Effectiveness of a
Motivational Interviewing Intervention on Medication Compliance This study investigated the effectiveness of training geriatric homebased primary care (HBPC) nursing staff in motivational interviewing (MI) techniques, with the goal of increasing patient medication adherence. Nursing staff received 4 hours of training in MI techniques from a licensed psychologist. Results indicated that the MI training increased medication adherence in the HBPC veteran sample by a small, but statistically significant, margin both 1 month and 6 months after the intervention. Although the effect size may be considered small, the clinical and cost ramifications of even a small gain in adherence are extremely important for the patient, clinician, and the medical facility. MI techniques may provide a cost-effective and impactful means of enhancing patient adherence to medications.
T
he management of chronic disease is an expensive and growing problem for the U.S. healthcare system. Americans spend $2 trillion annually on healthcare, and management of chronic disease accounts for 75% or $1.65 trillion. Moreover, chronic disease causes 7 out of 10 deaths in the United States each year, and leads to substantial functional impairment and reduced quality of life (Institute of Medicine, 2012; Kung et al., 2008). Older adults are especially at risk for chronic disease, and nearly 75% of adults aged 65 years or over have multiple chronic conditions (Anderson, 2010). As the U.S. population ages, the rates and associated medical costs of these conditions will rise. Many of these conditions can be prevented or successfully managed through medications and/or lifestyle changes. Healthcare providers across disciplines strive to educate patients on their treatment options and encourage acceptance of their interventions. However, although healthcare professionals can encourage their patients by providing education and tools, adherence and behavior change are, ultimately, up to the patient. Ambivalence about change is common in those with chronic disease, and the nonadherence rate averages as high as 50% (Sabate, 2003). As noted by the New England Healthcare Institute (2009), nonadherence leads to $290 billion in healthcare costs annually that could otherwise be avoided.
Alison Minkin, PhD, Jill Snider-Meyer, MSW, Debra Olson, MSN, MHA, CPHQ, Susan Gresser, MS, GCNS-BC, APNP, Heather Smith, PhD, and Frederick J. Kier, PhD, MSHCA
490
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Motivational interviewing is formed between clinician (MI) may provide assistance and patient. Patients are Motivational interviewing is to healthcare workers in guided toward establishment a client-centered therapeutic improving adherence. MI is a of goals, identification of approach aimed at helping client-centered therapeutic potential barriers, and approach aimed at helping enhanced self-efficacy and patients understand and resolve patients understand and commitment toward goal their ambivalence about resolve their ambivalence attainment. It is the patient behavior change. about behavior change. who articulates his or her Whereas traditional medical ideas and plans, rather than models value education and the healthcare provider. The persuasion as the means to eliciting healthier behealthcare provider’s role is to facilitate, rather haviors, MI is based on the theory that the key to than dictate, and what may have once felt like a lasting change is to nurture the intrinsic motivation struggle is now a collaborative and egalitarian that is inherent in all individuals. Through openrelationship (Rollnick et al., 2008). ended questions, reflections, and an understandOriginally developed as a model for treating ing of the patient’s personal values, a partnership substance abuse, MI has been adapted for use
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with numerous target behaviors in medical settings (Miller & Rollnick, 2002). MI techniques are portable, low-tech, and can be integrated into existing consultation models. Although developed as a longer-term psychotherapy to be conducted by mental health clinicians, individual MI interventions also may be used by other healthcare providers in the context of brief medical appointments (Rollnick et al., 2008). Previous studies of MI have indicated that both MI and MI-based interventions are effective in promoting health behaviors, and MI has been linked to positive health outcomes such as lower blood pressure, reduced cholesterol, and better control of blood sugar (Britt et al., 2004; Knight et al., 2006; Martins & McNeil, 2009). MI also has been successfully used to encourage health behavior change in older adults. A review by Cummings et al. (2009), for example, found evidence that MI interventions can lead to significant improvements in physical activity, blood pressure, cholesterol, glycemic control, and diet, and decreases in smoking in elderly patients. Research indicates that MI interventions need not be extensive to be effective. A randomized controlled trial of 217 overweight women with diabetes demonstrated that those who received just five sessions of MI over a 12-month period had better adherence to a behavioral weight control program and lost significantly more weight at 6 and 18 months. Hemoglobin A1C reductions after 6 months were also significantly greater for the intervention group as compared with an attention control group (West et al., 2007). A randomized controlled trial of 106 patients with obstructive sleep apnea found that those who received three sessions of MI were significantly more likely to accept continuous positive airway pressure treatment for sleep apnea and had a 50% greater adherence rate (Olsen et al., 2012). A randomized controlled trial of 200 high-risk smokers in Spain found that those who received three 20-minute sessions of MI were significantly more likely to have abstained from smoking at both 6- and 12-month follow-up (Soria et al., 2006). Telephone-based MI interventions have also demonstrated promising results. A small randomized controlled trial of 24 patients found that those who received a single MI-based telephone consultation demonstrated significantly better total cholesterol and low-density-lipoprotein
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cholesterol compared with the attention controls (Kreman et al., 2006). A randomized controlled trial with 130 adults with multiple sclerosis found that patients who received a brief, MI-based intervention conducted primarily by telephone showed significantly greater improvement in physical activity, stress management, and fatigue impact than a control group. Participants in the intervention group received only one in-person session and five telephone follow-up sessions (Bombardier et al., 2008). Cancer survivors (n = 28) who received a 30-minute in-person MI session and three 20-minute telephone sessions engaged in more physical activities than a control group (as measured by weekly caloric expenditure) (Bennett et al., 2007). A similar randomized controlled trial of 86 rural adults found that, although physical activity did not increase, self-efficacy was significantly greater for those receiving MI-based telephone interventions (Bennett et al., 2008). Positive effects for MI have been demonstrated in home settings, as well. MI-based interventions delivered via home visits from a trained, advance practice nurse (APN) led to improvements in self-care in patients recently hospitalized with heart failure (Riegel et al., 2006). The study examined outcomes for 15 patients, average age 59.7 years, who received an average of three visits from the APN over 3 months. Self-care was conceptualized to include adherence behaviors, self-care decision-making, and self-care confidence related to heart failure. Twelve of the 15 patients demonstrated improvement in self-care on posttest. Although the sample size was small, results suggest that MI has promise as a means of improving self-care in home care patients with chronic disease. A much larger study, involving 273 smokers, average age 57 years, who were receiving home healthcare services, found that those randomly assigned to receive an MI-based smoking intervention had a significantly greater reduction in cigarette smoking through 12 months of posttreatment follow-up. The MI-based intervention was brief, consisting of three sessions lasting 20 to 30 minutes each, as well as a single followup phone call. The intervention was administered by the patient’s own home care nurses, and the in-person treatment sessions were incorporated into existing home care visits (Borrelli et al., 2005).
