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Motivational Interviewing: The Right Questions Help Drive Behavior Change

Editor's Update: This article was first published June 24, 2018. It was most recently reviewed and updated November 14, 2022.

Mark D. Valenti, Highmark Health director of operational excellence and continuous quality improvement, who led the creation of the Enhanced Community Care Management program.

Mark D. Valenti, Highmark Health director of operational excellence and continuous quality improvement, who led the creation of the Enhanced Community Care Management program.

From health decisions to job performance, external rewards and punishments alone seldom drive us to achieve our full potential. We must also tap intrinsic motivation — the values we have and things we do regardless of outside pressure or influence.

Helping people get in touch with, and act on, intrinsic motivation is central to the work of Mark D. Valenti, director of operational excellence and continuous quality improvement at Highmark Health. In addition to seminars and training throughout the organization, Valenti had a leading role in creating the Enhanced Community Care Management (ECCM) program. The first iteration of ECCM embedded specially trained nurses in doctors’ offices to work directly with patients on managing challenging, complex health issues. The program has since evolved to support people with progressive disease, including during palliative care. What has remained consistent is a collaborative, patient-centered behavioral approach that’s about understanding what matters to an individual and then supporting them in setting and achieving goals.

“I have a strong drive toward mastery, and toward purpose,” Valenti says of his own intrinsic motivation. “For me, it’s always been about activating other people to be the best that they can be.”

His first work experience combining communication, health and behavior change came with the Alcoholism and Family Interaction Initiative at the Western Psychiatric Institute and Clinic in 1994. He went on to positions involving autism research, treatment of bipolar depression, being an office director or manager with family medicine and internal medicine practices, grant program work with the Jewish Healthcare Foundation and Pittsburgh Regional Health Initiative, and coaching parole officers on guiding behavior change in people under their supervision.

Valenti has appeared twice on Mark Graban’s LeanBlog podcast to discuss Motivational Interviewing, a technique he has taught in multiple contexts, including patient care. Take a listen to the 2018 podcast below, or check out this 2020 episode on Motivational Interviewing and masking with Valenti and Brittany Wilson, Highmark Health manager of training, education & workflow integration. Then enjoy additional insights in a conversation with Mark and strategic communications advisor Nikki Buccina.

Joining Highmark Health and the birth of ECCM

Don Bertschman: There’s a strong sense of purpose through all your work in different environments. What made Highmark Health an attractive choice relative to that purpose?

Mark D. Valenti: What makes me happy here, and makes me feel activated, is the mission. I know that sounds like a publicity comment, but in some organizations I had to sell the ideas of community health, and patient-centered care, and the behavior change work I do. Here, people had already bought in to the fundamentals. When I look at what we’re doing in our communities, it’s easy to feel that this organization believes in the values I do.

Many leaders underestimate what it takes to train someone. My department, with Jo Clark as vice president of Value-Based Care, and up to Dr. Tony Farah as chief medical and clinical transformation officer, tells me to not only do the trainings but also get out in the field with nurses and other health professionals, because there’s a recognition that training and development are the key. I’ve never worked in an organization that embraced learning and development so much. There’s a fear in most places that training takes people away from their core work. But training really has to be viewed as part of the core work they do. I’m lucky to have leadership that sees that and acts on it.

Don Bertschman: There’s much to talk about with the Enhanced Community Care Management (ECCM) program — can you give us a high-level overview of how that started?

Mark D. Valenti: As background, about 4 in 10 adults in the U.S. have two or more chronic health conditions. This isn’t just diabetes and breathing disorders and congestive heart failure, it’s often things like anxiety and depression. The overlapping conditions are often exacerbated by choices like smoking or unhealthy eating, or environmental factors like lacking access to transportation. Sometimes these people are referred to as “complex care patients” — there are complex challenges, and also much higher costs, when it comes to managing their health.

Traditionally, the U.S. health care system isn’t great at helping these people. There tends to be a check-the-box mentality. Give the patient the after-visit summary — check. Provide instructions for medications — check. These are important protocols, but no one necessarily asks what the patient thinks about their treatment, what they’re doing day to day, what’s causing them to smoke or struggle with their diet, what their fears and values are, what they want for themselves. As a result, people feel disengaged from the health care system, they don’t go to their doctors or they’re afraid to tell a doctor about alcohol use or other issues, and many chronic conditions that could be addressed effectively early just keep getting worse.

