Prevention Learning and Action Network Webinar Slides with Recording

1. Improving Patient Adherence
Through Health Behavior Change
Kevin Townsend, PharmD, MSc, BCPS
April 18, 2012
MMM00028A © 2007 Pfizer Inc. All rights reserved. May 2007
NPC05009A/281792-01 © 2011 Pfizer Inc. All rights reserved. June 2011 1

2. Health Behavior
Welcome to the Web Ex Change
• If you are seeing this slide, you have successfully entered the Web Ex.
Congratulations!
• To join the audio portion of the conference please use this:
– Call in: 1-866-462-0164
– Passcode/Meeting Number: *9747004*
• You should see, at least, the “Participant” and “Chat” panels on the right
side of your screen. If not, go to “View” menu at top.
– “View” > “Panels” > “Manage Panels”
– Click on chat or participant and click on arrow to move them to the
right
• ***In the CHAT window: Please enter your practice name, your name,
and number of participants from your office. Thanks!***
• To ask for help during the workshop enter a request in the chat window.

3. Health Behavior
Welcome to the Web Ex Change
Session 2
Improving Patient Adherence Through Health Behavior Change
• MPRO Comments
• LAN Updates
• HBC Workshop
• Speaker information
Kevin Townsend, PharmD, MSc, BCPS
Medical Outcomes Specialist; Pfizer Inc
• Slide content developed by Pfizer Inc.
MMM00028A © 2007 Pfizer Inc. Printed in USA/May 2007
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4. Health Behavior
Welcome to the Web Ex Change
• Chat “monitors” will be used to capture your questions and other
feedback
• Notes will be taken during the call and made available after the
workshop.
• Information entered into the “Chat” panel can be seen by everyone
(Unless you are only chatting with some participants.)
• Note pad type computers may not have full functionality (e.g., polling
features)
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5. Health Behavior
Welcome to the Web Ex Change
• Prepare for an active workshop!
• Key concepts will be presented on the slides
• Live polls will be used to gather your answers and opinions
• Questions that can’t be addressed during the workshop will be answered
afterwards or at a future workshop
• Suggestions, best practices, and tips that are captured in the chat room
will be summarized and made available to all attendees as a reference.
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6. Feedback From Last Workshop (2/9/12)
Chat NOW!
• Which “Behavioral” model communication styles did offices pick to work
on? HERE IS WHAT YOU TOLD US:
– Acting in “Servant Role” to patient.
– “Negotiating” not “Dictating” (4 offices).
– “Assessing Motivation” instead of trying to motivate the patient.
– “Understanding and accepting” the patients current stage (2 offices).
– “Labeling” the patient.
– “Information exchange”.
• What disease or patient type did this refer to? HERE IS WHAT YOU TOLD
US:
– Weight loss.
– Adherence (3 offices).
• TELL US MORE (Use CHAT window)
– From your “homework ”, what were some specific things you did or
modified that were useful?
– In what types of patients?
– EVERYONE: please share your successes, challenges, and ideas
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7. Health Behavior
Change
Stages of change model Stages of
Change
 5 stages of change
 By identifying patient's
position in the change
process, health care
providers can tailor
intervention, usually with
skills they already possess
 Focus is not to convince
patient to change behavior
but to help patient move
along stages of change
Prochaska JO et al. Am Psychol 1992; 47:1102-1114.
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Rollnick S, et al. Health Behavior Change: A Guide For Practitioners. 2003:17-39.
Zimmerman GL, et al. Am Fam Physician. 2000;61:1409-1416.

8. Adherence
Poll Question Research
Use Web Ex Poll Window to Answer Poll Question!
• When helping someone start a new goal or treatment,
does your practice start by thinking about the patient's
stage of change (or readiness to change)?
– YES
– NO
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9. Health Behavior
Change
Precontemplation stage Stages of
Change
• Characteristics
– Patient not even considering changing
– May be in denial or not consider problem serious
– May have tried to change and failed so many times they have
given up
• Strategies
– Educate on risks benefits
– Highlight the positive outcomes related to the change
• Example
– Smoker is in denial of health risks: “heart attack won’t happen
to me, my father smoked for 92 years”
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Zimmerman GL, et al. Am Fam Physician. 2000;61:1409-1416.

10. Health Behavior
Change
Contemplation stage Stages of
Change
• Characteristics
– Person is ambivalent about changing
– During this stage the person weighs benefits costs or barriers
of the change including time, expense, fear
• Strategies
– Identify barriers and misconceptions the patient has
– Address their concerns and identify appropriate support
systems
• Example
– A patient with high cholesterol recognizing need to change: “I
know I need to change my diet, but I don’t want to give up the
foods I like”
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Zimmerman GL, et al. Am Fam Physician. 2000;61:1409-1416.