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Although in-home MI interventions have shown promise, more research is needed to establish their efficacy, particularly with the elderly, medically frail individuals who are typical recipients of home health services. Homebound patients with chronic medical illness may be especially vulnerable to the effects of nonadherence. These individuals may lack resources and access to social support, which can be critical to managing serious disease. Home healthcare services can improve outcomes for this population through medication set-up, monitoring of vital signs and other critical health markers, physical therapy, wound care, or nutrition counseling. Often, home healthcare programs include access to an interdisciplinary team of healthcare professionals, all of whom provide specialized and complementary services to the same patients. Researchers have hypothesized that MI interventions may be even more effective when they are initiated by patients’ existing healthcare providers (Soria et al., 2006). Given that MI is cost-effective, portable, and can be initiated by a variety of disciplines, it is likely to benefit home healthcare providers who hope to improve adherence in their patients.
Methods This is a retrospective pre-post design aimed at examining the effectiveness of MI training for Veterans Administration (VA) home-based primary care (HBPC) nursing staff to assist them in enhancing the medication adherence of a sample of their patients. The HBPC program involves the provision of primary care services by interdisciplinary staff in the veteran’s home, typically because of a veteran not having the mobility or ability to transport himself or herself to a hospital or clinic for care. HBPC patients typically have chronic conditions, such as diabetes, congestive heart failure (CHF), or mental illness, that require ongoing care and support. The HBPC program involved with this project is based in a large, urban VA medical center in the Midwest, but with a large coverage area that includes suburban and rural areas. The HBPC staff involved in the study were nurses (RNs or LPNs). These nurses, as part of routine HBPC care, record via the VA’s electronic charting system the adherence of the veteran to the medication regime prescribed. The chart notes use a template that includes documentation regarding medication adherence.
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The healthcare provider’s role is to facilitate, rather than dictate, and what may have once felt like a struggle is now a collaborative and egalitarian relationship.
As part of their annual continuing education, all HBPC nursing staff underwent training in MI techniques. The education was 4 hours in duration and was conducted by a licensed psychologist with training in MI. Every week for 6 months thereafter, relevant MI techniques were briefly reviewed during HBPC staff meetings. Staff members also offered case examples during weekly staff meetings describing their use of MI interventions, and the licensed psychologist offered feedback and reinforced MI techniques. HBPC patient data were collected via a retrospective chart review for three time periods: the first 6 months before the MI training (Time 1), 1 month after the MI training (Time 2), and 6 months after the MI training (Time 3). Chart notes of patients seen by HBPC nurses were examined to determine the patient’s medication adherence, which is monitored during the HBPC nursing staff’s home visits and recorded into the VA’s electronic chart record system as noted above. In addition to overall adherence to the medication regimen, adherence with warfarin regimens was specifically investigated because of its frequency in our patient population (i.e., an average of 23.1% of the patients in our sample were prescribed warfarin) and because of the relatively high rates of nonadherence and early termination of treatment per documented clinical trials. For example, Cruess et al. (2010) noted a warfarin nonadherence rate of 22% as measured objectively (i.e., rather than relying on patient self-report), and studies suggest that up to 33% of patients discontinue warfarin treatment within 2 to 3 years (Kneeland & Fang, 2010). Nonadherence to warfarin is associated with significant underanticoagulation and increased stroke risk; Kimmel et al. (2007) noted that even moderate levels of warfarin nonadherence are clinically important. Studies have suggested that patient motivation has a statistically significant impact on warfarin adherence, highlighting the
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Table 1. Medication Nonadherence Rates 6 Months Pre Overall
Warfarin
1 Month Post
6 Months Post
22.3%
13.1%
14.0%
(N = 175)
(N = 168)
(N = 168)
22.2%
22.7%
12.8%
(N = 44)
(N = 35)
(N = 39)
importance of incorporating motivational enhancement strategies (such as MI) into treatment for this patient population (Kääriäinen et al., 2013).
Results At any given time, the number of veterans enrolled in the HBPC program varies between 150 and 200 patients, with an average of 178 veterans enrolled during the survey period (n = 181 at Time 1, n = 168 at Time 2, and n = 186 at Time 3). The average number of veterans prescribed warfarin during the survey period was 40 (n = 45 at Time 1, n = 35 at Time 2, and n = 39 at Time 3). The average age of the veterans enrolled in the HBPC program at the time of the study was 78.8 years. The sample was overwhelmingly male, with an average of six female veterans in the program during the study time period. Approximately 58% of the sample was White, 24% Black, 1% Hispanic, and 1% Asian. For 16% of the charts reviewed, race or ethnicity was not clearly indicated. Table 1 provides data regarding average overall medication adherence rates and average warfarin regimen adherence rates for veterans enrolled in HBPC 6 months before the MI training and at 1 and 6 months following the staff education. At Time 1 (6 months before the MI training), 39 of a total of 175 patients (22.3%) enrolled in HBPC were documented to be nonadherent with medications at their most recent nursing visit. Adherence data were not available for six patients in Time 1. One month after the intervention (Time 2), 22 of a total of 168 (13.1%) patients were nonadherent. Six months after the intervention (Time 3), 26 of a total of 186 patients (14.0%) were nonadherent. Independent samples t -tests were conducted to determine whether significant differences existed between patient medication adherence
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rates before and after the MI intervention. Relative to rates 6 months before the intervention (N = 175, M = 1.22, SD = 0.42), there were significant improvements in medication adherence both at Time 2 (N = 168, M = 1.13, SD = 0.34), t (341) = 2.235, p = .026, and at Time 3 (N = 186, M = 1.14, SD = 0.35), t (359) = 2.059, p =.040. Effect sizes were small, but significant, for both Time 2 (d = 0.24) and Time 3 (d = 0.21). When data from patients prescribed warfarin were examined independently, results indicated no significant improvement in adherence from Time 1 (N = 44, M = 1.23, SD = 0.42) to Time 2 (N = 35, M = 1.14, SD = 0.36), t (77) = 0.94, p = .055. There was, however, a significant improvement in medication adherence at Time 3 (N = 39, M = 1.13, SD = 0.34), t (81) = 1.17, p = .018). Adherence data were not available for one patient in the warfarin group at Time 1.
