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Motivational Interviewing as Case Management Intervention • Part I of II

By Brendali F. Reis, PhD ; Victoria Vaughan Dickson, PhD, CRNP; and Barbara Riegel, DNSc, RN, CS, FAAN, FAHA

Patients with chronic diseases such as diabetes, heart failure (HF) or high blood pressure, present an ongoing challenge in the outpatient and
home arenas. Ideally, with help and support these patients will be motivated to develop self-care habits that optimize their level of health and
reduce the number of hospitalizations or other acute crises.

Self-care is the cornerstone of therapy for many persons with sense of discomfort within patients due to the newly perceived
chronic conditions. It is an active cognitive process in which persons discrepancies between their larger goals and their current behaviors,
engage for the purpose of maintaining their health or managing their ultimately fostering greater motivation for change.
disease and illness1. Self-care encompasses maintenance or adherence MI is particularly suited to enhance self-care because it addresses
strategies such as special diets, medication regimens and symptom both the patient’s readiness to take action as well as how confident
monitoring (e.g., weight monitoring for individuals with HF or glucose he/she feels about being successful. This aspect of confidence – one’s
testing for those with diabetes). Self-care management builds on such belief regarding how successful one can be at a planned action – is a
maintenance practices with symptom identification and action in fundamental yet often overlooked component of motivation for change.
relation to that symptom (e.g., take an extra diuretic, insulin, etc.) and This approach also provides a framework for collaboratively
evaluation of treatment effectiveness. negotiating a change plan without taking over or undermining the
Pharmaceutical and clinical interventions allow patients to remain patient’s autonomy. It takes into account the patient’s lived experience
in more stable health today than once was the case, and it is more
important than ever for patients to engage in self-care. This presents
a challenge for healthcare professionals, however, as motivation for
patients to become active managers of their own health is frequently a Naturalistic Decision Making
problem. On a daily basis, individuals have to make decisions about the
food they will eat, whether to take medication, and whether to engage
in healthy behaviors. These choices are often tied to life-long habits, so
change is difficult – even when faced with a chronic disease diagnosis.
Person Environment
WHY A MOTIVATIONAL INTERVENTION?
Motivational Interviewing (MI) is a clinical tool that has been
developed by psychologists in the fields of substance abuse counseling
and health psychology and that utilizes a different approach to
counseling and education. Historically, nurses have been trained to
engage in problem solving, teaching, and direct care to help their PROBLEM
patients, sometimes referred to as “fixing, telling and doing.” Teaching
is effective for people who perceive a need to know or want to change,
but motivating is needed for those who do not see the importance of
change, have no confidence that they can effect change, or both.2
Studies have shown that a motivational intervention based on
MI can significantly improve a patient’s health maintenance,
management, and confidence in his or her self-care ability.3 MI is a
Decision Influences
client-centered approach based on the humanistic premise that Knowledge
individuals, provided with a supportive, non-judgmental atmosphere,
will come to resolution for their problems. According to humanistic Experience
counselors, the three essential conditions to facilitate change are Skill
empathy (careful listening), warmth, and genuineness.4 Thus, MI is
collaborative and non-confrontational. Rather than seeking to educate Compatibility with Values
about solutions, MI seeks to evoke solutions from the patient himself/
herself. Rather than demonstrating the provider’s authority, MI affirms
the patient’s autonomy to make informed choices. (See Figure A)
Through a solid rapport based on empathetic listening, the MI
counselor seeks to enhance the client’s intrinsic motivation to change,
primarily “by exploring and resolving [the patient’s] ambivalence” Decision Making About Self-Care
about change2. Ambivalence is gradually resolved as patients start to
see the discrepancies between their life goals and values, and their
current behaviors. Realizing and internalizing this opposition causes a
FIGURE A

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of the problem, past successes and failures at changing, and supports.

Once motivation is enhanced (i.e., the patient establishes the
General Strategy
importance of change and feels confident that he or she can affect it),
skills and knowledge level can then be improved if needed. At this point
in the process, the clinician’s expertise on the problem at hand – heart
disease, for example, and its effective management – is reflected in his
Establish Rapport
or her ability to elicit a range of possible courses of action, rather than
in his ability to prescribe to the patient any one in particular, or
engaging in “fixing, telling and doing.”
What is most innovative in an MI-based approach compared to
traditional self-care management is the acceptance that
• knowledge of the risks associated with poor self-care does not, Set Agenda
by itself, automatically create motivation for change,

EXCHANGE INFORMATION
• ambivalence about change is normal and affects all of us, and

