Using MOHR for Behavior Change: A Webinar for

CliniciansSherri Sheinfeld Gorin, PhD: sherri.gorin@gmail.com

Alex Krist, MD, MPH: ahkrist@vcu.eduKurt Stange, MD, PhD (discussant)

March 20131

Outline of the webinar• Background• Introduce you to the MOHR tool• Approaches to Counseling Patient

Self-Management• Clinical cases and discussion• Summary and resources

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National efforts to capture patients’ voices

Patient Centered Medical Home

Meaningful Use

Annual Wellness Visit

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Goal of the MOHR study

Pragmatic evaluation of: (1) feasibility of collecting patient

reported behavior and psychosocial information and

(2) impact on office visits

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Basic MOHR study design• 9 diverse pairs of primary care practices

participating

• Outcomes measured by Patient Experience Survey and repeated use of MOHR website

• Findings selected to inform practice, Electronic Health Record (EHR) design, policy, and payment

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Background supporting MOHR study

JAMA 2011;

Vol 305: 300-301

JAMIA 2012; Vol 19(4): 575-582

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How the MOHR website works • Initial screen.

• Follow-up on positive screens for depression, anxiety, risky drinking, and drug use.

• Assessment on readiness to change.

• Identifies patient’s most important topic.

• Automated patient and clinician feedback

• Goal setting exercise.7

The MOHR website supports the 5As

• Ask: Assess health behaviors and factors affecting behaviors.

• Advise: Provide clear, specific, and personalized advice, including harms and benefits.

• Agree (Assess): Select treatment goals and approach based on patient’s needs.

• Assist: Aid patient in achieving agreed-upon goals through self-help, counseling, and medical treatment as appropriate.

• Arrange: Schedule follow-up contacts to provide ongoing assistance.

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Patient answers 18 questions on 10 topics

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Patient reviews information

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Patient selects readiness to change

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Patient selects MOST important topic

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Patients can

download or print

their summary

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Practices can track their progress

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Practices can access patient summaries

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The paper MOHR assessment tried to recreate the website

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Patient completes patient survey

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Practice scores the assessment

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Next the clinician…

• Considers administering follow-up questionnaires for positive screens.

• Uses scored assessment during the visit.• Considers doing readiness assessment

and goal setting during the visit.• Gives the patient the scored assessment

and keeps a copy for the medical record.

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How?

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Strategies for Health Behavior Change using the MOHR Tool:

5 A’sStages of Change

Setting S.M.A.A.R.T. Goals Brief Motivational Interviewing

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Principles of Effective Communication that Encourage Patient Self-Management

• Explore and hear the patient's perspective.• Provide emotional support and express empathy.• Share information that is useful and relevant.• Negotiate a plan.• Anticipate problems and barriers and identify

potential solutions.

• Modified from Rorer D. Kinmonth AI.. What is the evidence that increasing participation of individuals in self-management improves the processes and outcomes of care? In: Williams R., Kinmonth, A, Warchain N, et al. eds., The evidence base for diabetes care. John Wiley and Sons, 2002

• Glasgow, R.E., Goldstein, M.G. (2007) Introduction to the Principles of Health Behavior Change. In: Health Promotion and Disease Prevention in Clinical Practice. S. Woolf (Editor). 2nd Edition. Williams and Wilkins, pp129-147.

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Application to Clinical Practice : Four Cases

• Cases are designed to illustrate the use of the MOHR tool in clinical practice.

• Each case varies by patient age, gender, and presenting problem.

• Each case applies the 5 A’s, and S.M.A.R.T. goal-setting.

• Each case applies the “stages of change” model (preparation, action, or maintenance).

• Some cases illustrate the use of brief motivational interviewing.

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Case One

An active 29-year old female who is in good health has begun to increase her physical activity over the past month. She has a family history of diabetes and heart disease.

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Assessing Readiness to Change with the MOHR tool

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Stages of Change: Physical Exercise as an Example

• Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot (1997 Sep-Oct) 12(1):38-48.

Contemplation

Preparation

ActionMaintenance

Relapse

Precontemplation

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Possible responses to Case One

• Assess stage of change: Action • Assist: identify facilitators to change

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Goal-setting • Direct activity and emphasize the link between

behavior and outcome

– Long- and short-term• Focusing only on long-term not effective

– Process vs. outcome goals• Exercise 3 times per week vs. lose 10 lbs.

