View Entire Collection
By Clinical Topic
Diabetes – Summer 2012
Future of Nursing Initiative
Heart Failure - Fall 2011
Influenza - Winter 2011
Nursing Ethics - Fall 2011
Trauma - Fall 2010
Traumatic Brain Injury - Fall 2010
Fluids & Electrolytes
Purpose/Objective: As professional case managers seek to improve outcomes, including the health status of their clients, it becomes imperative to gather and assess as much relevant information as possible to identify and address the client's needs in a holistic manner. Motivational interviewing is a highly effective technique case managers employ for this purpose. They also rely on it to move their clients toward a course of successful, desirable, and sustainable change, such as healthier diet, exercise, self-care, and adherence to medications regime and follow-up care.
Primary Practice Setting: Across the case management spectrum, including hospitals, accountable care organizations, patient-centered medical homes, physician practices, clinics, and other settings in which case managers work with clients and their support systems.
Findings/Conclusions: Motivational interviewing is a highly effective technique for gathering accurate and comprehensive information that is supportive of and additive to the assessment phase of the case management process. Using motivational interviewing, case managers can more readily uncover health and lifestyle needs of their clients. This results in building trusting relationships and developing rapport with clients, which can motivate them to move toward successful and desirable change.
Implications for Case Management Practice: The design and implementation of a comprehensive and effective case management plan of care is facilitated by motivational interviewing, whereby professional case managers establish collaborative, respectful, trusting and individualized relationships with clients. Using the specific principles and techniques of motivational interviewing, case managers take a holistic approach to care to address a client's willingness and ability to change; addressing self-confidence and other emotional triggers that affect change and support the client's ability to embrace and sustain positive change.
In the midst of the assessment process, a client confidently and proudly informs a case manager that she has quit smoking, ending a 20-plus-year habit. This is a positive development for the client who has multiple chronic health conditions, including diabetes and hypertension. What the client does not share, however, is that she has not quit completely. In fact, she has smoked on at least 10 occasions in the past 3 months, including just the day before the meeting with the case manager.
Whether out of embarrassment, shame, fear of judgment, or for no specific reason, the client never reveals her struggles with smoking cessation. Despite the fact that this client has been under the care of the same case manager for the past several months, she still hesitates to share all the facts or convey a thorough picture of her health status and needs. Without more robust and accurate information about the client's behaviors and other factors that contribute to her health, the case manager is unable to address such needs as smoking cessation or incorporate in the client's holistic, patient-centered case management plan of care.
This example begs several questions, such as the following:
* What could make a meaningful difference in the ability of the case manager to establish better rapport with her client-particularly when the professional case manager is thought to have demonstrated advanced knowledge, skills, and competence in case management practice?
* What could assist both the case manager and the client to establish a mutually trusting relationship that allows a client of case management services to reveal all the necessary details to the case manager?
* How could a competent and experienced case manager draw out additional, essential information that would reveal a fuller picture of the client's needs especially when the client is reluctant to share such important information voluntarily?
The answer is motivational interviewing. This highly effective technique of gathering important information and obtaining insights about a client's situation (in every aspect including social, financial, emotional, and health status) draws upon a supportive and empathic counseling style of communication. Such a style helps clients move toward a course of successful and desirable change. Motivational interviewing also assists case managers to identify a client-centered and preferred approach or strategy to getting there (Hettema, Steele, & Miller, 2005).
Through motivational interviewing, professional case managers can establish collaborative, respectful, trusting and individualized relationships with their clients/support systems to design a comprehensive and effective case management plan of care. This article describes what motivational interviewing is, highlights its specific principles and techniques, and suggests some tactics case managers may apply while caring for their clients/support systems, especially those who may be reluctant to open up and be transparent about some or all aspects of their health status and situation.
The client's ability to tell an accurate and complete story makes a big difference in the case manager's ability to develop an appropriate case management plan of care, achieve expected care goals, and meet the client/support system's interests and needs. Conversely, the case manager's knowledge, skills, and proficiency in ensuring the client shares such story are important. This undoubtedly relies on the case manager's degree of competence in, and level of, comfort with motivational interviewing.
Motivational interviewing (Exhibit 1) is a client-centered yet directive style of case management interaction that helps clients explore and resolve their ambivalence and concerns about changing one or more lifestyle and risk behaviors. Motivational interviewing is a counseling-like, bidirectional, and collaborative interaction that aims to build trust between the client/support system and the case manager (Burke, Arkowitz, & Menchola, 2003; Miller & Rollnick, 2002) to ultimately influence the achievement of desired outcomes.
When effectively conducted, motivational interviewing not only reduces the client's resistance to change it also increases his/her desire and readiness to change. As a result, the client demonstrates the positive effects of motivational interviewing through demonstrating healthy lifestyle behaviors and adherence to the health care regimen. To achieve these outcomes, case managers work closely with their clients/support systems and help them to recognize the need for and importance of change. Through motivational interviewing, case managers also enhance their clients' belief that they are able to achieve and feel comfortable with making changes.
