Let’s Talk! Improving Communication Skills to - PowerPoint Presentation

1. Let’s Talk! Improving Communication Skills toEnhance Outcomes for Your Patients with Diabetes

2. Presenter DisclosureRelationships with Financial Sponsors[Presenter Name, Credentials][Affiliations]GRANTS/RESEARCH SUPPORT:SPEAKERS BUREAU/HONORARIA:CONSULTING FEES:OTHER:

3. The members of the scientific planning committee acknowledge that their participation was made possible by sponsorship funding from Guardians for Health and Boehringer Ingelheim Canada Ltd. The scientific planning committee was solely and fully responsible for developing all content and was involved at all stages of development to achieve scientific integrity, objectivity and balance. As such, the content does not necessarily reflect the opinion of Guardians for Health or Boehringer Ingelheim Canada.The content of these slides may contain information not reviewed by Health Canada. Boehringer Ingelheim Canada Ltd. benefits from the sale of products that may be discussed in this program.Disclaimer

4. Scientific Planning CommitteeMichael Vallis, PhD, R.Psych. (Chair)Associate Professor, Family MedicineAdjunct Professor, Department of Psychology and NeuroscienceDalhousie UniversityAffiliate Scientist, Nova Scotia HealthHalifax, NSKeith Thompson, MD, CCFP, FCFPFamily PhysicianAdjunct Community Based Faculty Research Eligible Clinical ProfessorDept. of Family MedicineWestern UniversityLondon, ONJeffrey Habert, MD, CCFP, FCFP Family PhysicianAssistant Professor, University of TorontoDepartment of Family and Community MedicineToronto, ONShelley Tuscherer, BSc PharmClinical Pharmacist Certified Diabetes EducatorSherwood Park Primary Care NetworkSherwood Park, AB

5. Having attended this learning activity, participants will be empowered to:Recognize the need to further optimize guideline-directed care of patients with type 2 diabetes;Integrate shared decision-making in clinical practice to optimize outcomes in primary care;Conduct effective conversations with peers and patients to recommend and educate on appropriate management strategies; andUse motivational communication strategies to promote peer and patient readiness to change.Learning Objectives

6. Program OverviewLet’s Talk End GoalImportance of guideline-directed care for optimal outcomes among patients with type 2 diabetes (T2D)About Guardians for HealthLet’s Talk PushbackIdentifying common patient and peer barriers in primary-care management of type 2 diabetes12Let’s Put it All into ActionExamples of conversations with patients and peers, using motivational communication strategies4Let’s Talk StrategyMotivational communication strategies to address patient and peer barriers and optimize care of T2D (and other chronic conditions)3

7. Let’s Talk End GoalOptimizing Patient Outcomes with Guideline-directed Therapy

8. Diabetes Canada’s ABCDES3 tool includes many potential therapies for cardiorenal protection in type 2 diabetes:AntihypertensivesLipid-lowering agentsRAAS inhibitorsStatinsASASGLT2 inhibitors / GLP1-RAsWhat Is Our Goal? Optimize Guideline-directed Therapy to Minimize Cardiorenal RiskA1C: glycated hemoglobin; ACEi: angiotensin-converting enzyme inhibitor; ACR: albumin-creatinine ratio; ARB: angiotensin II receptor blocker; BP: blood pressure; CVD: cardiovascular disease; ECG: electrocardiogram;GLP1-RAs: glucagon-like peptide-1 receptor agonists; LDL-C: low-density lipoprotein cholesterol; RAAS: renin-angiotensin-aldosterone system; SGLT2: sodium-glucose cotransporter-2https://www.diabetes.ca/managing-my-diabetes/tools---resources/abcdes-of-diabetes-care-quick-reference-guideGUIDELINES TARGET (or personalized goal)AA1C targetsA1C ≤7%If on insulin or insulin secretagogue, assess for hypoglycemia and ensure driving safetyBBP targetsBP <130/80 mmHgIf on treatment, assess for risk of fallsCCholesterol targetsLDL-C <2.0 mmol/LDDrugs for CVD risk reductionACEi/ARB (if CVD, age ≥55 with risk factors, OR diabetes complications)Statin (if CVD, age ≥40 for Type 2, OR diabetes complications)ASA (if CVD)SLGT2i/GLP1-RA with demonstrated CV benefit (if have type 2 DM with CVD and A1C not at target)EExercise goals and healthy eating150 minutes of moderate to vigorous aerobic activity/week and resistance exercises 2-3 times/weekFollow healthy dietary pattern (i.e., Mediterranean diet, low glycemic index)SScreening for complicationsCardiac: ECG every 3-5 years if age >40 OR diabetes complications Foot: Monofilament/Vibration yearly or more if abnormalKidney: Test eGFR and ACR yearly, or more if abnormalRetinopathy: yearly dilated retinal examSSmoking cessationIf smoker: Ask permission to give advice, arrange therapy and provide supportSSelf-management, stress, other barriersSet personalized goals (see “individualized Goal Setting” panel) Assess for stress, mental health, and financial or other concerns that might be barriers to achieving goals