• Bandura, A. (1986). Social Foundations of Thought and Action. Upper Saddle River, NJ: Prentice Hall.• Bandura, (1998). Health promotion from the perspective of social cognitive theory. Psychological Health,

13, 623-649 Becker, M. (1986). The tyranny of health promotion. Public Health Review, 14, 15–23.

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Goal setting for the most important problem

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S.M.A.A.R.T Goals Specific: what, where, when, why, how Measurable: allows for progress evaluation◦ how often, how long, and how intensely

Adjustable: flexible to accommodate unexpected challenges Action-oriented: should be focused on personal action Realistic: set according to individual abilities Time-based: clear end-point (short- & long-term)

Example: • I will begin some exercise… versus• I will jog outside or use the elliptical machine at the gym at a

moderate intensity for 30 minutes 4 times per week and stop eating potato chips every day to lose 1-2 lbs per week for the next 3 weeks.

• Nakamura Y, Tanaka K, Yabushita N, Sakai T, Shigematsu R. Effects of exercise frequency on functional fitness in older adult women. Arch Gerontol Geriatr. 2007 Mar-Apr;44(2):163-73.

• Croteau J, Ryan D. Achieving your SMART health goals. BeWell@Stanford. 2013; http://bewell.stanford.edu/smart-goals. Accessed Jan, 2013.

• O'Neil j. SMART Goals, SMART Schools. Educational Leadership. 2000;Feb:46-50.31

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Stages of Change: Action• Individuals modify their behavior, experiences, or

environment in order to overcome their problems • Requires considerable commitment of time and

energy• At high risk of dropping out of exercise program • Strategies to move forward:

• Self-monitoring• Social support

• Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot (1997 Sep-Oct) 12(1):38-48.

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Give Feedback for Self-Monitoring

• Individual and specific• Review progress and

recognize achievements(e.g. Time, intensity, fitness testing)

• Measurable health outcomes (e.g., Blood pressure, Cholesterol)

• Bandura, A. (1986). Social Foundations of Thought and Action. Upper Saddle River, NJ: Prentice Hall.• Bandura, (1998). Health promotion from the perspective of social cognitive theory. Psychological Health,

13, 623-649 Becker, M. (1986). The tyranny of health promotion. Public Health Review, 14, 15–23.

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Social Support• Strong correlate of PA• Exercise partner/group• Motivation from friends and

family• Possible methods:◦ Buddy system Someone with similar goals, time

schedule, progression◦ Checking in ◦ Arrange physically active

outings• Bandura, A. (1986). Social Foundations of Thought and Action. Upper Saddle River, NJ: Prentice Hall.• Bandura, (1998). Health promotion from the perspective of social cognitive theory. Psychological Health,

13, 623-649 Becker, M. (1986). The tyranny of health promotion. Public Health Review, 14, 15–23.

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Case Two

An enthusiastic first-time 54-year old female patient wants to work on all behaviors now; she is a current smoker;she defers to her physician for her advice, and is willing to consider quitting at this time.

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Assessing Readiness to Change with the MOHR tool

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Possible Response to Case Two

• Brief smoking cessation counseling using 5 A’s and 5 R’s, particularly Assist.

• She is in the “preparation” stage for quitting smoking.

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5 A’s applied to smoking cessation

Ask/Assess: Using the MOHR tool, you have identified and documented her tobacco use at every visit. Advise: In a clear, strong, and personalized manner, urge her to quit.Agree/Assess: Since she is willing to make a quit attempt at this time, collaboratively set goals based on her interest and confidence (self-efficacy) in stopping smoking. Use the 5 R’s, particularly to address “roadblocks.” Assist: Since she is willing to make a quit attempt, use counseling and pharmacotherapy to help her quit. Arrange: Schedule followup contact, in person or by telephone, preferably within the first week after the quit date.

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S.M.A.A.R.T Goals Specific: what, where, when, why, how Measurable: allows for progress evaluation◦ how often, how long, and how intensely

Adjustable: flexible to accommodate unexpected challenges Action-oriented: should be focused on personal action Realistic: set according to individual abilities Time-based: clear end-point (short- & long-term)

Example: ◦ I will stop smoking… Versus◦ I will substitute a walk for my morning cigarette, chew 4 mg

nicotine replacement gum every time that I feel like smoking, and wear a nicotine patch on my left arm for the next 3 months.

• Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T.Can nicotine replacement therapy (NRT) help people quit smoking? Cochrane Review. Epub: November 14, 2012.