Discussion Results indicate that rates of patient medication adherence increased by a statistically significant margin both 1 month and 6 months after the in-home MI intervention. These results appear consistent with previous studies examining the effects of MI in other treatment domains, which also show that even brief MI training and interventions can have significant effects on patient behavior and treatment (Bombardier et al., 2008; Olsen et al., 2012; Soria et al., 2006; West et al., 2007). That our result was achieved with a rather modest MI intervention is also consistent with Touchette and Shapiro’s (2008) conclusion from their meta-analysis of treatment adherence studies that indicated no clear association between intervention intensity and effect size. Results of the present investigation are also consistent with effect sizes calculated through metaanalysis of MI interventions, which has indicated an overall effect size of g = 0.28 and an effect size of g = 0.19 for studies targeting positive health behaviors (Lundahl et al., 2010). The research evidence along with our results suggests that even modest interventions can produce improvement. Given the costs of nonadherence, both to the individual and to healthcare systems, a small increase in adherence may nonetheless translate to significant systemic cost savings and enhancement of patients’ quality of life.
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With regard to warfarin, our results indicate a significant improvement in warfarin adherence 6 months postintervention, but no significant improvement 1-month postintervention. Our results may be related to the complexity of managing warfarin, which requires frequent blood draws and dose adjustments. As Kneeland and Fang (2010) note, management of warfarin places a rather unique burden on patients, which impacts adherence. It is possible that greater exposure to MI interventions was required to secure this level of commitment. It should be noted that the study compared an average rate of compliance in the veterans enrolled in HBPC at a particular set point in time—not necessarily the same patients were in each set. Future studies using a matched prepost methodology looking at the same sample of veterans at each time may lead to more precise results.
Limitations
The research literature in this area suggests that nursing staff appreciate the addition of MI in their practice. Nurses in one study reported that MI enriched their work in health promotion (Brobeck et al., 2011), and, although actual data on nursing staff satisfaction with MI training was not directly collected, anecdotally, many staff in the present study expressed to their supervisors the feeling that MI enhanced their effectiveness with patients. Providing healthcare staff with these tools to improve their practice may increase nurses’ identification with their role in health promotion and their self-efficacy and job satisfaction. The use of MI is a natural fit in the home care setting as long-term relationships are typically established between the nurse and patient. It is these relationships that draw many nurses into home care, and the relationship is the foundation from which nursing staff build knowledge about patient preferences and desires. This knowledge base, the established trusting relationship, and the use of MI are a powerful combination in motivating patients to make positive heathcare choices. This is particularly rewarding for the nurse, who may have previously reached an impasse with patients and is now able to help the patient move forward. In summary, the results of the present study suggest that MI training of home care nursing
The correlational nature of the study limits its ability to infer a direct relationship between training in MI techniques and improved patient medication adherence. Future studies might use an experimental design with matched controls. In addition, although techniques were reinforced weekly during staff meetings and cases were reviewed, the study did not include measures of fidelity to MI techniques during nursing visits. Therefore, it is Research indicates that motivational interviewing not possible to know whether nursing interventions need not be extensive to be effective. staff consistently used MI techniques at each visit and whether those techstaff can increase medication adherence in niques were implemented correctly. Additionally, veterans enrolled in HBPC by a small, but statisdata collection was based on adherence as docutically significant, margin. Although the effect mented in a single nursing visit for each patient size may be considered small, the clinical and at the identified time frames (i.e., 6 months cost ramifications of even a small gain in treatbefore intervention, 1 month postintervention, ment adherence are extremely important for and 6 months postintervention). Trends in indithe patient, clinician, and the medical facility. vidual patient adherence were not tracked, and That the gain in adherence held 6 months postwe cannot be certain that the data collected are staff MI training suggests that the gain in adherrepresentative of patients’ overall medication ence is durable. In addition, many medical cenadherence. A significant strength of the study is ters may have experts in MI already on staff that the data were collected from an established, who could provide such training at relatively ongoing treatment program (an HBPC program), low cost to the facility. The results of our study which arguably increased the external validity would conclude that staff MI training has a and generalizability of the study results. For exsmall, but persistent and clinically important ample, the usual method and conduct of the care effect on home care patient medication being provided, beyond the addition of the MI adherence, and, given its relatively low cost to intervention, were not changed.
