2 3 4 5

Low - HighCollaboration 1 2 3 4 5

Low - HighAutonomy/ Support 1 2 3 4 5

Low - HighDirection 1 2 3 4 5

Low - HighEmpathy 1 2 3 4 5

Low - High

Giving

Behavior CountsGiving Information: MI AdherentAsking permission

affirm, emphasize control, supportGiving Information: MI Non-adherent

Advise, confront, directQuestions

Closed QuestionOpen Question

MITI Coding System


Measurement: Proposed Outcomes• Compare the number of MI Components used• Engagement Rates for same time period• Compare top engagers and low engagers

More to come!


To Change How One CommunicatesRequires effortMeans working through:

The Concept: The harder you work for someone else to change – the less likely he or she will change

The “awkwardness” More energy is spent on avoiding the “Awkward” then on trying

something newEffort means being in the awkward, passing through it,

to get to the other side when you acquire new skills as your own