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5 R’s of Smoking CessationRELEVANCE - 1 minute Ask patient about how quitting may be personally relevant. Longer and better quality of life Extra money People you live with will be healthier Decrease chance of heart attack, stroke or cancer

RISKS - 1 minute Ask the patient about her perception of short-term, long-term and environmental risks of continued use. Acute (breathing, asthma) Long-term (heart, lungs, health)

REWARDS - 1 minute Ask the patient about perceived benefits/rewards for quitting tobacco useHealth (self & others) Food taste Sense of smell Feel better Example to others Additional years of life

ROADBLOCKS - 3 minutesAsk patient about perceived roadblocks to

quitting. Withdrawal symptoms Fear of failure Weight gain Lack of support Depression Enjoyment of tobacco

REPETITION - 1 minute +Respectfully repeat 5 R’s each visit, providing

motivation and information.

Refer non-pregnant patient to 1-866-PITCH-EM, and community cessation services or Internet as appropriate.

• Fiore M; United States. Tobacco use and dependence guideline panel. Treating tobacco use and dependence. Clinical practice guideline. Rockville, (MD): U.S. Department of Health and Human Services, USPHS; 2000.41

Arrange for followup • Schedule follow-up contact, in person or by telephone,

preferably within the first week after the quit date. • Provide:

o Smoking Quitline in English or Spanish, toll free within the US, Monday through Friday 8:00 a.m. to 8:00 p.m. Eastern Time: 1-877-44U-QUIT (1-877-448-7848).

o LiveHelp Online Chat: confidential online text chat with an information specialist from NCI's Cancer Information Service - Monday through Friday, 8:00 a.m. to 11:00 p.m. Eastern Time: LiveHelp (https://livehelp.cancer.gov/)

o NCI's QuitPal App has tips and tools to help her become smoke-free.

• At follow-up, repeat the 5 A’s and 5 R’s, as necessary for sustained cessation.

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Case Three

Long-standing 64-year old male diabetic patient who is obese, low-income, and will not discuss weight loss.

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Possible Response to Case Three• Brief Motivational Interviewing to begin the

“change talk.” • In preparation stage. • Use 5 A’s:

– Assess conviction and confidence (self-efficacy) – Advise on reducing high fat foods. – Agree on a realistic plan to reduce high-fat foods– Assist in setting goals for changing intake of high

fat foods– Arrange for follow-up, refer to community

resources

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Stages of Change: Preparation

• Individuals are intending to take action in the next month and have been unsuccessful in changing over the past year

• Strategies to move forward: • Setting goals• Tipping of cost-benefit scale• Increasing self-efficacy

• Plan to overcome barriers• Good role models

• Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot(1997 Sep-Oct) 12(1):38-48.

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S.M.A.A.R.T Goals Specific: what, where, when, why, how Measurable: allows for progress evaluation◦ how often, how long, and how intensely

Adjustable: flexible to accommodate unexpected challenges Action-oriented: should be focused on personal action Realistic: set according to individual abilities Time-based: clear end-point (short- & long-term)Example: ◦ I will begin to eat less high fat foods… Versus◦ Using the list that I received from my doctor’s office, I will choose

low fat foods over high fat foods at one meal each day over the next four weeks.

• Croteau J, Ryan D. Achieving your SMART health goals. BeWell@Stanford. 2013; http://bewell.stanford.edu/smart-goals. Accessed Jan, 2013.

• O'Neil j. SMART Goals, SMART Schools. Educational Leadership. 2000;Feb:46-50.

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Identify benefits and rewards of lower fat intake

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Rewards • Tangible reward• Specific to the individual (e.g. weight loss,

better management of diabetes)• Should coincide with health risk reduction

goals• Involvement of others

- Meal planning and preparation• Bandura, A. (1986). Social Foundations of Thought and Action. Upper Saddle River, NJ: Prentice Hall.• Bandura, (1998). Health promotion from the perspective of social cognitive theory. Psychological

Health, 13, 623-649 Becker, M. (1986). The tyranny of health promotion. Public Health Review, 14, 15–23.

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To conduct brief MI, Assess:

1. His conviction to or the importance of change; and

2. His confidence (self-efficacy) in taking action.

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Overcoming His Resistance to Change with Motivational Interviewing (MI)

“A collaborative, person-centered form of guiding to elicit and strengthen motivation for change.”

Use OARS:

• Open-ended questions posed by the provider; these are not easily answered by yes/no, or by a short, specific, limited response.

• Affirmations are statements that recognize client strengths, and support client self-efficacy.

• Reflections or reflective listening are key to MI. The provider guides the client towards resolving ambivalence by focusing on the negative aspects of the status quo and the positives of making change.