11. Your Thoughts Please!
Chat NOW!
Use Chat Panel to Tell Us
• What’s a common example of a patient you see in
your practice who is………..
– PRECONTEMPLATIVE
– CONTEMPLATIVE
– For Example:
• Precontemplative: Smoker who refuses to talk about quitting
• Contemplative: Patient with high cholesterol (who’s friend just
had an MI) asks if there are any “easy” diets he can try.
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12. Health Behavior
Change
Preparation stage Stages of
Change
• Characteristics
– The person is prepared to experiment with small changes
• Strategies
– Develop realistic goals and timelines for the change
– Don’t try too many changes or too much change all at once
– Provide positive reinforcement about patient’s willingness to
change
• Example
– Overweight patient preparing to exercise by identifying
exercise facilities in their area and planning on how to fit this
into their schedule
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Zimmerman GL, et al. Am Fam Physician. 2000;61:1409-1416.

13. Health Behavior
Change
Action stage Stages of
Change
• Characteristics
– The person takes definitive action to change their behavior
• Strategies
– Provide positive reinforcement
– Remind them of the positive benefits of the change
– Verify their support system
• Example
– Patient with high blood pressure fills medication, self-
monitors BP daily, and continuously takes medication. They
use reminder system to help them not forget to take
medication
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Zimmerman GL, et al. Am Fam Physician. 2000;61:1409-1416.

14. Health Behavior
Maintenance and relapse prevention Change
Stages of
stage Change
• Characteristics
– The person strives to maintain the new behavior over the long
term
• Strategies
– Provide encouragement and support
– Identify any potential barriers that may sideline them from
their goals
• Example
– Patient refills their medication regularly, continues to follow
their diet, and incorporates daily visits to the gym
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Zimmerman GL, et al. Am Fam Physician. 2000;61:1409-1416.

15. Your Thoughts Please!
Chat NOW!
Use Chat Panel to Tell Us
• What’s a common example of a patient you see in your
practice who is………..
– PREPARATION
– ACTION
– MAINTENANCE
– For Example:
• Preparation: HTN patient who agrees to try a pill box as a reminder
• Action: DM patient who has started dieting and using insulin
• Maintenance: Patient who quit smoking 8 months ago
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16. Health Behavior
The 4 general principles of Change
Health Behavior Change REDS
• REDS
1. Roll with resistance
2. Express empathy
3. Develop discrepancy
4. Support self-efficacy
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Miller WR, et al. Motivational Interviewing. 2002:33-42.

17. Health Behavior
Change
The principles of Health Behavior Change REDS
1. Roll with resistance
• Use understanding, empathy
• Get clarification
• New perspectives are invited, not imposed
• Resistance is not directly opposed
• Resistance is a signal to respond differently
• Repeat your understanding
• The patient is primary resource in finding
answers and solutions
Miller WR, et al. Motivational Interviewing. 2002:33-42
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18. Poll Question Health Behavior
Change
Use Web Ex Poll Window to Answer Poll Question
1. Roll with resistance
If a 50-year old patient with hypertension says:
“I just don’t like the idea of taking a medicine every
day,” what is an appropriate response?
– “Well, if you want to get your blood pressure under control,
you need to take the medicine every day”
– “High blood pressure is a chronic illness and you have to
take your medication every day”
– “What in particular don’t you like about taking your
medication every day?”
– “Having to take medicine every day concerns you?”
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19. Poll Answer Health Behavior
Change
Use Web Ex Poll Window to Answer Poll Question
1. Roll with resistance
If a 50-year old patient with hypertension says:
“I just don’t like the idea of taking a medicine every
day,” what is an appropriate response?
– “Well, if you want to get your blood pressure under control,
you need to take the medicine every day”
– “High blood pressure is a chronic illness and you have to
take your medication every day”
– “What in particular don’t you like about taking your
medication every day?”
– “Having to take medicine every day concerns you?”
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20. Health Behavior
The principles of Health Behavior Change Change
2. Express empathy REDS
• Acceptance facilitates change
• Skillful reflective listening is fundamental
• Identify and understand resistance and reasons
for unhealthy behaviors without judgment
• Empathy creates a climate for change through
trust and must be shown throughout the
process
Miller WR, et al. Motivational Interviewing. 2002:33-42
Berger BA. Case Manager. 2004:15:58-62.
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21. Poll Question Health Behavior
Change
Use Web Ex Poll Window to Answer Poll Question
2. Express empathy
If a patient with hypertension says “I can’t
believe I have high blood pressure, I have always
been so healthy,” what is an appropriate
response?
– “This has come as a shock to you, especially since you
have been so healthy”
– “Well, even healthy people get high blood pressure”
– “Millions of people have high blood pressure and it is
perfectly treatable”
– “You are having a hard time accepting you have high
blood pressure because you have always been so
healthy”
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22. Poll Answer Health Behavior
Change
Use Web Ex Poll Window to Answer Poll Question
2. Express empathy
If a patient with hypertension says “I can’t
believe I have high blood pressure, I have always
been so healthy,” what is an appropriate
response?
– “This has come as a shock to you, especially since you
have been so healthy”
– “Well, even healthy people get high blood pressure”
– “Millions of people have high blood pressure and it is
perfectly treatable”
– “You are having a hard time accepting you have high
blood pressure because you have always been so
healthy”
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23. Health Behavior
The principles of Health Behavior Change Change
3. Develop discrepancy REDS
• Discrepancy = dissonance
• Point out the good things and bad things about change,
the pros and cons
• Discrepancy throws the patient’s system out of kilter
• Restate the discrepancies heard
• The patient should identify the arguments for change
• Change is motivated by a perceived discrepancy between
present behavior and important personal goals or values
Miller WR, et al. Motivational Interviewing. 2002:33-42.
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Berger BA. Case Manager. 2004:15:58-62.