9. How Are We Doing? Lots of Room for ImprovementResearch suggests that <10% of people with type 2 diabetes and ASCVDreceive all treatments recommended by guidelines*1–4*ASCVD defined as coronary artery disease (including prior myocardial infarction or revascularization), cerebrovascular disease (including nonhemorrhagic stroke), peripheral arterial disease (including claudication, revascularization and amputation). ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; ASCVD: atherosclerotic cardiovascular disease; CKD: chronic kidney disease; GLP-1 RA: glucagon-like peptide–1 receptor agonist; SGLT2: sodium–glucose cotransporter-21. Nelson AJ, et al. J Am Heart Assoc. 2021; 10:e016835; 2. Bonora E, et al. Nutr Metab Cardiovasc Dis. 2020; 30(11):1945-53;3. Arnold SV, et al. Circulation. 2019; 140:618–20; 4. Ardissino M, et al. Circulation. 2019; 140:A14740.U.S. database study, 2018N=155,958 with T2D & ASCVDOnly 2.7% of people were receiving all three evidence-based therapies:High-intensity statinACE inhibitor or ARBSGLT2 inhibitor or GLP-1 receptor agonistThe problemNumber of evidence-based therapies

10. The problem<10% of patients with type 2 diabetes and cardiovascular disease receive the full set of treatments* recommended by guidelines1,2 contributing to high rates of morbidity and mortality1.Ardissino M, et al. Circulation. 2019;140:A14740.11; 2. Arnold SV, et al. Circulation. 2019;140:618–620.Guardians for Health Why, What, and How?Our visionStop early mortality, by reducing cardiovascular and kidney complications in people with type 2 diabetesOur missionEnsure guideline implementation and empower clinicians and people living withtype 2 diabetes to engage in shared, evidence-based decision-making

11. Global Multi-partnership InitiativeGuardians for Health 3-Pillar ApproachTowards Better Patient OutcomesFacilitating guideline implementation and shared decision-makingIMPACT on Clinical Practice and Patient OutcomesQUALITY IMPROVEMENTMedical education and continuous quality improvementCOMMUNITY OF IMPLEMENTERSIndividuals and OrganizationsPRACTICAL TOOLSFor clinicians and patientsThe mission

12. Guardians for Health 3-Pillar ApproachTowards Better Patient OutcomesFacilitating guideline implementation and shared decision-makingVisit Guardians for Health’s website:www.guardiansforhealth.ca Access to free quick-reference materials and education for both clinicians AND patients

13. Guardians for Health: Practical Tools for HCPs and Their PatientsFree Access at www.guardiansforhealth.caDiabetes Canada GuidelineQuick-reference Pocket CardPatient Record BookletAvailable in digitalor printableSAD MANS tear sheetsWith information forHCPs and tear sheetsfor patientsOffice Wall PosterEmphasizing risk factorsand complications of diabetesYou / your team can use these tools to help ensure consistency in the care of people with diabetes

14. These medical education options and others are available on the GUARDIANS FOR HEALTH website:guardiansforhealth.ca Quality ImprovementMedical Education to Support Evidence-based DecisionsShort videos and animationsLinks to guidelines & other resources for HCPsDiabetes Canada GuidelineQuick-reference Pocket Card

15. Guardians for Health 3-Pillar ApproachTowards Better Patient OutcomesFacilitating guideline implementation and shared decision-makingToday, we will discuss communication skills, as part of Guardians for Health’s commitment to quality improvement

16. Let’s Talk Pushback Patient and HCP barriers to guideline-based care in diabetesHCP: healthcare professional

17. What Can Trigger Patient Pushback to Guideline-based Care?Adapted from McCoy MA, et al. Int J Nurs Sci. 2019; 6(4):468-77; Pereira MD, et al. Int J Nurs Pract. 2019; 25(5):e12768; and Kalra S, et al. Diabetes Ther. 2020; 11(3):585-606.

18. Now that my sugar is controlled,can I stop a pill or two?My blood pressure is fine, so why add a BP med?My cholesterol is fine, so why add a cholesterol med?During my last visit, you said my sugars were "GREAT", and now you are telling me I should add a medication to protect my heart and kidneys?!Can we wait before we start a new medication? I just need to stop cheating so much…Common Patient Pushback ScenariosDisease & Treatment Acceptance

19. Why do I need a statin? I heard they are dangerous. Don’t they cause dementia?I’m not sure this is the best thing to do. I remember a terrible reaction I had to another medication. I don’t want that to happen again! Do I really need to keep increasing my dose of insulin? Aren’t my numbers good enough?Common Patient Pushback ScenariosTreatment AcceptanceI won’t take a needle.

