Every healthcare professional I know strives to get the most out of their limited time with clients, especially in today’s fast-paced health and behavioral health world. We may be tasked to conduct a quick client intake in an acute care setting, or swift assessment in the brief few minutes of a practitioner visit. These experiences can be challenging and stressful, manifesting as confrontations more than well-intended dialogues. Over recent years there has been considerable focus on the use of short term interventions to maximize verbal interactions with populations, as motivational interviewing (MI) or screening, brief intervention and referral to treatment (SBIRT). I’m a fan of both approaches, though have found that an overreliance on these templates highlights their limitations.
First and foremost, no single intervention works for every client. I’ve seen many an organization invest heavily in training staff on one intervention that is hoped will address, if not also fix every client issue; most unrealistic. Professionals can become frustrated when the approach doesn’t work, sometimes even blaming the client. It is vital to remember that there are a variety of alternative interventions and strategies that can be used.
Second, reliance on a template intervention can limit assessment of client self-determination. Professional standards, codes, and principles speak to respect for autonomy; where the client is as opposed to where the professional wants the client to be. This slippery slope is a challenge for the workforce, and easily gets reversed. We want so badly for the client to be in a better place, such as have a safe discharge plan or to experience less symptoms of depression or anxiety. In fact, our employers often mandate these outcomes. While well-intended, we end up deciding what we think is best for the client, instead of respecting the client’s wishes.
Third, template-based approaches can prompt clinicians to talk ‘at’ clients rather than ‘to’ them. We become so fixated on following the flow of questions for a particular approach, the ability to engage in critical thinking about the answer is forgotten. We stop listening after hearing what we think we need to hear. The popularity of electronic health record checklists for interviewing and assessing clients emphasizes this issue. A frustration ensues if more time is needed than allowed, or a response takes us off script. Intervening with human beings cannot always be relegated to a check list alone, or time limits.
As a result, I’m brought back to the power of interviewing strategies; ways to effectively communicate with clients about where they are at, what they expect or need in the moment and potentially longer term, and how you can best partner with the client to develop and achieve their most paramount goal(s).
The ABCs of Interviewing
One of my favorite TV shows, is New Amsterdam. Inspired by Bellevue hospital in New York City, this drama based on a true story, details the experience of Dr. Max Goodwin,the medical director at America's oldest public hospital. He strives to promote his own version of the Quadruple Aim; provide the best care, at the right cost or in some situations no cost, at the right time, with full engagement and enjoyment by all. Dr. Goodwin challenges his interprofessional team to practice with the optimism, commitment, and enthusiasm they had at the start of their careers, stopping at nothing to advocate for the best care the hospital’s target population can have. His first question to all is “how can I help”, whether patient, colleague, or person he meets on the street.
Following Dr. Goodwin’s lead, I developed, The ABCs of interviewing; five steps to consider as you interview and establish rapport with clients. These are valuable steps to employ, whether used during a single interaction, or multiple visits:
· Ask: Today’s practitioner is rushed, but starting where the client is can help to prioritize any effort. Remember, the client’s reality is different from our own, and we won’t know what that reality is unless we ask. Pull a Dr. Goodwin and inquire, What Matters to You?
· Be Mindful: We work amid the most diverse client populations and contexts to date.Be attuned to unique client circumstances, as age appropriate languageandcultural awareness. Be sensitive to gender identity and sexual orientation. Be mindful of not onlylanguage literacy (whether a client is proficient in a language), but also health literacy (whether a client understands their illness, prognosis, and treatment regime). I could go on and on, but you get the gist of it.
· Consider: I learned long ago that the type of question I ask yields the type of response I want (if not need). You want a yes or no reply, or require a short answer, then ask a closed-ended question such as, ‘are you’, ‘do you’, ‘where do you’, ‘can you’, ‘may I’, ‘will you’, or ‘would you’. When you prefer a more expanded reply, go with an open-ended question. Examples of these types of questions include ‘what’, ‘why’, ‘how’, ‘tell me about’, or ‘let’s discuss’.
· Dig Deeper:I get it, everyone is busy. We can be relieved when a client responds, ‘I don’t know’ to our well-intended query. Don’t always take a client’s answers at face value. Perhaps the client is embarrassed to share that more is happening, or doesn’t know how to convey the truth to us. Don’t accept ‘I don’t know’. How often have you thought, “hmmm…more is happening here, but I’m unsure what it is?” The client then leaves, only to be readmitted for the reason we never dug deeper to find. Listen to your clinical gut and try to delve further.
· Engage as possible: I’ve had colleagues share how frustrated they become with clients and their families who present as angry, or resistant in the moment. One of the first things I ask professionals, is if at any point in the process they asked those involved, ‘how are you doing?’. We can become so focused on wanting to move the client’s discharge planning or care process along, that we simply forget to do so. I know there are organizational expectations to achieve length of stay goals. Yet, decision-making can take time. Add the emotional layers which present during a client’s sudden illness, and facilitating coping for all involved becomes tougher. The support system may not have wrapped their head around the reality of their loved one’s diagnosis or prognosis, let alone be ready to make a decision about which homecare agency to use or nursing home to pursue?
Imagine your family member is hospitalized suddenly for a severe illness or unplanned surgery. A case manager approaches you to discuss the treatment process and discharge planning options. What would you expect of that communication process? My gut says at the least, you would want to hear, “Hello, how are you doing today?”
Learn more about the ABCs of Interviewing in my new book, The Social Determinants of Health: Case Management’s Next Frontier, published by HCPro. Publication is June 2019, and pre-orders start soon. Watch the Case Management store on the HCPro website for more details.
Until next time.......Stay Resilient,
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