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implement, can be an effective intervention to improve medication adherence rates for this population. Alison Minkin, PhD, is a Psychologist, Mental Health Division, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. Jill Snider-Meyer, MSW, is a Program Manager, CommunityBased Programs, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. Debra Olson, MSN, MHA, CPHQ, is a Deputy Program Manager, Community-Based Programs, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. Susan Gresser, MS, GCNS-BC, APNP, is a Program Manager, Community Living Center, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. Heather Smith, PhD, is a Lead Psychologist, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, and an Associate Professor, Department of Psychiatry, Medical College of Wisconsin, Milwaukee, Wisconsin. Frederick J. Kier, PhD, MSHCA, is a Division Manager, Rehabilitation, Extended and Community Care, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, and an Associate Professor, Department of Psychiatry, Medical College of Wisconsin, Milwaukee, Wisconsin. This material is based on work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development. The contents do not necessarily represent the views of the Department of Veterans Affairs or the United States government. This study, although initiated and performed by VA staff, was not directly funded by the VA or any other entity. The authors declare no conflicts of interest. Address for correspondence: Frederick J. Kier, PhD, MSHCA, RECC Division, Zablocki VAMC, 5000 W. National Ave., Milwaukee, WI 53295 ([email protected]). DOI:10.1097/NHH.0000000000000128
REFERENCES Anderson, G. F. (2010). Chronic care: Making the case for ongoing care. Princeton, NJ: Robert Wood Johnson Foundation. Bennett, J. A., Lyons, K. S., Winters-Stone, K., Nail, L. M., & Scherer, J. (2007). Motivational Interviewing to increase physical activity in long-term cancer survivors: A randomized controlled trial. Nursing Research, 56(1), 18-27. Bennett, J. A., Young, H. M., Nail, L. M., Winters-Stone, K., & Hanson, G. (2008). A telephone-only motivational intervention to increase physical activity in rural adults. Nursing Research, 57(1), 24-32. Bombardier, C. H., Cunniffe, M., Wadhwani, R., Gibbons, L. E., Blake, K. D., & Kraft, G. H. (2008). The efficacy of telephone counseling for health promotion in people with multiple sclerosis: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 89(10), 1849-1856. Borrelli, B., Novak, S., Hecht, J., Emmons, K., Papandonatos, G., & Abrams, D. (2005). Home health care nurses as a new channel for smoking cessation treatment: Outcomes from project CARES (Community-nurse Assisted Research and Education on Smoking). Preventive Medicine, 41(5-6), 815-821. Britt, E., Hudson, S. M., & Blampied, N. M. (2004). Motivational interviewing in health settings: A review. Patient Education and Counseling, 53(2), 147-155. Brobeck, E., Bergh, H., Odencrants, S., & Hildingh, C. (2011). Primary healthcare nurses’ experiences with motivational interviewing in health promotion practice. Journal of Clinical Nursing, 20(23-24), 3322-3330.
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Cruess, D. G., Localio, A. R., Platt, A. B., Brensinger, C. M., Christie, J. D., Gross, R., …, Kimmel, S. E. (2010). Patient attitudinal and behavioral factors associated with warfarin non-adherence at outpatient anticoagulation clinics. International Journal of Behavioral Medicine, 17(1), 33-42. Cummings, S. M., Cooper, R. L., & Cassie, K. M. (2009). Motivational interviewing to affect behavioral change in older adults. Research on Social Work Practice, 19(2), 195-204. Institute of Medicine. (2012). Living well with chronic illness: A call for public health action. Retrieved from http://iom.edu/~/media/ Files/Report Files/2012/ Living-Well-with-Chronic-Illness/livingwell_chronicillness_reportbrief.pdf Kääriäinen, M., Paukama, M., & Kyngäs, H. (2013). Adherence with health regimens of patients on warfarin therapy. Journal of Clinical Nursing, 22(1-2), 89-96. Kimmel, S. E., Chen, Z., Price, M., Parker, C. S., Metlay, J. P., Christie, J. D., ?, Gross, R. (2007). The influence of patient adherence on anticoagulation control with warfarin: Results from the International Normalized Ratio Adherence and Genetics (IN-RANGE) study. Archives of Internal Medicine, 167(3), 229-235. Kneeland, P. P., & Fang, M. C. (2010). Current issues in patient adherence and persistence: Focus on anticoagulants for the treatment and prevention of thromboembolism. Patient Preference and Adherence, 4, 51-60. Knight, K. M., McGowan, L., Dickens, C., & Bundy, C. (2006). A systematic review of motivational interviewing in physical health care settings. British Journal of Health Psychology, 11(Pt 2), 319-332. Kreman, R., Yates, B. C., Agrawal, S., Fiandt, K., Briner, W., & Shurmur, S. (2006). The effects of motivational interviewing on physiological outcomes. Applied Nursing Research, 19(3), 167-170. Kung, H. C., Hoyert, D. L., Xu, J., & Murphy, S. L. (2008). Deaths: Final data for 2005. National Vital Statistics Reports, 56(10), 1-120. Retrieved from http://www.cdc.gov/ nchs/data/nvsr/ nvsr56/nvsr56_10.pdf Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of Motivational Interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137-160. Martins, R. K., & McNeil, D. W. (2009). Review of Motivational Interviewing in promoting health behaviors. Clinical Psychology Review, 29(4), 283-293. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing (2nd ed.). New York, NY: Guilford. New England Healthcare Institute. (2009). Thinking outside the pillbox: A system-wide approach to improving patient medication adherence for chronic disease. Retrieved September 6, 2009, from http://www.nehi.net/writable/publication_files/file/pa_ issue_brief_final.pdf Olsen, S., Smith, S. S., Oei, T. P., & Douglas, J. (2012). Motivational interviewing (MINT) improves continuous positive airway pressure (CPAP) acceptance and adherence: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 80(1), 151-163. Riegel, B., Dickson, V. V., Hoke, L., McMahon, J. P., Reis, B. F., & Sayers, S. (2006). A motivational counseling approach to improving heart failure self-care: Mechanisms of effectiveness. Journal of Cardiovascular Nursing, 21(3), 232-241. Rollnick, S., Miller, W. R., & Butler, C. C. (2008) Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford. Sabate, E. (2003). Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization. Soria, R., Legido, A., Escolano, C., López Yeste, A., & Montoya, J. (2006). A randomised controlled trial of motivational interviewing for smoking cessation. British Journal of General Practice, 56(531), 768-774. Touchette, D. R., & Shapiro, N. L. (2008). Medication adherence, adherence, and persistence: Current status of behavioral and educational interventions to improve outcomes. Journal of Managed Care Pharmacy,14 (6), S2-S10. West, D. S., DiLillo, V., Bursac, Z., Gore, S. A., & Greene, P. G. (2007). Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care, 30(5), 1081-1087.