Miller and Rollnick (2002) describe four main general principles of motivational interviewing (Exhibit 2) that are essential for clients to achieve desired change. Change may include eating a healthy diet, adherence to health regimen, self-management ability, and avoidance of health risk behaviors such as smoking, lack of exercise, and substance abuse. When case managers apply the principles of motivational interviewing in their relationships with the clients, they are able to enhance the clients' ability to recognize the intrinsic motivation to change, thereby revealing and addressing existing barriers such as fear and lack of confidence. These emotions tend to negatively affect the clients and potentially interfere in achieving effective change and, therefore, delay progress toward the identified care goals.
Clients are not always ready, willing, or able to change. When counseling clients about changing their behaviors to those most desirable, case managers face the challenge of assessing the clients' state of readiness to change, willingness to change, and ability to change. These are always key aspects of the comprehensive assessment that case managers conduct for each of their clients. If taken lightly, such assessments result in an incomplete picture of the client's state. This lack of focus and ineffective assessment ultimately results in an inappropriate or deficient case management plan of care. Effective motivational interviewing skills enhance the case manager's ability to conduct thorough and relevant assessments that inform the development of client-centric plans of care that incorporate behavioral lifestyle modification as an integral and necessary component.
Case managers may use several techniques during a comprehensive client's assessment that allow them to have a good handle on the client's situation and state of readiness for change. When case managers assess their clients, they apply various techniques to maximize the development of effective case management plans of care and interventions. However, there are eight highly important techniques professional case managers use when engaged in motivational interviewing of their clients. These techniques (Exhibit 3) specifically relate to the general principles of motivational interviewing. They facilitate the gathering of necessary information about the client and his/her health status in a way that enhances the client's willingness and desire to share sensitive issues, feelings, or concerns the client may be experiencing.
Assessing the client using motivational interviewing techniques allows the case manager to effectively develop a plan of care that meets the client's needs and desires. When professional case managers use these techniques, they demonstrate respect for the client's right to choice, autonomy, and self-determination. These techniques also facilitate the transition of the client from a state of ambivalence, fear, or anxiety to a state of readiness and willingness to change and demonstrated ability to achieve the desired change.
Although the focus of the motivational interview is, of course, the client, the process actually begins with the case manager. It is absolutely necessary to establish trust and overcome barriers or fears that may impede the relationship between the case manager and client/support system. Once case managers establish rapport with their clients, they are better able to assure their clients do not feel threatened or concerned about being judged in any way. In other words, professional case managers must act in an emotionally intelligent manner.
Emotional intelligence has been identified as a critical skill for professionals and leaders across all industries, including health care. Although this term is widely used, it is important for our purposes here to define it in the context of the case management process and motivational interviewing (Exhibit 4). Emotional intelligence relates to the case managers being highly self-aware, particularly of their own emotions, including how they manage and express these emotions. With greater self-knowledge, comes a deeper understanding of others, being cognizant of the emotional undercurrents that impact interactions, decisions, and actions.
The more professional case managers are aware of own emotions, the better they can manage how they manifest appropriate and desired emotions in their interactions with others, including their clients/support systems and fellow health care professionals. Case managers are also able to influence how others access and express their feelings related to a particular situation or challenge, shifting behavior toward more positive responses and outcomes, which ultimately facilitate the development of trusting and respectful relationships (Tahan, 2000). These approaches are essential for effective interactions between case managers and clients/support systems during the motivational interviewing encounter.
With greater emotional intelligence, professional case managers exercise empathy and active listening. These techniques allow the client to be more forthcoming and truthful with the information shared. Ultimately, the case manager is able to more easily see and understand things from the client's perspective and accept them as expressed without appearing judgmental or critical. This does not readily occur, especially if the client/support system perceives the case manager as only a title, position or an authority figure in a health care uniform, rather than as a person (an advocate) who has the client's interest at heart. This shift must occur from the beginning of the relationship or interaction, at the moment the professional case manager introduces him/herself to the client/support system.
One of the first actions of the professional case manager to establish client's trust and comfort is to tell the client her name and how she prefers to be addressed. Now, the case manager is no longer "Ms Smith," as printed on her identification badge; she is "Betty," a person to whom the client can relate. Notice the subtlety of using the case manager's preferred name "Betty" rather than "Elizabeth." Choosing to introduce oneself to the client/support system during the initial encounter using a preferred name (e.g., nickname) demonstrates to the client that one is open, comfortable, trusting, honest, and genuine-values that facilitate the development of an effective and patient-centered relationship and promote a productive emotional interviewing encounter. When the client sees the case manager as a person instead of a function and as forthcoming and trusting, there is a greater chance that the client does not hesitate to share accurate information more candidly and in more depth. This "friendliness with purpose" type of interaction allows the case manager to be counseling-like, yet directive.