REDUCE RESISTANCE
• change is not an all-or-nothing or a linear process; people present at
different stages in the change process, and setbacks are to be expected.
Most important, this approach restores the patient’s autonomy, Assess Importance
placing back on him or her the choice and responsibility for change. & Confidence
The overall strategy is outlined in Figure B.5

MECHANISMS OF EFFECTIVE MOTIVATIONAL INTERVENTION

In promoting self-care using a motivational approach, several
mechanisms are critical for success: effective communication, effective Explore Build
cultural integration, and effective hospital-to-home transition. Importance Confidence

Ambivalence is gradually resolved as patients

start to see the discrepancies between their life
Negotiate Plan of Action
goals and values, and their current behaviors.

Effective Communication Source: Rollnick, Mason & Butler (1999)5

The key elements of effective communication are the expression
of empathy and the ability to not oppose “resistance,” but to “roll with
it” – analogous to the way a judo master uses an opponent’s attack to
his/her own advantage2. Reflective listening and open-ended
questions, both fundamental tools in any effective counseling, are the
primary techniques used by MI providers to ensure empathic and
non-frictional communication. Reflective statements can range from
a simple restatement of the whole or a part of what the patient has said,
a restatement emphasizing the feelings accompanying it, to what is
called a “double sided reflection.” The latter is particularly effective
in clarifying ambivalence. For example:
• “So you don’t like exercising.”
• “You are discouraged by all this…”
• “On the one hand you’d love to be the energetic, productive person
you’ve always been and on the other hand you don’t want to spend
time exercising, shopping for fresh food, cooking….”
Even “wrong” or “inaccurate” reflective statements can be of great
value, as they lead to a strong desire on the part of the patient to
FIGURE B
“correct” the counselor, in the process further elaborating on the
problem or on the solution. Reflective statements are deceptively
simple to use, their use is highly learnable, and they have a high pay off.
Cultural Integration
Because sustaining self-care relies on decisions and changes that
take place in the context of a patient’s natural environment, it is critical
for a case manager to acknowledge the patient’s cultural beliefs. From
the provider’s perspective, these culturally-laden views and practices
may represent barriers and constraints to effective self-care. However,
the only place from where to start the movement toward lasting change
is, not surprisingly, where the patient stands. It is not the provider’s
“correcting” of the patient’s views that will help he/she to see the
problem in a new light, but rather the provider’s genuine, empathic
curiosity about what at first may appear to be a barrier. “Correction”
attempts typically lead to the patient’s further entrenchment in a
“resistant,” “non-compliant,” or “difficult” position.6