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Motivational Interviewing Intervention on Medication Compliance This study investigated the effectiveness of training geriatric homebased primary care (HBPC) nursing staff in motivational interviewing (MI) techniques, with the goal of increasing patient medication adherence. Nursing staff received 4 hours of training in MI techniques from a licensed psychologist. Results indicated that the MI training increased medication adherence in the HBPC veteran sample by a small, but statistically significant, margin both 1 month and 6 months after the intervention. Although the effect size may be considered small, the clinical and cost ramifications of even a small gain in adherence are extremely important for the patient, clinician, and the medical facility. MI techniques may provide a cost-effective and impactful means of enhancing patient adherence to medications.
T
he management of chronic disease is an expensive and growing problem for the U.S. healthcare system. Americans spend $2 trillion annually on healthcare, and management of chronic disease accounts for 75% or $1.65 trillion. Moreover, chronic disease causes 7 out of 10 deaths in the United States each year, and leads to substantial functional impairment and reduced quality of life (Institute of Medicine, 2012; Kung et al., 2008). Older adults are especially at risk for chronic disease, and nearly 75% of adults aged 65 years or over have multiple chronic conditions (Anderson, 2010). As the U.S. population ages, the rates and associated medical costs of these conditions will rise. Many of these conditions can be prevented or successfully managed through medications and/or lifestyle changes. Healthcare providers across disciplines strive to educate patients on their treatment options and encourage acceptance of their interventions. However, although healthcare professionals can encourage their patients by providing education and tools, adherence and behavior change are, ultimately, up to the patient. Ambivalence about change is common in those with chronic disease, and the nonadherence rate averages as high as 50% (Sabate, 2003). As noted by the New England Healthcare Institute (2009), nonadherence leads to $290 billion in healthcare costs annually that could otherwise be avoided.
Alison Minkin, PhD, Jill Snider-Meyer, MSW, Debra Olson, MSN, MHA, CPHQ, Susan Gresser, MS, GCNS-BC, APNP, Heather Smith, PhD, and Frederick J. Kier, PhD, MSHCA
490
Home Healthcare Nurse
www.homehealthcarenurseonline.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BROKER / Alamy
Motivational interviewing is formed between clinician (MI) may provide assistance and patient. Patients are Motivational interviewing is to healthcare workers in guided toward establishment a client-centered therapeutic improving adherence. MI is a of goals, identification of approach aimed at helping client-centered therapeutic potential barriers, and approach aimed at helping enhanced self-efficacy and patients understand and resolve patients understand and commitment toward goal their ambivalence about resolve their ambivalence attainment. It is the patient behavior change. about behavior change. who articulates his or her Whereas traditional medical ideas and plans, rather than models value education and the healthcare provider. The persuasion as the means to eliciting healthier behealthcare provider’s role is to facilitate, rather haviors, MI is based on the theory that the key to than dictate, and what may have once felt like a lasting change is to nurture the intrinsic motivation struggle is now a collaborative and egalitarian that is inherent in all individuals. Through openrelationship (Rollnick et al., 2008). ended questions, reflections, and an understandOriginally developed as a model for treating ing of the patient’s personal values, a partnership substance abuse, MI has been adapted for use
vol. 32 • no. 8 • September 2014
Home Healthcare Nurse
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
491
with numerous target behaviors in medical settings (Miller & Rollnick, 2002). MI techniques are portable, low-tech, and can be integrated into existing consultation models. Although developed as a longer-term psychotherapy to be conducted by mental health clinicians, individual MI interventions also may be used by other healthcare providers in the context of brief medical appointments (Rollnick et al., 2008). Previous studies of MI have indicated that both MI and MI-based interventions are effective in promoting health behaviors, and MI has been linked to positive health outcomes such as lower blood pressure, reduced cholesterol, and better control of blood sugar (Britt et al., 2004; Knight et al., 2006; Martins & McNeil, 2009). MI also has been successfully used to encourage health behavior change in older adults. A review by Cummings et al. (2009), for example, found evidence that MI interventions can lead to significant improvements in physical activity, blood pressure, cholesterol, glycemic control, and diet, and decreases in smoking in elderly patients. Research indicates that MI interventions need not be extensive to be effective. A randomized controlled trial of 217 overweight women with diabetes demonstrated that those who received just five sessions of MI over a 12-month period had better adherence to a behavioral weight control program and lost significantly more weight at 6 and 18 months. Hemoglobin A1C reductions after 6 months were also significantly greater for the intervention group as compared with an attention control group (West et al., 2007). A randomized controlled trial of 106 patients with obstructive sleep apnea found that those who received three sessions of MI were significantly more likely to accept continuous positive airway pressure treatment for sleep apnea and had a 50% greater adherence rate (Olsen et al., 2012). A randomized controlled trial of 200 high-risk smokers in Spain found that those who received three 20-minute sessions of MI were significantly more likely to have abstained from smoking at both 6- and 12-month follow-up (Soria et al., 2006). Telephone-based MI interventions have also demonstrated promising results. A small randomized controlled trial of 24 patients found that those who received a single MI-based telephone consultation demonstrated significantly better total cholesterol and low-density-lipoprotein
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cholesterol compared with the attention controls (Kreman et al., 2006). A randomized controlled trial with 130 adults with multiple sclerosis found that patients who received a brief, MI-based intervention conducted primarily by telephone showed significantly greater improvement in physical activity, stress management, and fatigue impact than a control group. Participants in the intervention group received only one in-person session and five telephone follow-up sessions (Bombardier et al., 2008). Cancer survivors (n = 28) who received a 30-minute in-person MI session and three 20-minute telephone sessions engaged in more physical activities than a control group (as measured by weekly caloric expenditure) (Bennett et al., 2007). A similar randomized controlled trial of 86 rural adults found that, although physical activity did not increase, self-efficacy was significantly greater for those receiving MI-based telephone interventions (Bennett et al., 2008). Positive effects for MI have been demonstrated in home settings, as well. MI-based interventions delivered via home visits from a trained, advance practice nurse (APN) led to improvements in self-care in patients recently hospitalized with heart failure (Riegel et al., 2006). The study examined outcomes for 15 patients, average age 59.7 years, who received an average of three visits from the APN over 3 months. Self-care was conceptualized to include adherence behaviors, self-care decision-making, and self-care confidence related to heart failure. Twelve of the 15 patients demonstrated improvement in self-care on posttest. Although the sample size was small, results suggest that MI has promise as a means of improving self-care in home care patients with chronic disease. A much larger study, involving 273 smokers, average age 57 years, who were receiving home healthcare services, found that those randomly assigned to receive an MI-based smoking intervention had a significantly greater reduction in cigarette smoking through 12 months of posttreatment follow-up. The MI-based intervention was brief, consisting of three sessions lasting 20 to 30 minutes each, as well as a single followup phone call. The intervention was administered by the patient’s own home care nurses, and the in-person treatment sessions were incorporated into existing home care visits (Borrelli et al., 2005).