20. Why can't I control my sugar through diet only?If I start taking this medication, which one can I stop taking?Why test my sugars? I can feel when they are too high.If I lose a lot of weight, will I be able to get off my meds?Common Patient Pushback ScenariosTreatment Acceptance and Readiness for Self-management

21. Let’s Talk About Motivational InterviewingMotivational Communication Strategies Presented by: Michael Vallis, PhD, R.Psych. Associate Professor, Family MedicineAdjunct Professor, Department of Psychology and NeuroscienceDalhousie UniversityAffiliate Scientist, Nova Scotia HealthHalifax, NS

22. Simple steps to support our colleguesIncorporate the basics of motivational interviewingFrom “Yes…but” to “Yes”Ask permission to provide your ideas on solutionsAsk the person what their thoughts are on possible solutionsAsk permission to work together to better understand and consider strategiesAcknowledge, empathise and normalize the responseAdapted from Levounis P (ed.). Motivational Interviewing for clinical practice. 2017, American Psychiatric Association Publishing.

23. From ThereTo HereHCP:The Expert: Diagnose, Implement Treatment, Measure OutcomeNo time to counselPerson with diabetes:No one wants to be sickHealthy behaviour is ABNORMAL behaviourHCP:Shared decision making between HCP and person living with diabetesPrompt behaviour change within scope of practicePerson with diabetes:Behavioural activation using values-based goalsDisease acceptance, treatment acceptance, readiness to adhereHCP: healthcare professional

24. COMMUNICATETO NEGOTIATE

25. Motivational communication frameworkSummarizeInformListenInviteAskVallis M, et al. Public Health. 2018;154:70-78.

26. Think about how you might use this when discussing intensification strategiesto achieve targets with your patients.Motivational communication frameworkVallis M, et al. Public Health. 2018;154:70-78.AskMotivational communication!Ask questions, minimize statementsExpress empathyBe curious, non-judgementalExpect resistance

27. The pushback It’s not the end, it’s the beginningIt’s normal for people to push back Motivational communication frameworkListenVallis M, et al. Public Health. 2018;154:70-78.

28. Acknowledgee.g.,“...thank you for letting me know your concerns/feelings”ReflectBased on your assessment respond in a way that lets the person know that you have heard themThe art of this is to be non-threateningYou know you have been successful when the person responds in a calm manner (e.g., “yes, that is exactly it”)SummarizeMotivational communication frameworkVallis M, et al. Public Health. 2018;154:70-78.

29. Ask permission to move toward changeNow that we understand your experience, could I share...?Given the importance of what you have said, are there any reasons for you to change?Do you think it would make any difference to you if we were to overcome this barrier?Now that we have addressed your fears and barriers, what would be the next feasible step for you?InviteMotivational communication frameworkVallis M, et al. Public Health. 2018;154:70-78.

30. Ask permission to educateIf it’s okay, I’d like to share with you the reasons why changing your routine/pathway is a good option? Try to organize your comments in an efficient manner that is likely to be received as unbiased, evidence-based information InformMotivational communication frameworkVallis M, et al. Public Health. 2018;154:70-78.

31. Understanding a person’s attitudes helps us understand their readinessReadiness can be seen as a state not a traitReadiness is the starting point not the endAssessing readinessEmpathyexpressionActioncommitmentValuesaction

32. Motivational communication frameworkSummarizeInformListenInviteAskVallis M, et al. Public Health. 2018;154:70-78.

33. Let’s Put it into Action!Examples of Communication Techniquesto Help Enhance Readiness to Change –for Colleagues and Patients

34. You told me on my last visit that my sugars were "GREAT", and now you are telling me I should add a medication to protect my heart and kidneys???I’d like to suggest that you start a medication called an SGLT2 inhibitor, which will help protect your heart and kidneys and also help lower your blood sugar.SGLT2: sodium-glucose cotransporter-2

35. I really don’t want to be adding more medications. I was actually hoping that we could stop one because my sugars were so good.It sounds like maybe you have some questions or concerns about this new medication. Can you tell me a little more about that?

36. Yes, that’s right. Thank you for letting me know your concerns. I understand that adding another medication is the opposite of what you were hoping for.

37. Hmm… I guess. I am always worried about side effects. Plus, it just makes me feel like I’m sicker if I have to keep adding pills. I don’t really feel sick at all, and it’s upsetting to think that I am.Can you let me know what it is about adding a medication that you don’t like?

38. Well, I guess you think that it will help somehow or else you wouldn’t be suggesting it. You said something about the heart and kidneys?Thank you very much for that. This all makes total sense to me. Can you think of any good reasons for you to make the change I’m recommending?

39. Okay.That’s right. Do you mind if I share a little bit about how this medication works, what it can do and why I think it’s a good idea?

40. Recognize that there are barriers to implementing guideline-based care,but it is worth the effort to overcome these barriersRemember that being not ready for change is perfectly acceptable; the key is to not give upTry to incorporate the elements of motivational interviewing into everydaydiscussions with patients and/or peers: Ask, Listen, Summarize, Invite, Inform1Conclusions: 3 Practical Tips You Can Take Back to Your PracticeHighlighting key actionable pearls from the program1231. Vallis M, et al. Public Health. 2018;154:70-78.

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