Three Strategies for Implementing Motivational Interviewing on Medical Inpatient Units
Condition: See One; Do One; Order One
Study type: Interventional

Summary: 
      General medical hospitals provide care for a disproportionate share of patients who misuse
      substances. Motivational interviewing (MI) is a well-recognized, evidenced-based substance
      use treatment. However, it is unclear which implementation strategies lead to the efficient
      and proficient uptake of MI in general medical settings, such as medical inpatient units.
      Because medical providers have multiple practice demands and time constraints, new practices
      have the greatest chance of being implemented if they are simple and compatible with existing
      workflows and systems. Two widely used strategies to bring specialized practices into use
      within general hospital settings are the apprenticeship model of training and use of
      consultation-liaison (CL) services. The apprenticeship model requires that appropriate
      patients and trainers are available with high flexibility for teaching and supervision; when
      applied to behavioral counseling approaches, this model may be incompatible with the
      providers' medical role and time constraints. In contrast, ordering MI through CL is
      relatively simple, minimally burdensome, and highly compatible with the way clinicians secure
      other specialist services for their patients in the hospital. This cluster randomized
      controlled trial examines the effectiveness of three different strategies for integrating MI
      into the practice of medical providers working within an academically affiliated internal
      medicine hospitalist service. Specifically, the trial randomizes 38 healthcare providers to
      one of three conditions: (1) a continuing medical education workshop that provides background
      and "shows" healthcare providers how to conduct MI (the control condition, called SEE ONE);
      (2) a "see one, do one" apprenticeship model involving workshop training plus live
      supervision of bedside practice (DO ONE); and (3) ordering MI from CL after learning about it
      in a workshop (ORDER ONE). Following the respective MI trainings, each healthcare provider
      will be assessed for the provision of MI to 40 study-eligible inpatients, recruited by the
      research team after admission to our general medical units. Trial hypotheses are 1) the
      percentage of MI sessions delivered by providers to study-eligible inpatients will be higher
      in both Do One and Order One than See One, and 2) providers in both Do One and Order One will
      conduct MI sessions with greater integrity than those in See One. This study is an
      implementation trial examining provider, not patient, outcomes.
    

Detailed description: 
      General medical hospitals provide care for a disproportionate share of patients who abuse or
      are dependent upon substances. This group is among the most costly to treat and has the
      poorest medical and substance use outcomes. Motivational interviewing(MI) is a
      well-recognized, evidenced-based substance use treatment that has been adapted for use as a
      brief intervention in health care settings. MI is applicable to many health-related
      behavioral problems, and can be taught to a broad range of health care clinicians. However,
      it is unclear which implementation strategies will lead to the efficient and proficient
      uptake of MI in general medical settings, such as medical inpatient units.

      Primary care clinicians have multiple practice demands and time constraints. New practices
      have the greatest chance of being implemented if they are simple and compatible with existing
      workflows and systems. Two widely used strategies to bring specialized practices into use
      within general hospital settings are the "see one, do one" apprenticeship model of training
      and use of consultation-liaison (CL) services. "See one, do one" has been a modus operandi in
      medical education for centuries and relies upon a competency-based supervision training
      approach. While it has been empirically validated in the specialty addiction field, less
      controlled testing of this implementation strategy is available in general medical settings.
      The apprenticeship approach requires that appropriate patients and trainers are available
      with high flexibility for teaching and supervision; when applied to behavioral counseling
      approaches, this may be seen as incompatible with the medical role and time constraints of
      clinicians. In contrast, ordering MI through CL is a relatively simple, minimally burdensome
      process and highly compatible with the way clinicians secure other specialist services for
      their patients in the hospital.

      We propose to conduct a randomized controlled implementation trial using mixed quantitative
      and qualitative methods to examine the effectiveness of three different strategies for
      integrating MI into the practice of healthcare providers working within Yale New Haven
      Hospital's internal medicine hospitalist service and other general medical inpatient units.
      Specifically, we will randomize 40 healthcare providers to one of three conditions: (1) a
      continuing medical education workshop that provides background and "shows" healthcare
      providers how to conduct MI (the control condition, called SEE ONE); (2) a "see one, do one"
      apprenticeship model involving workshop training plus live supervision of bedside practice
      (DO ONE); and (3) ordering MI from CL after learning about it in a workshop (ORDER ONE).
      Following the respective MI trainings, each healthcare provider will be assessed for the
      provision of MI to 40 study-eligible inpatients, recruited by the research team after
      admission to our general medical units.We hypothesize that the percentage of MI sessions
      delivered by providers to study-eligible inpatients would be higher in both Do One and Order
      One than See One. We also hypothesize that providers in both Do One and Order One would
      conduct MI sessions with greater integrity (i.e., adherence to core components of MI and
      delivery of them with competence) than those in See One.

      Please note, as an implementation trial, the primary outcomes for this study focus on
      provider behaviors, namely, uptake of MI sessions with patients and the adherence and
      competence in which they conduct MI sessions. No outcome data will be collected and reported
      at the patient level.
    

Intervention name(s): See One; Do One; Order One
Intervention type(s): Behavioral; Behavioral; Behavioral
Intervention description(s): A 1-day workshop conducted by a member of the Motivational Interviewing Network of Trainers (MINT), according to MINT recommendations, to build providers' skills needed to use MI with patients who misuse substances.; A 1-day workshop conducted by a member of the Motivational Interviewing Network of Trainers (MINT), according to MINT recommendations, to build providers' skills needed to use MI with patients who misuse substances. Following the workshop training, providers conduct two motivational interviews bedside with patients under the supervision of one of the MI-trained CL clinicians, who subsequently give them performance feedback and coaching. Providers receive one more supervised practice case mid-trial. In addition, they can request additional supervision at any point during the trial.; A 1-day workshop conducted by a member of the Motivational Interviewing Network of Trainers (MINT), according to MINT recommendations, to build providers' skills needed to use MI with patients who misuse substances. Following the workshop, providers have the option to conduct MI with patients themselves or to "order" a MI for delivery by one of the MI-trained CL clinicians.
Other intervention name(s): Workshop; Workshop plus live supervision; Workshop plus consultation-liaison service
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: In this three-arm parallel assignment, study-eligible and consented provider participants are randomized to one of three conditions (See One, Do One, or Order One) in which they receive their respective motivational interviewing training in parallel with provider participants assigned to the other conditions.
Masking: Single (Participant)
Primary purpose: Health Services Research
Keywords: implementation study; motivational interviewing; substance use