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Although in-home MI interventions have shown promise, more research is needed to establish their efficacy, particularly with the elderly, medically frail individuals who are typical recipients of home health services. Homebound patients with chronic medical illness may be especially vulnerable to the effects of nonadherence. These individuals may lack resources and access to social support, which can be critical to managing serious disease. Home healthcare services can improve outcomes for this population through medication set-up, monitoring of vital signs and other critical health markers, physical therapy, wound care, or nutrition counseling. Often, home healthcare programs include access to an interdisciplinary team of healthcare professionals, all of whom provide specialized and complementary services to the same patients. Researchers have hypothesized that MI interventions may be even more effective when they are initiated by patients’ existing healthcare providers (Soria et al., 2006). Given that MI is cost-effective, portable, and can be initiated by a variety of disciplines, it is likely to benefit home healthcare providers who hope to improve adherence in their patients.
Methods This is a retrospective pre-post design aimed at examining the effectiveness of MI training for Veterans Administration (VA) home-based primary care (HBPC) nursing staff to assist them in enhancing the medication adherence of a sample of their patients. The HBPC program involves the provision of primary care services by interdisciplinary staff in the veteran’s home, typically because of a veteran not having the mobility or ability to transport himself or herself to a hospital or clinic for care. HBPC patients typically have chronic conditions, such as diabetes, congestive heart failure (CHF), or mental illness, that require ongoing care and support. The HBPC program involved with this project is based in a large, urban VA medical center in the Midwest, but with a large coverage area that includes suburban and rural areas. The HBPC staff involved in the study were nurses (RNs or LPNs). These nurses, as part of routine HBPC care, record via the VA’s electronic charting system the adherence of the veteran to the medication regime prescribed. The chart notes use a template that includes documentation regarding medication adherence.
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The healthcare provider’s role is to facilitate, rather than dictate, and what may have once felt like a struggle is now a collaborative and egalitarian relationship.
As part of their annual continuing education, all HBPC nursing staff underwent training in MI techniques. The education was 4 hours in duration and was conducted by a licensed psychologist with training in MI. Every week for 6 months thereafter, relevant MI techniques were briefly reviewed during HBPC staff meetings. Staff members also offered case examples during weekly staff meetings describing their use of MI interventions, and the licensed psychologist offered feedback and reinforced MI techniques. HBPC patient data were collected via a retrospective chart review for three time periods: the first 6 months before the MI training (Time 1), 1 month after the MI training (Time 2), and 6 months after the MI training (Time 3). Chart notes of patients seen by HBPC nurses were examined to determine the patient’s medication adherence, which is monitored during the HBPC nursing staff’s home visits and recorded into the VA’s electronic chart record system as noted above. In addition to overall adherence to the medication regimen, adherence with warfarin regimens was specifically investigated because of its frequency in our patient population (i.e., an average of 23.1% of the patients in our sample were prescribed warfarin) and because of the relatively high rates of nonadherence and early termination of treatment per documented clinical trials. For example, Cruess et al. (2010) noted a warfarin nonadherence rate of 22% as measured objectively (i.e., rather than relying on patient self-report), and studies suggest that up to 33% of patients discontinue warfarin treatment within 2 to 3 years (Kneeland & Fang, 2010). Nonadherence to warfarin is associated with significant underanticoagulation and increased stroke risk; Kimmel et al. (2007) noted that even moderate levels of warfarin nonadherence are clinically important. Studies have suggested that patient motivation has a statistically significant impact on warfarin adherence, highlighting the
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Table 1. Medication Nonadherence Rates 6 Months Pre Overall
Warfarin
1 Month Post
6 Months Post
22.3%
13.1%
14.0%
(N = 175)
(N = 168)
(N = 168)
22.2%
22.7%
12.8%
(N = 44)
(N = 35)
(N = 39)
importance of incorporating motivational enhancement strategies (such as MI) into treatment for this patient population (Kääriäinen et al., 2013).
Results At any given time, the number of veterans enrolled in the HBPC program varies between 150 and 200 patients, with an average of 178 veterans enrolled during the survey period (n = 181 at Time 1, n = 168 at Time 2, and n = 186 at Time 3). The average number of veterans prescribed warfarin during the survey period was 40 (n = 45 at Time 1, n = 35 at Time 2, and n = 39 at Time 3). The average age of the veterans enrolled in the HBPC program at the time of the study was 78.8 years. The sample was overwhelmingly male, with an average of six female veterans in the program during the study time period. Approximately 58% of the sample was White, 24% Black, 1% Hispanic, and 1% Asian. For 16% of the charts reviewed, race or ethnicity was not clearly indicated. Table 1 provides data regarding average overall medication adherence rates and average warfarin regimen adherence rates for veterans enrolled in HBPC 6 months before the MI training and at 1 and 6 months following the staff education. At Time 1 (6 months before the MI training), 39 of a total of 175 patients (22.3%) enrolled in HBPC were documented to be nonadherent with medications at their most recent nursing visit. Adherence data were not available for six patients in Time 1. One month after the intervention (Time 2), 22 of a total of 168 (13.1%) patients were nonadherent. Six months after the intervention (Time 3), 26 of a total of 186 patients (14.0%) were nonadherent. Independent samples t -tests were conducted to determine whether significant differences existed between patient medication adherence
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rates before and after the MI intervention. Relative to rates 6 months before the intervention (N = 175, M = 1.22, SD = 0.42), there were significant improvements in medication adherence both at Time 2 (N = 168, M = 1.13, SD = 0.34), t (341) = 2.235, p = .026, and at Time 3 (N = 186, M = 1.14, SD = 0.35), t (359) = 2.059, p =.040. Effect sizes were small, but significant, for both Time 2 (d = 0.24) and Time 3 (d = 0.21). When data from patients prescribed warfarin were examined independently, results indicated no significant improvement in adherence from Time 1 (N = 44, M = 1.23, SD = 0.42) to Time 2 (N = 35, M = 1.14, SD = 0.36), t (77) = 0.94, p = .055. There was, however, a significant improvement in medication adherence at Time 3 (N = 39, M = 1.13, SD = 0.34), t (81) = 1.17, p = .018). Adherence data were not available for one patient in the warfarin group at Time 1.
