Speaker: William Polonsky, PhD, CDE
Engaging the Disengaged: Strategies for Promoting Behavior Change in Diabetes
Webinar Description: The provision of appropriate psychosocial support to people with diabetes is crucial to maintaining and improving overall health. Johnson & Johnson Diabetes Institute is pleased to have William H. Polonsky, PhD, CDE discuss engagement strategies for promoting behavior change in diabetes care. >> Download Slides
Speaker: Dr. Jen Nash, CPsychol, AFBPsS, ClinPsyD, BSc
Psychological Strategies for Weight Change Conversations
Webinar Description: The Johnson & Johnson Diabetes Institute is thrilled to have Jen Nash, CPsychol, AFBPsS, ClinPsyD, BSc discuss the psychological aspect of people who are struggling to implement weight loss advice. Dr. Nash reviews skills that address the emotional and motivational barriers to implementing weight loss education, and participants will be equipped with strategies to approach weight change conversations. >> Download Slides
Psychological Strategies to Improve Weight Management Conversations Q&A
with Dr. Jen Nash, Chartered Clinical Psychologist
1. Do you have any suggestions about how to approach teenagers who overeat and eat junk food? Their executive functioning is not completely developed.
I am qualified in adult psychology, so am not able to comment professionally on working with adolescents. I am aware of the following resource for adolescents which you may find useful: http://www.energykrazed.org.
2. Do you use a motivational interviewing style when talking with clients? It seems like some of these questions are yes/no answers.
Motivational interviewing is a valuable style for weight change conversations. Some of these suggested questions purposefully encourage a 'yes/no' response as they are designed to be used in time limited conversations to allow healthcare professionals to quickly 'screen out' individuals for whom non-hunger eating is not an issue. You are encouraged to use a motivational interviewing style to follow up these questions.
3. What is furlongs and feet?
‘Furlongs and feet' is a colloquial term for the physical distance between a person and food. It describes the well-known phenomenon that if food is within our reaching distance we’re more likely to eat it. ‘Furlongs and Feet’ is part of my '30 Day Why the F? Challenge' which is a self-help programme that encourages people to reflect on the 30 reasons why we eat, and gives psychological strategies about how to make changes. You can find out more here: http://eatingblueprint.com/products/.
4. What does flap mean?
‘Flap' is a colloquial term for overwhelm. ‘Being in a flap’ is an informal way of describing those times when we feel overwhelmed, in a way that leads us to become agitated or flustered. Eating can be a way of attempting to soothe against this internal feeling of chaos, and many people find that they nervously or anxiously eat when they are in this ‘flap’ like state. 'Flap' is part of my '30 Day Why the F? Challenge' which is a self-help programme that encourages people to reflect on the 30 reasons why we eat, and gives psychological strategies about how to make changes. You can find out more here: http://eatingblueprint.com/products/.
5. How to handle conversations with people who love to eat?
I generally come from the stance of agreeing with the person that food is designed to be pleasurable, and we have evolved to find food immensely rewarding, so there is nothing at all wrong with loving to eat! However, like most things in life that are pleasurable, if we overindulge in seeking pleasure from one source, we may be at risk of other problems. If they feel inclined, writing out a pros and cons list of ‘loving food’ can be a way of exploring the downsides (e.g. increased weight and health problems) and the impact of this on other areas of their life (e.g. their work or family roles, their appearance, mobility, etc.).
One of the areas of the Eating Blueprint approach is ‘Fun’ – which is helping people see that it may benefit their health if they can increase the number and range of ways they receive fun and pleasure into their life so that food becomes just one, rather than the only, or main way to get pleasure. People are often using food to show themselves care and self-love and may be helped by finding non-food ways that are pleasurable. You can find out more here: http://eatingblueprint.com/products/.
6. Do you recommend Take off Pounds Sensibly (TOPS) program?
TOPS is not available in the UK, however I believe it to be a sound resource for healthy weight loss education and principles. I encourage people towards healthy weight loss approaches that resonate with them. I often prefer two or three approaches to recommend, so the person feels free to explore and make their own choice independent of my viewpoint.
7. What advice would you give for patients who binge and purge?
If someone is binging and purging then I would recommend referring to the DSM criteria for eating disorders. You can find the bulimia criteria here at https://www.allianceforeatingdisorders.com/portal/dsm-bulimia. If the person meets the criteria, please follow your local protocols for referral to a mental health professional. Individuals who use binging and purging are likely to be using these behaviors to manage their feelings/life experiences and need professional support from a psychologist or other mental health professional to be able to work through these issues.
