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Directions Read through each Dialogue. Listen to each Dialogue’s audio example. Complete score sheet for each Dialogue. |
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Purpose This module requires that you apply the skill sets of Brief Motivational Interviewing (BMI). |
Overview: As noted in Module 1, BMI is an effective, time-saving tool to spend quality time with your patient to increase the chances of adherence and compliance through patient-centered dialogue. To be effective, the dialogue should generally follow this pattern. The skill set includes: Agenda-Setting Dialogue, Ask-Tell-Ask Dialogue, Closing- the- Loop Dialogue, Readiness- to- Change Dialogue, Goal-Setting Dialogue.
Dialogue 1. Agenda-Setting Dialogue
During the Agenda-Setting Dialogue, the provider asks questions to encourage the patient to set goals and focus on options to improve their health. Use a bubble chart to help patients understand options; for example: exercise, healthy eating, medication … and even a patient-defined option.
Read through the Dialogue:
Provider: Your hemoglobin A1c has gone up from 7.5 to 8.5.
Patient: That’s not good. It’s supposed to be under 7, right?
Provider: Would you like to spend a few minutes discussing what we might do?
Patient: OK.
Provider: Let me ask you this, do you have any idea how you might bring your HbA1c back down?
Patient: Well, probably the way I eat, doing exercise – and taking my pills – has a lot to do with it.
Provider: That’s right. We have a tool called the bubble chart that has some choices for improving your HbA1c. Is there anything on this chart you might like to focus on?
Patient: I think I’d like to talk about exercise.
Bubble Chart
Example of a typical bubble chart used as a visual tool to help patients understand the options for managing their condition.
Patients may either select from among the choices displayed or suggest their own alternatives.
Listen to Audio Example Dialogue 1:
After listening to the example, review guide/check sheet 1 to note if the provider successfully completed these steps.
| Step 1 Scoring Guide/Check Sheet | YES | NO |
| Use of bubble chart | ||
| Ball in client’s court |
Dialogue 2. Ask-Tell-Ask Dialogue
During the Ask-Tell-Ask Dialogue, the provider asks to see what the patient already knows, tells the patient the correct way to prevent complications, and has the patient repeat the concepts/information to help the patient remember key points.
Read through the Dialogue:
Provider: I just checked you blood sugar, and I have to tell you something very important. You have diabetes.
Patient: Diabetes? Oh, my God.
Provider: Do you know what diabetes is?
Patient: I know someone who had it. Her blood sugar went way up, and she went into a coma and died.
Provider: A coma is actually very rare in your kind of diabetes.
Patient: Another person I know had to get his toe cut off. He also had major trouble with his eyes.
Provider: Those things can happen in diabetes, but they can also be prevented. Tell me this: What would you like to know about diabetes?
Patient: I need to know how to keep my feet attached to my body, how not to get really sick like the other people I’ve known.
Provider: Do you have any idea what to do to prevent bad complications like amputations?
Patient: I’d say you lose weight, and there is probably some pill that can help.
Provider: Three things help prevent complications: improving your diet, exercising more, and taking medicines. Can you repeat that back to me so I know it’s clear?
Patient: Eat less, walk more, and take pills.
Provider: Good. Where do you want to start?
Listen to Audio Example Dialogue 2:
After listening to the example, review guide/check sheet 2 to note if the provider successfully completed these steps.
Step 2 Scoring Guide/Check Sheet
| YES | NO | ||
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| Provide health education in her/his preferred learning style | |||
| Use teach-back method |
Dialogue 3: Closing-the-Loop Dialogue
During the Closing-the-Loop Dialogue, the provider encourages the patient and uses the ‘teach-back’ method to check for understanding.
Read through the Dialogue:
Provider: Three things help prevent complications: improving your diet, exercising more, and taking medicines. Can you repeat that back to me so I know it’s clear?
Patient: Eat less, walk more, and take pills.
Provider: Good.
Listen to Audio Example 3 Dialogue:
After listening to the example, review guide/check sheet 3 to note if the provider successfully completed these steps.
| Step 3 Scoring Guide/Check Sheet | Yes | No |
| Ask: Readiness to move on |
Dialogue 4: Readiness-to-Change Dialogue
During the Readiness-to-Change Dialogue, the provider asks the patient how important change is on a 1-10 scale, one being not important and 10 being more important than anything else. Use this to discover how the patient is feeling in regard to their possible behavior change. Use this information to help them become more apt to change.
Read through the Dialogue:
Provider: I just got back your last HbA1c; it’s gone up to 8.5.
Patient: It’s supposed to be 7 or lower.
Provider: That’s right. What would you like to do about this?
Patient: I’m already on a diet, and I’m so busy I have no time for exercise. I don’t know what to do.
Provider: Could we talk a bit about the exercise?
Patient: Umm, yeah, OK.