Discussion Results indicate that rates of patient medication adherence increased by a statistically significant margin both 1 month and 6 months after the in-home MI intervention. These results appear consistent with previous studies examining the effects of MI in other treatment domains, which also show that even brief MI training and interventions can have significant effects on patient behavior and treatment (Bombardier et al., 2008; Olsen et al., 2012; Soria et al., 2006; West et al., 2007). That our result was achieved with a rather modest MI intervention is also consistent with Touchette and Shapiro’s (2008) conclusion from their meta-analysis of treatment adherence studies that indicated no clear association between intervention intensity and effect size. Results of the present investigation are also consistent with effect sizes calculated through metaanalysis of MI interventions, which has indicated an overall effect size of g = 0.28 and an effect size of g = 0.19 for studies targeting positive health behaviors (Lundahl et al., 2010). The research evidence along with our results suggests that even modest interventions can produce improvement. Given the costs of nonadherence, both to the individual and to healthcare systems, a small increase in adherence may nonetheless translate to significant systemic cost savings and enhancement of patients’ quality of life.
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With regard to warfarin, our results indicate a significant improvement in warfarin adherence 6 months postintervention, but no significant improvement 1-month postintervention. Our results may be related to the complexity of managing warfarin, which requires frequent blood draws and dose adjustments. As Kneeland and Fang (2010) note, management of warfarin places a rather unique burden on patients, which impacts adherence. It is possible that greater exposure to MI interventions was required to secure this level of commitment. It should be noted that the study compared an average rate of compliance in the veterans enrolled in HBPC at a particular set point in time—not necessarily the same patients were in each set. Future studies using a matched prepost methodology looking at the same sample of veterans at each time may lead to more precise results.
Limitations
The research literature in this area suggests that nursing staff appreciate the addition of MI in their practice. Nurses in one study reported that MI enriched their work in health promotion (Brobeck et al., 2011), and, although actual data on nursing staff satisfaction with MI training was not directly collected, anecdotally, many staff in the present study expressed to their supervisors the feeling that MI enhanced their effectiveness with patients. Providing healthcare staff with these tools to improve their practice may increase nurses’ identification with their role in health promotion and their self-efficacy and job satisfaction. The use of MI is a natural fit in the home care setting as long-term relationships are typically established between the nurse and patient. It is these relationships that draw many nurses into home care, and the relationship is the foundation from which nursing staff build knowledge about patient preferences and desires. This knowledge base, the established trusting relationship, and the use of MI are a powerful combination in motivating patients to make positive heathcare choices. This is particularly rewarding for the nurse, who may have previously reached an impasse with patients and is now able to help the patient move forward. In summary, the results of the present study suggest that MI training of home care nursing
The correlational nature of the study limits its ability to infer a direct relationship between training in MI techniques and improved patient medication adherence. Future studies might use an experimental design with matched controls. In addition, although techniques were reinforced weekly during staff meetings and cases were reviewed, the study did not include measures of fidelity to MI techniques during nursing visits. Therefore, it is Research indicates that motivational interviewing not possible to know whether nursing interventions need not be extensive to be effective. staff consistently used MI techniques at each visit and whether those techstaff can increase medication adherence in niques were implemented correctly. Additionally, veterans enrolled in HBPC by a small, but statisdata collection was based on adherence as docutically significant, margin. Although the effect mented in a single nursing visit for each patient size may be considered small, the clinical and at the identified time frames (i.e., 6 months cost ramifications of even a small gain in treatbefore intervention, 1 month postintervention, ment adherence are extremely important for and 6 months postintervention). Trends in indithe patient, clinician, and the medical facility. vidual patient adherence were not tracked, and That the gain in adherence held 6 months postwe cannot be certain that the data collected are staff MI training suggests that the gain in adherrepresentative of patients’ overall medication ence is durable. In addition, many medical cenadherence. A significant strength of the study is ters may have experts in MI already on staff that the data were collected from an established, who could provide such training at relatively ongoing treatment program (an HBPC program), low cost to the facility. The results of our study which arguably increased the external validity would conclude that staff MI training has a and generalizability of the study results. For exsmall, but persistent and clinically important ample, the usual method and conduct of the care effect on home care patient medication being provided, beyond the addition of the MI adherence, and, given its relatively low cost to intervention, were not changed.