Speaker: Mark Peyrot, PhD
Barriers to Mealtime Insulin Dosing
Webinar Description: Patient and provider related challenges pose numerous obstacles to insulin use. There are, however, some strategies that may help both patient and provider overcome these obstacles. These strategies emphasize individualized patient care and provide clinicians with implementation strategies and tools. Listen as Dr. Peyrot discusses barriers and strategies to mealtime insulin dosing. >> Download Slides
Speaker: Rita A. Kenahan, RN, EdD
Adult Learning Theories & Teaching Strategies
Webinar Description: The majority of adults engage with learning experiences to create change in their skills, behavior, knowledge or attitudes. When providing diabetes education, it is important to acknowledge what people with diabetes bring to a learning situation such as hopes and fears, motivations, and questions. By combining adult learning principles and skill-building strategies, healthcare professionals can more successfully help people with diabetes identify and address their needs and successfully manage their health. >> Download Slides
Speaker: Mark Heyman, PhD, CDE
Acceptance and Diabetes: Helping patients integrate diabetes into their lives
Webinar Description: Acceptance of diabetes and its related self-management principles is complex and involves a number of skills and tasks. Assessment of diabetes acceptance may aid in the identification of high risk patients for whom interventions can be targeted. Mark Heyman, PhD, CDE joins the Johnson & Johnson Diabetes Institute to share his experience and case studies related to working with people who are having difficulty with acceptance and diabetes. >> Download Slides
Acceptance and Diabetes Webinar Question and Answer
Mark Heyman, PhD, CDE
Question: How do you help patients change their language to facilitate acceptance?
Language can be a window into how a person is doing with accepting diabetes. When a patient says things like 'I can't handle diabetes', 'I'm not good at managing diabetes', or 'I'll focus on my diabetes when I feel less depressed/anxious', that is a sign that they are having a hard time with accepting diabetes.
However for many people, changing patients' language is not enough. The language people use is a symptom, not the cause. It's important to focus our efforts on the issues underneath the language. There are several things we can do to support patients along the continuum of acceptance and help them change their language in the process.
First, is to work to make people with diabetes feel empowered. Specifically this means showing them that their diabetes management behavior impacts their glycemic control. This can help move the language from 'I can't' to 'I can'.
Second, help your patients be more flexible in their thinking. Often, people who are having trouble with acceptance have very rigid thinking, which comes out in the language they use. Techniques including asking open-ended questions (e.g., ‘Tell me more about why you can't handle it?’) and gently challenging rigid thinking (e.g. 'You can't work to manage diabetes, or sometimes you just don't want to?’) can help people think about their situation in a more flexible manner.
Speaker: Mary Ann Hodorowicz, RD, MBA, CDE, Certified Endocrinology Coder
Key Tools for Patients’ Successful Behavior Change for Use in Telephonic Coaching
Webinar Description: Motivational Interviewing (MI) is a form of collaborative conversation designed to facilitate behavior change. MI is a goal-oriented, person-centered counseling style that is used to strengthen a person’s motivation for and movement toward a specific goal within an atmosphere of patient engagement, acceptance, and compassion. Mary Ann Hodorowicz, RD, LDN, MBA, CDE, CEC discusses motivational interviewing, adult learning principles, and practical conversation techniques for use in telephonic healthcare. >> Download Slides
Mary Ann Hodorowicz’s Answers to Questions Submitted by Webinar Attendees on Tuesday, June 30, 2015
Webinar: KEY TOOLS FOR PATIENTS’ SUCCESSFUL BEHAVIOR CHANGE FOR USE IN TELEPHONIC COACHING
Tools are Organized and Summarized in the Table Below, Via the Vowels A, E, I, O, U
These tools are noted in my answers, and intended to be part of each answer. I suggest that the table be posted along with my answers on the JJDI site, so it can be printed by the telephonic coaches to use as a desk-top reference guide.