The most natural next action for the case manager is to explain her role and what it means for the client to have a health care professional advocating for him. Using simple and clear language that is free of medical jargon allows the client to understand the personal value of having a case manager involved in his care. This explanation attempts to proactively answer the client's potential questions regarding what case management is especially during the initial encounter when the client may be embarrassed or hesitant to ask for clarification. Introduction of oneself and description of the role are two key prerequisites to effective motivational interviewing-type interaction between the case manager and client/support system.
Keeping abreast of what case management is and the obligations of the Code of Professional Conduct at all times allow the case manager to easily and confidently communicate his/her professional standing and responsibility toward the client/support system. As the Commission for Case Manager Certification (CCMC) states in its Definition and Philosophy of Case Management, "case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management, and promotes quality and cost-effective interventions and outcomes" (CCMC, 2011, p. 1). The heart of the case manager's role as reflected in this definition is advocacy for the client. Advocacy behaviors of a case manager enhance the client's ability, willingness, and readiness to open up about sensitive issues and voluntarily share important information that ultimately impacts the success of the case management plan of care.
As the CCMC's Code of Professional Conduct for Case Managers states, "certified case managers will serve as advocates for their clients and ensure that a comprehensive assessment will identify the client's needs; options for necessary services will be provided to the client; [and that] clients are provided with access to resources to meet individual needs" (CCMC, 2009, p. 4). A skilled and emotionally intelligent case manager is able to communicate his/her obligations toward the client/support system during a motivational interviewing interaction. Such a case manager leaves the client/support system at ease and encouraged to reconsider answering questions by sharing of honest and accurate information with the case manager and in a manner that is free of any concern or doubt.
Stated in terminology that a lay person can understand, a knowledgeable and expert case manager helps the client understand, decide, and access the appropriate care, treatment, and other resources needed and at the right time. Such a professional case manager is the "hub" that connects the "spokes" of the health care team-doctors, nurses, social workers, pharmacists, counselors, occupational and physical therapists, and other clinicians-so that everyone is working on the client's behalf. Simply put, the case manager is on the client's side, protecting privacy and confidentiality, autonomy and self-determination, and providing for what will make a difference in the client's life. Adherence to these ethical standards and demonstrating such ethical behaviors are essential for a motivational interviewing interaction with the client to occur successfully and result in the client's readiness, willingness, and comfort in seeking necessary change.
Furthermore, rather than having a health care professional telling the client what to do and pointing out weakness and undesired behaviors, which are actions in conflict with the principles and techniques of motivational interviewing, this professional (i.e., the case manager) collaborates with the client in making decisions that are appropriate for effective change and in a nonjudgmental or nonthreatening manner. It is up to the case manager to ensure that the client is informed and knowledgeable about care options and choices, and that all of the client's questions are answered. It must be emphasized, however, that it is the case manager's responsibility to counsel, teach, and inform, not to make decisions for the client. These tactical activities enhance the client's readiness and willingness to change. At all times the client must be treated as autonomous, independent, and self-determining being. A client who is educated about her condition, available treatment options and interventions, and what she can do to improve her overall health status is able to make informed decisions in pursuit of positive outcomes.
At this point in the motivational interviewing process, the case manager has not asked one question regarding the client's health status or medical condition. The focus until now has been on establishing rapport, laying the groundwork for a trusting relationship with the client/support system to pursue common goals: the health, well-being, and autonomy of the individual. Now the information-gathering process begins.
From a foundation of trust and mutual respect, case managers apply the technique of motivational interviewing in the case management process especially during the assessment and reassessment phases. This is important because it builds upon information members of the client's health care team may have already collected, such as findings from a prior screening or review of available client's records. The assessment findings allow the case manager to determine the client's baseline health condition; level of physical functioning; strengths, limitations, and dysfunction(s); willingness to participate in care activities and decisions; self-care management abilities; and motivation for healthy behaviors and lifestyle changes. If applied effectively and appropriately, motivational interviewing facilitates a client's assessment that ultimately enhances readiness for and ability to change. This results from the client-centered, directive therapeutic style of interaction that occurs between the case manager and client during motivational interviewing (Hettema et al., 2005).
Before case managers identify a desired change and explore a path or course of action, they must first know where a client is. This requires candid information exchanges between the client and case manager to construct a holistic view of the individual. Motivational interviewing uses questions (Exhibit 5) that not only draw out information about factors that affect a person's health status but also explore the client's feelings and emotional reactions to a particular medical/health condition or circumstance. The main objectives of the questions a case manager asks a client are to influence the client to assess current status of readiness for change, look deeper inside and identify facilitators and barriers to change, and provide meaningful responses that can influence the development of a case management plan of care that is conducive to change.