With the initial ECCM program, we proactively reached out to the top 5% of the most complex cases. We embedded specially trained nurses in primary care offices who talked to the patients we identified, take the time to get to know them, and work on health goals tied to the patient’s intrinsic motivations. So many patients would tell us, “no one ever asked me before about what I want to do about my health.” Because we do ask, we get better results.

Nikki Buccina: You were tasked with starting ECCM — could you talk more about the initial motivating factors for the organization?

Mark D. Valenti: I joined Highmark Health as part of the Strategy and Transformation team, and complex care was one of several initiatives within the organization’s long-term strategy. At the time, we were looking at about 2,300 insured patients who had total costs of about $25 million, so the challenge was, how can we better help those patients and control costs? Dr. Sam Reynolds, then the chief quality officer at Allegheny Health Network (AHN), proposed creating a pilot program internally. He knew my experience, because I had worked with him on a project called the COMPASS Initiative, which had some overlaps with what we do now.

ECCM started officially in September 2016, and until June of 2017 it was part of AHN. Our initial success with seven nurses led to moving the program under Highmark Health and getting Jo Clark and others involved. She has been fully behind it and we’ve continued expanding and evolving.

Part of what makes us unique is that we incorporate motivational interviewing to understand and pull on a person’s intrinsic motivation — and that’s not just how we treat patients, it’s how we interact with other health care professionals.

Motivational Interviewing

A man looking at his mobile phone while driving

Don Bertschman: Tell us more about motivational interviewing, and why that’s central to your work.

Mark D. Valenti: Motivational interviewing goes back to the 1980s with Bill Miller, a psychologist, in the area of helping people with alcoholism and unhealthy substance use. At the time, someone suffering from alcoholism often got labeled as “in denial” and not wanting to change. Miller’s focus was on listening to understand each person’s fears and values — because they weren’t just a label. He developed an approach based on the idea that before we start trying to “fix” somebody, we should find out who they are as a person.

With ECCM, we not only have classroom trainings on motivational interviewing and activating the patient, I also spend time in the field with nurses and health professionals. And I use the same approach — it’s not “you did this wrong, do this differently,” it’s asking someone to tell me about the patient, understanding the goals and what the patient wants, and then looking at how to get to that point. Our ECCM staff report very high job satisfaction. And research shows that patients that are activated and believe they are part of their care have better outcomes — from following through on preventive measures and proper use of medications all the way up to reducing hospital readmissions.

Don Bertschman: Could you give an example of how that plays out in an interaction?

Mark D. Valenti: We had a patient, older, struggling with unhealthy substance use over many years, which caused some health conditions and he wound up in the hospital. When the doctor talked to our ECCM nurse, he labeled the person a “user” who didn’t want to change. The nurse reported that the patient told her he really wanted to make changes, which the doctor sort of dismissed as just something a “user” says. But we work from the belief that people do want to change.

I sat in on one of the nurse’s calls with this patient. Often, I don’t talk during these interactions, but I might type out a suggestion and show it to the nurse. I suggested she ask this patient simply, “What do you want for yourself?” That got him talking about how he wanted to change and also talk with younger people about the dangers of unhealthy substance use. So I suggested that the nurse ask, “What would you tell them?” And he started talking about that. He also became very emotional and told the nurse that she was a godsend because he could tell that she believed in what she did and that she actually cared about him.

Ok, that’s the engagement part of motivational interviewing, which is extremely important, but it’s only the first step. What makes this more than just great patient focus is that it’s directed toward changing behavior. So after the patient talked about what he would tell other people, the next part of the strategy was to ask how that related to him and what he could do for himself. Our approach is about focusing the conversation and activating the patient — what are your goals, what do you want to do for yourself, and then how we can support you with those goals?

Nikki Buccina: Do you feel like when you or the nurses talk with people, they’ve been craving someone to ask these questions, or is it more often that someone hasn’t thought about the change they need to make?

Mark D. Valenti: Great question. Behavior change occurs when two components are present. A person must find a change important — and be confident that they can do it. What I have found over many years is that 99% of people have thought about and placed importance on a change; it’s confidence that’s the issue. Our health care system gets so focused on telling a patient they need to lose weight, for instance — they’re trying to sell the patient on something they already believe, and not listening to learn what would best help the patient act on and achieve their goal.