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implement, can be an effective intervention to improve medication adherence rates for this population. Alison Minkin, PhD, is a Psychologist, Mental Health Division, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. Jill Snider-Meyer, MSW, is a Program Manager, CommunityBased Programs, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. Debra Olson, MSN, MHA, CPHQ, is a Deputy Program Manager, Community-Based Programs, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. Susan Gresser, MS, GCNS-BC, APNP, is a Program Manager, Community Living Center, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. Heather Smith, PhD, is a Lead Psychologist, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, and an Associate Professor, Department of Psychiatry, Medical College of Wisconsin, Milwaukee, Wisconsin. Frederick J. Kier, PhD, MSHCA, is a Division Manager, Rehabilitation, Extended and Community Care, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, and an Associate Professor, Department of Psychiatry, Medical College of Wisconsin, Milwaukee, Wisconsin. This material is based on work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development. The contents do not necessarily represent the views of the Department of Veterans Affairs or the United States government. This study, although initiated and performed by VA staff, was not directly funded by the VA or any other entity. The authors declare no conflicts of interest. Address for correspondence: Frederick J. Kier, PhD, MSHCA, RECC Division, Zablocki VAMC, 5000 W. National Ave., Milwaukee, WI 53295 ([email protected]). DOI:10.1097/NHH.0000000000000128
REFERENCES Anderson, G. F. (2010). Chronic care: Making the case for ongoing care. Princeton, NJ: Robert Wood Johnson Foundation. Bennett, J. A., Lyons, K. S., Winters-Stone, K., Nail, L. M., & Scherer, J. (2007). Motivational Interviewing to increase physical activity in long-term cancer survivors: A randomized controlled trial. Nursing Research, 56(1), 18-27. Bennett, J. A., Young, H. M., Nail, L. M., Winters-Stone, K., & Hanson, G. (2008). A telephone-only motivational intervention to increase physical activity in rural adults. Nursing Research, 57(1), 24-32. Bombardier, C. H., Cunniffe, M., Wadhwani, R., Gibbons, L. E., Blake, K. D., & Kraft, G. H. (2008). The efficacy of telephone counseling for health promotion in people with multiple sclerosis: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 89(10), 1849-1856. Borrelli, B., Novak, S., Hecht, J., Emmons, K., Papandonatos, G., & Abrams, D. (2005). Home health care nurses as a new channel for smoking cessation treatment: Outcomes from project CARES (Community-nurse Assisted Research and Education on Smoking). Preventive Medicine, 41(5-6), 815-821. Britt, E., Hudson, S. M., & Blampied, N. M. (2004). Motivational interviewing in health settings: A review. Patient Education and Counseling, 53(2), 147-155. Brobeck, E., Bergh, H., Odencrants, S., & Hildingh, C. (2011). Primary healthcare nurses’ experiences with motivational interviewing in health promotion practice. Journal of Clinical Nursing, 20(23-24), 3322-3330.
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Cruess, D. G., Localio, A. R., Platt, A. B., Brensinger, C. M., Christie, J. D., Gross, R., …, Kimmel, S. E. (2010). Patient attitudinal and behavioral factors associated with warfarin non-adherence at outpatient anticoagulation clinics. International Journal of Behavioral Medicine, 17(1), 33-42. Cummings, S. M., Cooper, R. L., & Cassie, K. M. (2009). Motivational interviewing to affect behavioral change in older adults. Research on Social Work Practice, 19(2), 195-204. Institute of Medicine. (2012). Living well with chronic illness: A call for public health action. Retrieved from http://iom.edu/~/media/ Files/Report Files/2012/ Living-Well-with-Chronic-Illness/livingwell_chronicillness_reportbrief.pdf Kääriäinen, M., Paukama, M., & Kyngäs, H. (2013). Adherence with health regimens of patients on warfarin therapy. Journal of Clinical Nursing, 22(1-2), 89-96. Kimmel, S. E., Chen, Z., Price, M., Parker, C. S., Metlay, J. P., Christie, J. D., ?, Gross, R. (2007). The influence of patient adherence on anticoagulation control with warfarin: Results from the International Normalized Ratio Adherence and Genetics (IN-RANGE) study. Archives of Internal Medicine, 167(3), 229-235. Kneeland, P. P., & Fang, M. C. (2010). Current issues in patient adherence and persistence: Focus on anticoagulants for the treatment and prevention of thromboembolism. Patient Preference and Adherence, 4, 51-60. Knight, K. M., McGowan, L., Dickens, C., & Bundy, C. (2006). A systematic review of motivational interviewing in physical health care settings. British Journal of Health Psychology, 11(Pt 2), 319-332. Kreman, R., Yates, B. C., Agrawal, S., Fiandt, K., Briner, W., & Shurmur, S. (2006). The effects of motivational interviewing on physiological outcomes. Applied Nursing Research, 19(3), 167-170. Kung, H. C., Hoyert, D. L., Xu, J., & Murphy, S. L. (2008). Deaths: Final data for 2005. National Vital Statistics Reports, 56(10), 1-120. Retrieved from http://www.cdc.gov/ nchs/data/nvsr/ nvsr56/nvsr56_10.pdf Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of Motivational Interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137-160. Martins, R. K., & McNeil, D. W. (2009). Review of Motivational Interviewing in promoting health behaviors. Clinical Psychology Review, 29(4), 283-293. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing (2nd ed.). New York, NY: Guilford. New England Healthcare Institute. (2009). Thinking outside the pillbox: A system-wide approach to improving patient medication adherence for chronic disease. Retrieved September 6, 2009, from http://www.nehi.net/writable/publication_files/file/pa_ issue_brief_final.pdf Olsen, S., Smith, S. S., Oei, T. P., & Douglas, J. (2012). Motivational interviewing (MINT) improves continuous positive airway pressure (CPAP) acceptance and adherence: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 80(1), 151-163. Riegel, B., Dickson, V. V., Hoke, L., McMahon, J. P., Reis, B. F., & Sayers, S. (2006). A motivational counseling approach to improving heart failure self-care: Mechanisms of effectiveness. Journal of Cardiovascular Nursing, 21(3), 232-241. Rollnick, S., Miller, W. R., & Butler, C. C. (2008) Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford. Sabate, E. (2003). Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization. Soria, R., Legido, A., Escolano, C., López Yeste, A., & Montoya, J. (2006). A randomised controlled trial of motivational interviewing for smoking cessation. British Journal of General Practice, 56(531), 768-774. Touchette, D. R., & Shapiro, N. L. (2008). Medication adherence, adherence, and persistence: Current status of behavioral and educational interventions to improve outcomes. Journal of Managed Care Pharmacy,14 (6), S2-S10. West, D. S., DiLillo, V., Bursac, Z., Gore, S. A., & Greene, P. G. (2007). Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care, 30(5), 1081-1087.
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