24. Poll Question Health Behavior
Change
Use Web Ex Poll Window to Answer Poll Question
3. Develop discrepancy1
• A patient who has a child with severe asthma
continues to smoke. Select the best motivational
interviewing responses from the following:
– “What you are doing is harmful to your child and you need to stop”
– “We’ve talked in the past about the effect your smoking could have
on your child’s asthma. Tell me what your thoughts are about that”
– “Cigarette smoke on your clothes can make your child’s asthma
worse even if you smoke outside. You must stop smoking”
– “What are your thoughts about smoking around your family? On a
scale of 1 to 10, how important is quitting to you? How confident are
you that you could quit if you tried?”
1. Miller et al. Motivational Interviewing: Preparing People for Change. 2002:33-42. 2

25. Poll Answer Health Behavior
Change
Use Web Ex Poll Window to Answer Poll Question
3. Develop discrepancy1
• A patient who has a child with severe asthma
continues to smoke. Select the best motivational
interviewing responses from the following:
– “What you are doing is harmful to your child and you need to stop”
– “We’ve talked in the past about the effect your smoking could have
on your child’s asthma. Tell me what your thoughts are about that”
– “Cigarette smoke on your clothes can make your child’s asthma
worse even if you smoke outside. You must stop smoking”
– “What are your thoughts about smoking around your family? On a
scale of 1 to 10, how important is quitting to you? How confident are
you that you could quit if you tried?”
1. Miller et al. Motivational Interviewing: Preparing People for Change. 2002:33-42. 2

26. Health Behavior
Change
The principles of Health Behavior Change REDS
4. Support self-efficacy
• A person’s belief in the possibility of change is an
important motivator
• The person, not the counselor, is responsible for choosing
and carrying out change
• Notice the positive, including statements, not just
behaviors
• Let the person know you’ve noticed
• Let them know how you feel
• Praise the behavior, not the person
• Continue to support self-efficacy throughout the process
Miller WR, et al. Motivational Interviewing. 2002:33-42.
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Berger BA. Case Manager. 2004:15:58-62.

27. Poll Question Health Behavior
Change
Use Web Ex Poll Window to Answer Poll Question
The principles of Health Behavior Change
4. Support self-efficacy
During his last visit a patient with diabetes is told he needs to
start exercising as part of his treatment. You have earlier
rolled with resistance and empathized with him. To support
his self-efficacy, what is an appropriate response?
– “What are your thoughts about your exercise program?”
– “You really need to do it, not just think about it”
– “Getting into a regular exercise routine will help you”
– “Good. What kind of exercise have you thought about?”
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28. Poll Answer Health Behavior
Change
Use Web Ex Poll Window to Answer Poll Question
The principles of Health Behavior Change
4. Support self-efficacy
During his last visit a patient with diabetes is told he needs to
start exercising as part of his treatment. You have earlier
rolled with resistance and empathized with him. To support
his self-efficacy, what is an appropriate response?
– “What are your thoughts about your exercise program?”
– “You really need to do it, not just think about it”
– “Getting into a regular exercise routine will help you”
– “Good. What kind of exercise have you thought about?”
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29. Your Thoughts Please!
Chat NOW!
Use Chat Panel to Tell Us
• Based on what we’ve covered so far, in what types of
patients will you apply motivational interviewing
techniques?
– Example: “We will begin using motivational interviewing
with our non-adherent CHF patients.”
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30. Thank You!
Next workshop date: July
Action item for next time: One-One-One
Pick one HBC technique and use it at least one time with one
patient.
We’ll collect feedback during our next workshop.
Example:
•Move a precontemplative patient to contemplation.
•Try reflective listening with a patient
•Use R., E., D., or S. with a patient being asked to set a goal
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31. Thank You!
Next workshop date: July 12, 2012
You will be receiving an email from MPRO with the
following link that will take you to a program
evaluation survey.
http://www.surveymonkey.com/s/PBPLKRG
If you would please take a few minutes to respond
and give us your feedback we would greatly
appreciate it!
Thank you.
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