continued on page 12
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Motivational Interviewing as Case Management Intervention (continued from page 11)
In contrast, collaborative and non-judgmental clarification of
all that is at stake for patients regarding their self-care invariably
uncovers larger goals and values. At least some of these are, at the
end of the day, typically consistent with good self-care practices.
This provides patients with the opportunity to reach new vistas,
personal compromises, and eventually a well-negotiated change plan
that feels comfortable within the logic of their own worldview.
While authentic curiosity about the client’s perspectives is a crucial
aspect of any culturally sensitive counseling, MI’s emphasis on empathic
listening and collaboration makes it particularly useful in cross-cultural
communications. Unacknowledged and unaccepted cultural differences
between the provider and patient typically hinder providers’ capacity to
maintain a non-judgmental, curious, and genuinely open-minded
helping stance, with cultural clashes ultimately dooming the effort to
failure. It is better to “agree to disagree” than to ignore cultural or
perceptual differences, or worse, to try to correct or sanitize the patient’s
perspective in order to make it more congruent with the provider’s.
Acceptance with careful listening tends to disarm a patient’s reluctance
to entertain new possibilities and leads to collaboration.
Bridging the Transition from Hospital to Home
When a patient is hospitalized during the course of a diagnosis
or the progression of a chronic disease, case managers typically
facilitate the transition back home. Key elements of this transition
include providing information – regarding the disease, the
discharge instructions and follow-up care. Critical to the patient’s
success at long-term management of the disease will be the skills he
or she can build related to self-care and the activation of support
resources on the patient’s behalf.
Part 2 of this article will be featured in the Spring issue and will
present “A Motivational Intervention Primer.” This explores additional
conditions of brief counseling that have also been empirically
demonstrated to lead to change.
Brendali F. Reis, PhD, is Associate Faculty at the Institute for Graduate
Clinical Psychology at Widener University in Chester, PA. She earned her
Recovery Audit Contractor as Experienced by One California Hospital (continued from page 9)
relationships with other departments in the organization have become
prerequisite for managing payer changes, such as the RACs.
Dixie Eisenhauer
Eisenhauer, BSN, MSN, is Director of Social Services at Community
Hospital of the Monterey Peninsula in Monterey, CA, a position she has held
for ten years. She earned her BSN at the University of California at San
Francisco and her MSN at San Jose University in San Jose, CA. She has 34
years of experience in healthcare, and expertise in critical care, discharge
planning and utilization review.
ENDNOTES
1 Centers for Medicare and Medicaid Services. Recovery Audit Contractor:
Overview. March 10, 2008. http://www.cms.hhs.gov/RAC/
2 Centers for Medicare and Medicaid Services. Recovery Audit Contractor:
Expansion Strategy. March 10, 2008. http://www.cms.hhs.gov/RAC/10_
ExpansionStrategy.asp
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BA and Master’s in Psychology at the Federal University of Rio Grande
do Sul, Brazil, and her PhD at the California School of Professional
Psychology in Fresno, CA. Before joining the faculty at Widener University,
she was on the research faculty of the University of Pennsylvania and was
part of the Motivational Interviewing Network of Trainers (MINT).
Victoria Vaughan Dickson, PhD, CRNP, is Adjunct Assistant Professor at
the University of Pennsylvania School of Nursing in Philadelphia, PA.
She earned her BSN in Nursing at Temple University in Philadelphia, PA,
and her MSN and PhD in Nursing at University of Pennsylvania.
Dr. Dickson is an adult nurse practitioner with more than 20 years in
primary care and employee health experience.
Barbara Riegel, DNSc, RN, FAAN, FAHA is Professor at University
of Pennsylvania School of Nursing. She has been on the faculty
at the University of Pennsylvania for six years. She earned her BS in
Nursing from San Diego State University and her MN and DNSc from
the University of California, Los Angeles. During her 30-year nursing
career, she has had experience as a cardiovascular clinical nurse
specialist, case managing many cardiac patients with both stable
and acute cardiac illnesses.
ENDNOTES
1 Riegel, B., Carlson, B., Moser, D., Sebern, M., Hicks, F., & Roland, V. (2004).
Psychometric Testing of the Self-care of Heart Failure Index.
Journal of Cardiac Failure, 10(4), 350-360.
2 Miller, W., & Rollnick, S. (2002). Motivational Interviewing: Preparing People for
Change. (2nd ed.). New York: Guilford.
3 Riegel, B., Dickson, V., Hoke, L., McMahon, J., Reis, B., & Sayers, S. (2006). “A
Motivational Counseling Approach to Improving Heart Failure Self-care:
Mechanisms of Effectiveness.” Journal of Cardiovascular Nursing
Nursing, 21(3), 232-241.
4 Rogers, C. R. (1959). A Theory of Therapy, Personality, and Interpersonal
Relationships as Developed in the Client-Centered Framework.
In S. Koch (Ed.), Psychology: The Study of a Science: Vol. 3, Formulations of the
Person and the Social Contexts (pp.184 - 256). New York: McGraw Hill.
5 Rollnick, S., Mason, P., & Butler, C. (1999). Health Behavior Change: a Guide for
Practitioners. London: Churchill Livingstone.
6 Miller, W. R., Benefield, R. G., & Tonigan, J. G. (1993). “Enhancing Motivation for
Change in Problem Drinking: A Controlled Comparison of Two Therapist Styles.”
Psychology, 61, 455–461.
Journal of Consulting and Clinical Psychology
3 The RAC Demonstration has raised several questions and concerns regarding
the RAC methodology. Based on the experience of the demonstration program,
CMS is considering significant improvements for the permanent RAC program.
These include limiting the number of years past that RACs may audit records,
and increasing monitoring and oversight.
4 Centers for Medicare and Medicaid Services. RAC Expansion Schedule. March
10, 2008. http://www.cms.hhs.gov/RAC/Downloads/RAC%20Expansion%20
Schedule%20Web.pdf
5 Centers for Medicare and Medicaid Services, Office of Public Affairs. Press
Release (March 28, 2005): Demonstration to Work Toward Assuring Accurate
Medicare Payments – Tests Ability of Recovery Audit Contractors to Track Over
and Under Payments. March 10, 2008. http://www.cms.hhs.gov/apps/media/
press/release.asp?Counter=1405
6 Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual,
Chapter 1 – Inpatient Hospital Services Covered Under Part A. (Page 6-7).
March 10, 2008. http://www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf