1 Kay McLean-Grant, RN, CPNP Martha Coppage-Lawrence, RN, CPNPUtilizing Motivational Interviewing in School-Based Health Centers to Promote Healthy Behaviors Kay McLean-Grant, RN, CPNP Mary M. Stephens, MD, MPH Martha Coppage-Lawrence, RN, CPNP Lauren Foy, DO

2 Disclosures It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/ invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and if identified, they are resolved prior to confirmation of participation. Only these participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

3 Objectives Utilize the presentation of two PI projects as examples of successful implementation of practice change in an organization Describe a culture change within an organization leading to a focus on PI Learn basics of motivational interviewing and have an opportunity to practice in a small group setting Mary starts

4 School-Based Health Centers (SBHC) in DelawareProgram initiated in 1985 by Division of Public Health Currently 28 centers state-wide 14 centers managed by Christiana Care Health Systems (CCHS) Registered students eligible to receive services Staff at each site includes: Social Worker/Coordinator (LCSW), Nurse Practitioner, Registered Dietitian, Admin Assistant Funding – grants from DPH and billing

5 Goals of Centers To provide early intervention and preventative healthcare to address adolescent at-risk behaviors To increase accessibility and utilization of healthcare services in the adolescent population by removing or minimizing common barriers To work together with students’ medical home and/or primary care provider for purpose of coordinating services between school, parent, and community

6 Services Provided Medical CounselingPhysicals Health Screenings Immunizations Diagnosis and Treatment of Minor Illnesses/Injuries Diagnostic Testing Health Education/Risk Reduction Nutrition/Weight Management Reproductive Health Counseling – Individual, Group, and Family Crisis Intervention and Suicide Prevention

7 Two Performance Improvement Projects in SBHCsIdentification and Assessment of Overweight, Obesity and Hypertension Increasing STI Screening and Detection Rates in the School-Based Health Center Population

8 Motivational InterviewingLinked our two projects There is an evidence base to support it It is applicable in a variety of clinical settings It is a skill that can be learned

9 Motivational Interviewing: What Is It?Patient-centered, directive counseling style Builds on intrinsic motivation Helps create a partnership between provider & patient to explore and resolve ambivalence about behavioral change “Looking & seeing together from the patient’s perspective” Increases adolescent’s receptivity & decreases resistance Lauren starts Gold, Melanie A., DO, and Patricia K. Kokotailo, MD. "Motivational Interviewing Strategies to Facilitate Adolescent Behavior Change." Adolescent Health Update 1st ser. 20 (2007):

10 Stages of Change Model Prochaska & DiClemente Change is fluid!By identifying where teen is within the change cycle, can tailor interventions to patient's "readiness"

11 Essential Spirit of Motivational InterviewingCollaboration Provider & patient as partners! Positions adolescent as expert about his/her own experiences, values, beliefs, & goals Evocation Use of open-ended questions & reflections to help patient identify intrinsic motivation for change Patient’s own recognition of need to change is most powerful! Adolescent’s role articulate & resolve ambivalence about change Provider’s role help adolescent examine internal conflicts Autonomy Adolescent’s responsibility to change behaviors and decide how & when changes will occur MI proposes that direct persuasion is NOT effective way to resolve ambivalence Confrontation is counterproductive!

12 Motivational Interviewing: 5 Guiding PrinciplesDevelop discrepancy Adolescents need to be aware of inconsistencies between current behavior & important goals/values Avoiding arguments Roll with resistance Resistance usually occurs when patient feels pushed to do something they are not ready to do Express empathy Creation of nonjudgmental environment Use reflective listening! Support self-efficacy in each patient encounter Change most likely to occur when problem is recognized & patient believes in own ability to do something about it

13 Motivational Interviewing : Core TechniquesAgenda Setting Asking Permission Reflective Listening Identifying Discrepancies Effective Questioning Eliciting Change Talk

14 MI Applied to Adolescent PopulationAdolescence about identity, brain still developing, autonomy issues, values & culture different from adults Empower them! Help build motivation to change Positive reinforcement Identify competency & adapt Relapse as opportunity for learning

15 BMI Project 2007 Expert Committee recommendations:Children should be assessed annually for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits. Martha starts

16 Getting Started An interdisciplinary team met to discuss guidelines and how best to implement recommendations. Received funding through the institution to support staff training, RD hours, creation of a database and incentives to students for participating

17 The Goal To increase the consistency of incorporating the calculation of BMI and obtaining blood pressures on students who seek medical care to better identify, treat and appropriately refer overweight/obese students as well as those with hypertension and pre-hypertension

18 Components of the ProjectProviders trained in motivational interviewing and classification/identification of unhealthy weight and abnormal BP Overweight: BMI between 85th-94th percentile for age and gender Obese: BMI 95th percentile or greater for age and gender Pre-hypertension: 120/80 Hypertension: 140/90 Letter and information sheet for students and parents Letter for PCP reviewing project rationale/guidelines Algorithm to refer students who were overweight or had abnormal blood pressure to resources within the center or to PCP Excel database was created

19 Three year results Over 4000 students screened for BMI and blood pressure 40% referred for nutritional counseling 4-6% received monitoring for elevated BP 14-16% referred to their PCP

20 More results 43 students were followed from year one to three.Of the 10 students who were overweight initially, three moved to a healthy weight in year two. Between years two and three, one changed to a healthy weight and one changed to obese All six classified as obese in year one remained obese, but the maximum BMI decreased.

21 Internal Discussions Successful implementation of measuring BMIs and blood pressures with appropriate referral Fatigue in year 3 related to data capture Obese and overweight vs. at risk for overweight vs. unhealthy weight Unable to verify follow-up with PCP What else can we do better?

22 STI Project Initiated at 9 CCHS SBHC in 2010Goal was to increase STI screening and detection rates in adolescents Additional goal was to increase opportunities to provide treatment and sexuality education to this vulnerable population. Kay starts

23 Project Implementation – Keep it simple!Specimen collection timing altered STI testing offered to students as part of the routine discussion about health and sexuality Detected positive screens were treated All students who were screened were informed of their results and received additional health and sexuality counseling and education. Some SBHC sites provided group STI awareness presentations in a variety of settings within the school

24 Results New STI screening protocol resulted in a 32% increase in STI screenings (an additional 165 students were tested). We identified 40 more students with a positive STI screen for the school year than during the previous year. During the intervention year, 14% of students tested positive compared with 9.5% at baseline. This new protocol gave providers the opportunity to treat STIs that previously might have remained undetected. Increased STI screening gave opportunities for providers to educate adolescents about STIs and the potential consequences of sexual activity. . .and to utilize MI skills!

25 Results

26 Case Study 1 16 year old female presenting for sports physicalBMI is 32 BP is 124/86 FH significant for Type 2 DM and HTN in mother First visit to the SBHC – “my friend said you were nice” Martha/Mary lead role play

27 Case Study 2 17 year old female initially presenting for sports physical BMI/BP WNL “Sure you can test my urine. . . As long as you don’t forget to get my form to coach.” Follow up visit one week later to discuss positive chlamydia results Lauren/Kay lead role play

28 Wrap Up! PI is do-able even with a skeleton crew and a small budget. . . But it does take a team! Sometimes less is more STI project recognized by CCHS and NASBHC MI can support the unique learning style of teens and encourage health promoting behaviors MI is a skill that can make “difficult” conversations easier and more productive Kay leads wrap up