A 1. Ask open ended questions (OEQs) to prompt patient to say & do (adults learn and retain 90% of what they say & do; learning is necessary for behavior change outcomes, which are necessary for clinical and quality of life outcomes) 2. Ask permission to tell patient information, advice, suggestions 3. Act as a partner and negotiator…not as a boss or parent. 4. Assure that the patient-selected behavior goal is S.M.A.R.T. 5. Allow the patient to select topic for visit (or, Allow >50% of visit to be on the patient’s own topic). 6. Avoid even the slightest inference of angst, annoyance, disagreement or disappointment with the patient 7. Always K.I.S.S. your coaching: Keep It Simple and Short 8. Attempt to get the patient to answer his own questions (most patients have most of the answers within them, but often do not know it!) 9. Advance a list of topics to the patient to aid her in selecting topic for visit. Also ask what topic she wants for next visit.
10. Amend patient’s misinformation, untrue beliefs and errors (MUEs) by asking OEQs designed to challenge his MUEs in a more positive, supportive and non-judgmental way:
How or where did you obtain this information? What worries you about having ______ (diabetes)? Do you ever think that you might develop complications? Your last A1C was 9.2%....what does that mean to you?
E 1. Encourage the patient to say the key core message related to the topic….and write it down (create own handout) 2. Empower the patient to persuade herself to change her behavior by asking the B.I.G.G.E.S.T. questions (below)* 3. Emphasize what the patient has done right, instead of what he has done wrong 4. Enable the patient to answer his own questions (bounce questions back to patient with your OEQs) 5. Ensure that you start low and go slow with the depth of your coaching 6. Express affirmations and compliments, and also gratitude for coming to visit, at the end of the visit 7. Expand your partnership with the patient beyond the visit by reaching out to her in-between visits I 1. Individualize coaching to match the patient’s I.V.’s: Issues & Variables related to her lifestyle, culture, religion, economic status, educational level. Increase your knowledge on cultures and religions, relative to activities of self-care. 2. Inspire the patient to fix her own problems, reduce her barriers to change and participate in all treatment decisions 3. Inquire as to what is behind patient’s resistance (often it is not related to the medical condition at all) O 1. Often do remind yourself: patient first, coach second (patient is at the center of the visit, the one with the problem) 2. Obtain the patient’s own summary of what you coached her on; listen carefully for errors and correct errors (see A. 10.) 3. Occasionally summarize what the patient has said (~ every 10 minutes) 4. Order yourself to listen more than talk; your ears will never get you in trouble, and can prompt many more patient visits U 1. Use ‘strike 3 rule’: ask 3 OEQs to prompt patient to say key core message; if cannot, then tell, but first ask permission 2. Understand that the patient may not be ready to change his behavior, or even thinking about it. In this scenario, focus simply on increasing awareness about the activities of self-management, and benefits of, via OEQs 3. Urge the patient to tell his own story about the topic…i.e., what he already knows, his experiences, what he has tried before, what worked, what did not work, etc.
B.I.G.G.E.S.T. Questions to Prompt Patient to Persuade Self to Change Behavior
B How would you BENEFIT if you were to test your blood sugar with a meter 1 or 2 times a day? I What would IMPROVE or INCREASE in your life? What INCENTIVE would you need to start testing? I Who else in your life would GAIN if you did test? G What would you have to GIVE UP to start testing your blood sugar? How would you GAUGE the importance of testing on a 1-10 scale (10 being highest)? G What would you ENJOY about testing your blood sugar? G Would SOMEONE want to help you test your sugar before and after meals, or fasting in a.m.? T
What would it TAKE to:
• Get you started with your blood sugar testing?
• Keep testing on a regular basis?
• Reduce any barriers you may have to testing your blood sugar?
ATTENDEES’ QUESTIONS and MARY ANN’S ANSWERS :
- What if the patient doesn't answer your questions?
First, it’s so important not to express any angst or annoyance in this situation. One suggestion would be to ask open ended questions to prompt the patient to reveal what is actually behind his resistance to answer your questions. Or, this could mean that the patient may not be ready to change his behavior, or even be thinking about it. One good strategy for this scenario is to just increase the patient’s awareness about the activities of self-management, via your OEQs. Many MI experts would also say that when all else fails, JUST LISTEN. The patient may not answer your specific questions about the topic, but may instead want to talk about something else entirely…perhaps his fears, anxieties, family problems, etc., related to his disease.
Tools to Use
- Can you tell us about any cultural differences and experiences please?