By answering the case manager's questions and through the honest sharing of emotions, the client realizes that not only is change necessary (e.g., quitting smoking) but he must be committed to making such a change, which may require support and resources from counseling to medication instructions (Hettema et al., 2005). Case managers explore solutions and interventions within the context of the client's culture, values, and belief system, without imposition or even a hint of judgment or criticism. Information is obtained not only from the client but also from the support system/family, as appropriate and authorized by the individual.
By using motivational interviewing, the professional case manager is also able to address other areas that impact the client's health, such as behavioral, cognitive, emotional, or affective factors. With regard to behavioral factors, the issue is how a person's health status affects his/her ability to adhere to the medical regime and perform all aspects of self-care. On the cognitive side, the case manager determines whether the patient is able to gain knowledge and skills that will help him/her to change behaviors and adopt a healthier lifestyle. Emotional/affective aspects consider whether emotional issues (e.g., being angry, depressed, panicky, apprehensive, anxious) are being trigged by a recent diagnosis or underlying health issue-in other words, how health status is affecting the person's emotional state.
Case managers may apply specific techniques to manage the behavioral, cognitive, and affective issues that impact the client's willingness, readiness, and ability to change, such as empathy to show genuine care; counseling about health instructions to enhance client's knowledge in this area; and reflecting and summarizing what the client has said to demonstrate understanding and active listening. For example, a case manager may say to a client "What I hear you telling me is that although you want to quit smoking, you have tried unsuccessfully in the past and are worried now that you won't be able to eliminate this habit completely to be healthier." The case manager then awaits the client to acknowledge the accuracy of this reflective statement. The case manager may then continue to explore the client's emotions and ask "how do you feel about this" in an attempt to elicit if the client is ambivalent or unwilling to change.
By listening and conversing, a professional case manager seeks to identify those opportunities to change behaviors, as well as pinpoint those times or circumstances when the client has deviated from a particular regime, plan, or set goal. An individual cannot move to the next level of self-care or change unless those barriers, including lack of knowledge or social/cultural factors, are first identified and addressed in a nonjudgmental way and with the client's agreement. Exhibit 6 lists specific tactics and behaviors case managers may employ when working with their clients on a change effort. It also identifies the tactics and behaviors relevant to each of the various aspects or phase of change (e.g., recognition, readiness, planning and deployment, and maintenance of change). In addition, the exhibit warns case managers about certain behaviors if applied will impede the client's ability to change and will minimize, if not completely eliminate, the chance of success.
Although motivational interviewing can enhance the case management assessment and reassessment phases of the case management process, it is not yet widely employed. Many case managers, including those who are highly skilled in case management, may still need training and coaching in this area. Training allows the case managers to effectively incorporate motivational interviewing principles and techniques into their daily interactions with the clients/support systems. Therefore, it is essential that case managers seek out resources to learn and develop motivational interviewing techniques and the role that self-esteem, self-knowledge, and self-confidence play in the ability of the client to improve self-care, adopt healthier habits, and advocate for themselves.
As with any aspect of professional development and skill-building, the more professional case managers learn, the more tools and techniques they will have at their disposal to help clients/support systems achieve desired outcomes. Skills in motivational interviewing should become a routine expectation of case managers. They are essential for developing effective and trusting relationships with clients/support systems. Such relationships are necessary for effecting healthy lifestyle, self-care ability, and adherence to health regimen. As professional case managers become more aware of the role emotions play in influencing behavior (including their own and those of others) and of the importance of identifying where the client is as well as where she wants and needs to be, the better they will see the client's health holistically and advocate for the individual to achieve a desired, positive outcome.
Burke B., Arkowitz H., Menchola M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71(5), 843-861. [Context Link]
Commission for Case Manager Certification. (2011). Definition and philosophy of case management. Retrieved January 10, 2012, from http://www.ccmcertification.org/about-us/about-case-management/definition-and-ph
Commission for Case Manager Certification. (2009). Commission for Case Manager Certification's Code of Professional Conduct for Case Managers. Retrieved from http://www.ccmcertification.org/sites/default/files/downloads/2011/a.%20CCMCode%
Hettema J., Steele J., Miller W. (2005). Motivational Interviewing. Annual Review of Clinical Psychology, 1, 91-111. [Context Link]
Miller W., Rollnick S. (2002). Motivational interviewing: Preparing people for change (2nd ed.) New York, NY: Guilford Press. [Context Link]
Tahan H. (2000). Emotionally intelligent case managers make a difference. Lippincott's Case Management, 5(4), 162-167. [Context Link]
For more than 33 additional continuing education articles related to Case Management topics, go to http://NursingCenter.com/CE.
assessment; case management; holistic; motivational interviewing; patient-centric
Back to Top