The Distracted Driver Parable

Mark D. Valenti: Here’s an example I use to illustrate that shift in how we listen. This is about paying attention to my verbalizing and hearing that I want to make changes.

So, I pull out my phone and say, “I know that texting and driving can be dangerous, but I only look down for a few seconds if I’m on the road.” What might you say to that?

Don Bertschman: It only takes a few seconds to cause an accident, Mark.

Mark D. Valenti: That’s why I always stay five seconds behind the car in front of me if I need to check my phone.

Don Bertschman: Well, it’s not just timing, there are also motor skills that present a danger.

Mark D. Valenti: I’m careful. I have 155,000 miles on my car, and I haven’t been in an accident yet.

Don Bertschman: But that doesn’t mean — I think I’m using the wrong approach here.

Mark D. Valenti: Right! In motivational interviewing we talk about “change talk” and “sustain talk.” The idea is to listen, and ask questions, that help someone verbalize their reasons to change. In our interaction it became all about “sustain talk.” I leave feeling justified since I defended myself by verbalizing reasons I can sustain my behavior. I don’t feel engaged, because you were just correcting me and telling me what to do, so I may not come back for more conversation. Meanwhile, from your perspective, you’re thinking, “well, I gave him the information, he just doesn’t want to change.”

Now — the question is, did I say anything indicating that I had interest in changing?

Don Bertschman: The first thing you said was, “I know that texting and driving can be dangerous, but …” I seized on what came after the “but” instead of the “I know” part.

Mark D. Valenti: That’s what most people do. “I know that texting and driving can be dangerous” is change talk — which can be verbalizing a negative in the status quo of my behavior, and/or verbalizing a positive to making a change. The goal of motivational interviewing is to have me talk more about my change.

Maybe you respond with a reflective statement like, “So, you see the danger in texting while driving.” That might encourage me to say, “Yeah, you see these stories in the news all the time.” Now I’m verbalizing why the behavior should change instead of defending myself against you and coming up with reasons not to change. My behavior may not change immediately, but I’ve planted the seeds in my own mind, and I also feel heard.

This parallels what we see in medical encounters. Most providers focus on my deficits and what I’m not doing as a patient, as opposed to my strengths and the ways I’m already thinking about change. So, someone is overweight and a doctor warns them that puts them at risk of type 2 diabetes. The patient says, “I should drop a few pounds, but I’m young and diabetes effects old people.” The typical response is what we call a righting reflex — to correct the patient by saying diabetes can effect any age. Now the patient probably gets defensive, and we lose a chance to focus on “I should drop a few pounds.”

More Resources

Don Bertschman: Many copies of Daniel Pink’s book, Drive, have circulated here at Highmark Health. For someone interested in motivational interviewing, is that a good starting point? What other resources do you recommend?

Mark D. Valenti: Drive is a good starting point because it focuses on the components of someone who is intrinsically driven. It’d be great to combine that with Motivational Interviewing: Helping People Change, 3rd edition, which talks in detail about the skills and strategies. It is clinically based, but the concepts are pretty accessible. Be sure you get the 3rd edition, which has some important updates, like replacing the word “resistance” with two separate challenges — sustain talk and discord in a relationship — that need to be addressed differently.

If you’re a Highmark Health employee, Brittany Wilson has done a great Motivational Interviewing training series available through the myLearning portal.

There are also many books we embrace within ECCM. Two others I’ll mention are Emotional Intelligence 2.0 and The Speed of Trust, which breaks down trust into four quadrants. Traditionally, we think of trust revolving around integrity. This model says in addition to integrity and intent, trust depends on competencies. We may believe someone has good intentions and they’re a great person, but we don’t trust their competency in terms of capabilities or ability to follow through and get results.

Lean philosophy also influences our mindset, how we look at data, and the algorithms we’ve developed. What I like about Lean and continuous quality improvement methodology is that it’s very much about what frontline staff can use. Our ECCM philosophy is “every day closer to better” — everything we do is to get us one step closer to better. Everything that goes wrong is an opportunity to learn and understand something and make an improvement.

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Highmark Health and its subsidiaries and affiliates comprise a national blended health organization that employs more than 42,000 people and serves millions of Americans across the country.

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