Rapidly increasing ethnic diversity in the United States does present challenges to health coaches! Disease self-management requires that people engage in multiple healthy behaviors involving diet, physical activity, and other behaviors that are shaped by an individual's culture and beliefs. The most effective strategies you can use to improve culturally diverse patients’ outcomes are to:
- Increase your knowledge of the patient’s cultural and related lifestyle and beliefs
- Obtain this information:
- On the Internet
- By asking the patient
- By asking other coaches you work with if they have the information
- Organize this cultural information in a 3-ring binder for future use
- Obtain this information:
- Culturally tailor your coaching interventions to what you have learned
- Ensure that the patient-selected behavior change goal is S.M.A.R.T.
Tools to Use
- What is an MI response when a patient states something inaccurate? Or potentially dangerous?
Yes, this does happen frequently when coaches focus on self-care activities for a chronic disease. Many of the MI experts suggest that we prompt the patient to correct his own inaccuracies by asking OEQs designed to challenge the mistruths in a more positive, supportive and non-judgmental way. An example of these questions are:
- “How or where did you obtain this information?”
- “What worries you about having ______ (diabetes)?”
- “Do you ever think that you might develop complications?”
- “Your last A1C was 9.2%....what does that mean to you?”
To increase the patient’s learning of the topic, it’s also important to keep your education more simple (e.g., type 1 diabetes means that your body does not make any insulin) and also to avoid fire hosing the patient with too much information. Doing the latter can actually make the patient more confused, especially if the coach talks rapidly and orientates the patient not to speak or ask any questions. Learning is also enhanced when coaches encourage the patient to say the key core message related to the topic….and then ask the patient to write it down (e.g., create her own handout). Lastly, do ask the patient to summarize of what you just coached her on; listen carefully for errors, and correct any errors, especially if the self-care activity is life threatening if misapplied.
Tools to Use
- So how do you correct them (without making them feel stupid) when they summarize and get it wrong?
See my answers to question #3, and the “Tools to Use”.
- What is the best method to follow-up with your patient after their visit; i.e. phone call, thank you card?
I really love this question! It gives me the opportunity to emphasize that the more your partnership develops with the patient, the more the patient will want you to be her ‘first hello and her last good-bye”! The result is a decrease in patient appointment ‘no shows’ and requests for appointments even when the cycle of visits has ended. So how can you expand your partnership with the patient? One great way is to reach out to her after the visit with a warm gesture. Yes, please do consider a post-visit phone call to express to the patient how much you enjoyed spending time with her. If you are allowed by your employer (and with the patient’s permission on an assessment or registration form), also consider:
- Texting or emailing her a few kind words after the visit (but not related to protected health information)
- Recognizing important moments in her life (birthday, death of a loved one, birth of a child or grandchild, marriage, etc.) by sending her a card or e-card.
Tools to Use
- In our practice we have limited time to speak to a member. At the end of the conversation if you would like to speak to them again, how do you end the conversation so that you can speak to them again? What might you say to call them back again?
There are several things you can do! I call it the “law of accumulation”….the more strategies you use, the more likely the patient will attend the next visit! But many of these MI tools are to be used during the visit…not just at the end…in order to accomplish your goal of the patient returning in the future:
- Ask your patient what topic(s) she wants to focus on for her next visit, at the end of this current visit. It’s helpful to give her a list of topics, especially if she has just been diagnosed with the medical condition and most likely is in “kindergarten” with her level of knowledge of self-care activities. This has great potential to get her excited about the next visit.
- Emphasize what your patient has done right, instead of what she has done wrong, during the visit (e.g., How great you must feel that your A1C decreased from 11 % to 10%! Good for you!)
- Be generous with your affirmations and compliments during the visit (e.g., Yes, I know it’s tough to cut back on your soda intake, but I know you can do it! Even if it’s only 1 can less a week….that’s a good start! By the way, congratulations on your promotion at work…you must be so happy!)
- Express gratitude for coming to the visit, at the end of the visit.
Tools to Use
- Where and how do you recommend that we get additional training on MI? What are some good resources, courses, etc. to learn these skills? I am a CDE in private practice, so I was wondering more about courses for MI.
MARY ANN HODOROWICZ CONSULTING, LLC
Mary Ann Hodorowicz, RD, MBA, CDE, Certified Endocrinology Coder
Nutrition, Diabetes Care & Education, Health Promotion and Insurance Reimbursement for
Professionals in the Healthcare and Food Industry
12921 Sycamore • Palos Heights, IL 60463 • Ph: 708.359.3864 • Fax: 866.869.6279
Speaker: Amy Bucher, Ph.D.
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