Provider: How important is it to you to increase your exercise? Let’s do this on a scale of “1” to “10”. A “1” means it isn’t important, and “10” means it’s just about as important as it can get.
| 1 2 3 4 5 6 7 8 9 10 |
| NOT IMPORTANT MOST IMPORTANT |
Patient: It’s an “8”. I know I really need to do it.
| 1 2 3 4 5 6 7 8 9 10 |
| NOT SURE SURE |
Patient: It’s a “4”. Like I said; I have no time.
Provider: Why did you say “4” and not “1”?
Patient: I can exercise on the weekends, so it’s not something that is completely impossible.
Provider: What would it take to raise the confidence level of a “4” to an “8”?
Patient: Maybe if I could exercise with a friend, I’d enjoy it more, be more motivated. I have a friend at work that has diabetes too.
Provider: Do you want to set a short-term goal about your exercise? We could agree on an action plan.
Confidence ruler: a scale to help patients gauge their confidence in the changing process.
Listen to Audio Example Dialogue 4:
After listening to the example, review guide/check sheet 4 to note if the provider successfully completed these steps.
| Step 4 Scoring Guide/Check Sheet | Yes | No |
| Ask what they would like to do about the concern | ||
| Ask to rate Importance/Importance ruler – scale of 1-10 | ||
| If lower than 7: explain risks/benefits | ||
| Ask: how can it get higher | ||
| Ask to rate Confidence to change/Confidence ruler – scale of 1-10 | ||
| If lower than 7: explain risks/benefits | ||
| Ask: how can it get higher | ||
| Ask – ready to make an action plan/move on/set goal |
Dialogue 5: Goal-Setting Dialogue
During the Goal-Setting Dialogue, the provider encourages patient to set a goal. First, starting simply; then moving to be more specific: Ex. = Walk around the block two times when you feel stress.
Read through the Dialogue:
Provider: Your last lab test shows your HbA1c has gone up to 9.2. What do you think about that?
Patient: I don’t know. I’m taking my pills. I thought if I took them I didn’t have to worry about eating candy and sweets every day; the pills are supposed to protect me.
Provider: What is it you like about eating candy?
Patient: I love chocolate; it’s kind of comforting. I have all these things that stress me out, but I know that chocolate is one thing in my day I will definitely enjoy.
Provider: That makes sense. It there anything you don’t like about eating chocolate?
Patient: Well, it messes up that hemoglobin thing. But I don’t want to give it up. Like I said: It makes me happy.
Provider: Is there anything else you enjoy doing that helps reduce your stress but doesn’t get you HbA1c so high?
Patient: Maybe I could walk around the block a couple of times.
Provider: Do you want to give that a try?
Patient: Sure, but I’m not promising to give up chocolate.
Provider: I understand. Let’s do a reality check. How sure are you that you can walk around the block a couple of times when you feel stress? Let’s use a 1-to-10 scale: “1” means you aren’t sure you can succeed, and “10” means you are very sure you can succeed. How sure are you about this?
Patient: I can do it; I’m 100 percent sure.
Provider: Let’s try to make this as specific as possible. Rather than walking every time you feel stress, how about walking two times around the block every day after lunch?
Patient: Well, if I feel stress, that might be OK.
Provider: Why don’t we call it your action plan: You will walk around the block two times when you feel the stress coming on. When do you want to start?
Patient: We’ll see.
Provider: Do you want to start this week?
Patient: That might work.
Provider: OK. Why don’t we agree that you will walk around the block two times when you feel stress? Could I call you in a week to check up on how you are progressing?
Patient: Okay.
Listen to Audio Example Dialogue 5:
After listening to the example, review guide/check sheet 5 to note if the provider successfully completed these steps.
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Step 5 Scoring Guide/Check Sheet |
Yes | No |
| Set short-term goal | ||
| Check-in to see if goal is realistic | ||
| Rate percent they feel they can succeed (1-100%) | ||
| Turn into specific measureable objective | ||
| Set follow-up meeting |
CULMINATING EXERCISE FOR MODULE 3:
Listen to Audio Example Dialogue A or B.
After listening to the example, reviewFull Scoring guide/check sheet to note if the provider successfully completed these steps.
Full Audio A
Full Audio B
| Full Scoring Guide/Check Sheet | Yes | No |
| Use of bubble chart | ||
| Ball in client’s court | ||
| Ask specifically what the client wants to learn | ||
| Ask specifically how the client wants to learn | ||
| Provide health education in his/her preferred learning style | ||
| Use teach-back method | ||
| Ask: Readiness to move on | ||
| Ask what they would like to do about the concern | ||
| Ask to rate Importance/Importance ruler – scale of 1-10 | ||
| If lower than 7: explain risks/benefits | ||
| Ask: how can it get higher | ||
| Ask to rate Confidence to change/Confidence ruler – scale of 1-10 | ||
| If lower than 7: explain risks/benefits | ||
| Ask: how can it get higher | ||
| Ask – ready to make an action plan/move on/set goal | ||
| Set short-term goal | ||
| Check-in to see if goal is realistic | ||
| Rate percent they feel they can succeed (1-100%) | ||
| Turn into specific measureable objective | ||
| Set follow-up meeting |