• Summaries communicate interest, understanding and call attention to important elements of the discussion.

• Miller WB, Rose GS. Toward a Theory of Motivational Interviewing. American Psychologist. 2009 ; 64(6): 527–53751

Brief Use of MI approaches to elicit “change talk” in this long-term resistant patient:

• Provider: You know, we’ve discussed this many times before; perhaps eating high fat foods is so important to you that you won’t give it up, no matter what the cost. (Come alongside)

• Patient Response: I really should change; my health and staying around for my family is more important than eating burgers at McDonald’s. (Change talk)

• Provider: That’s great to hear you say; in what (specific) ways could you reduce the high fat foods in your diet? (Ask for elaboration/examples)

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With low conviction to change, begin there:

• Provide information and feedback (after asking his permission)

• Explore ambivalence• Provide a menu of options for treatment and

follow-up. • Seek his commitment to action, agreement to

think about change, to seek assistance when he is ready to take action.

• Arrange follow-up

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Low confidence/self-efficacy• His beliefs about his ability to successfully complete the

task(s)• Situation-specific (eating low-fat vs. high fat foods)

• Sources of efficacy information:• Past performance accomplishments• Vicarious experiences• Social persuasion• Physiological & affective states

• Miller WB, Rose GS. Toward a Theory of Motivational Interviewing. American Psychologist. 2009 ; 64(6): 527–537

• Glasgow, R.E., Goldstein, M.G. (2007) Introduction to the Principles of Health Behavior Change. In: Health Promotion and Disease Prevention in Clinical Practice. S. Woolf (Editor). 2nd Edition. Williams and Wilkins, pp129-147.

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With low self-efficacy:

• Review his past experiences with change, especially his successes

• Teach him problem-solving and coping skills• Encourage small steps that are likely to

lead to initial success. • Arrange follow-up to reinforce change

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Arrange for Followup

• Send an email or telephone within one month (MOHR tool as a cue)

• Reinforce his conviction to change, and his confidence in regularly eating low-fat (vs. high-fat) foods

• Re-iterate the rewards of dietary change for his health

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Case Four

Long-standing 40-year old female patient has been referred to a psychotherapist for depression, has received medication, but has irregular use of the medication, and infrequent visits to the therapist.

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Possible Response to Case Four • Stage of change: Maintenance of

adherence to treatment plan • Use 5 A’s:

– Assist (medication and psychotherapy) – Arrange (physician and other clinical

office staff, for follow-up) with community resources (e.g., community mental health centers).

• Review the SMAART goals

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S.M.A.A.R.T GoalsExample: ◦ I will start to keep my appointments with

my therapist and take my medication. vs.

◦ I will take my fluoxetine (Prozac) each morning before I go to work, and will go to Dr. Tappler’s office every Tuesday at 4 pm, as scheduled, for the next month.

• Croteau J, Ryan D. Achieving your SMART health goals. BeWell@Stanford. 2013; http://bewell.stanford.edu/smart-goals. Accessed Jan, 2013.

• O'Neil j. SMART Goals, SMART Schools. Educational Leadership. 2000;Feb:46-50.

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Stages of Change: Maintenance

• Individuals work to prevent relapse and secure the gains attained during action

• Strategies to maintain adherence: o Self-regulation o Reinforcemento Tactics to prevent relapse

• Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot (1997 Sep-Oct) 12(1):38-48.

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Facilitate Self-monitoring/Self-regulation/self-activation

Monitoring adherence behavior Ideas for self-regulation of adherence : ◦ Cues to action Planning for therapist appointment the night before Keeping medication in a visible spot; with

compartments for each day of the week◦ Scheduling in calendar/planner/on-line

• Bandura, A. (1986). Social Foundations of Thought and Action. Upper Saddle River, NJ: Prentice Hall.• Bandura, (1998). Health promotion from the perspective of social cognitive theory. Psychological Health,

13, 623-649 Becker, M. (1986). The tyranny of health promotion. Public Health Review, 14, 15–23.

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Arrange for Follow-up alongside other clinical staff, with community resources

• Contact via telephone or email within one month to reinforce adherence.

• Identify specific situations that keep her from taking her medication (e.g., oversleeping in the morning), and discuss coping approaches (e.g., putting medication near alarm clock).

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Putting MOHR into your practice

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Patient change is not just up to the patient or the provider!

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For more information, including downloadable resources for you and your patients, please go to: http://healthpolicy.ucla.edu/mohr

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Thank you for your time!

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