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NYS HIVQUAL Workshop:

Supporting Patient Self Management

July 17, 2009 Nanette Brey Magnani [email protected]

& Meera Vohra [email protected]

NYSDOH AIDS Institute National Quality Center (NQC)

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Agenda

• • • • • • • • Group Exercise: Health Care Self-Management Continuum Presentation: Literature Review Group Exercise: Case Study Group Exercise: The “To Do” List Group Exercise: Patient Self-Management Support Presentation: Harlem Hospital Group Discussion Evaluation and Wrap up National Quality Center (NQC)

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Activity 1: Personalizing Self-Management • • 9:15am Health care self-management continuum Share personal experiences with managing health and health care National Quality Center (NQC)

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9:35am Literature Review

Presentation

National Quality Center (NQC)

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Patient self management is…

“ The capability of patients with chronic illnesses, in a complementary partnership with their health care providers, to manage the symptoms, treatment, lifestyle behavior changes, and the many physical and psycho social challenges that they face each day.” A composite of definitions in the literature National Quality Center (NQC)

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The Problem

• • Patients often have difficulty in taking care of the long term, day-to-day management of their own health. They may: 

Miss appointments or follow-up referrals

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Not follow diet or activity recommendations

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Take medications or supplements that interfere with prescribed therapies

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Ignore or not recognize signs of adverse events or disease progression

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Behave in ways that put themselves at risk including not adhering with prescribed medical therapies

Clinicians have limited time to address these issues National Quality Center (NQC)

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Growing Support for Patient Self-Management

“Increasing evidence shows that self-management support reduces hospitalizations, emergency department use, and overall managed care costs.” “Physician support of patient self-management is one of the key elements of a system’s-oriented chronic care model.” Coleman and Newton. Supporting self-management in patients with chronic illness.

Am Fam Physician

2005;72(8):1503-10 National Quality Center (NQC)

Patient self-management is used effectively in many chronic illnesses and is an essential component of the Chronic Care Model (CCM)

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Asthma

Studies of asthma patient self management programs show that they can…  reduce morbidity  improve lung function  enhance feelings of self control  reduce absenteeism from school and number of days with restricted activity  reduce nocturnal episodes  reduce visits to an emergency department Guevarra P et al.Effects of educational interventions for self management of asthma in children and adolescents: a systematic review and meta-analysis.

BMJ

2003;326:1308-13 National Quality Center (NQC)

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Arthritis

• In multiple randomized trials, the Arthritis Patient Self-management Program has been found to improve  health behaviors  self-efficacy   health status cost savings 1,2 • Patient self-management of arthritis reduced anxiety and depression and improved participants’ perceived self-efficacy to manage symptoms.

3 1. Lorig K and Holman H. Arthritis Self-Management Studies: A Twelve-Year Review.

Health Education Quarterly

. 1993;20(1):17-28 2. Lorig K, et al. Arthritis Self;Management Program Variations: Three Studies. Arthritis Care and Research. 1998;11(6):448-454 3. Buszewicz M et al. Self management of arthritis in primary care: randomised controlled trial.

BMJ

2006;Online First bmj.com

National Quality Center (NQC)

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Diabetes

  Most well-studied disease category Group visits and individualized problem- solving are effective self-management tools resulting in • • Improved recommended prevention behaviors Improved health status (SF-36) • • • Fewer specialty and ED visits Enhanced patient satisfaction and self-efficacy Improved HbA 1c levels Wagner E et al. Chronic care clinics for diabetes in primary care.

Diabetes Care

2001;25:695-700; Anderson R et al. Patient empowerment: results of randomized controlled trial.

Diabetes Care

1995;18(7):943-949 National Quality Center (NQC)

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Systematic Review of 39 Diabetes Studies Using at least one component of the CCM

• 17 of 20 studies that included a patient self management component found positive outcomes    ↓ health care costs ↓ length of hospital stay ↑ health outcomes (e.g., improved HbA1c) Bodenheimer T, et al. Improving Primary care for Patients with Chronic Illness: The Chronic care Model, Part 2.

JAMA

. 2002;288(15): 1909-1914 National Quality Center (NQC)

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The body of evidence shows that supporting patient self management…

     reduces hospitalizations reduces ER visits reduces overall managed care costs increases patient satisfaction with care improves health outcomes (e.g.,) • • • Glycemic control Nocturnal asthma symptoms Blood pressure control Coleman and Newton,

Am Fam Physician

, 2005 National Quality Center (NQC)

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Few Self-Management Studies with HIV Patients

• • • • No strong evidence yet of efficacy Only pilot studies have been done Increase in self efficacy correlated with increase in CD4 count and decrease in viral load* More studies needed of in-office interventions and system supports *Ironson G, Weiss S et al(2005) The impact of improved self-efficacy on HIV viral load and distress in culturally diverse women living with AIDS: the SMART/EST Women’s Project.

AIDS Care

17:222-36 National Quality Center (NQC)

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Stanford HIV S-M Education Pilot Study

• • Pilot test of a group self-management course for HIV/AIDS patients  ↓ symptom severity index in the education session group and ↓ in the control group.  ↑ self-efficacy in the educational group and ↓ in the control group.  secondary outcomes (pain fatigue, psychosocial symptoms, changes in stress/relaxation exercises, and HIV/AIDS knowledge were not significantly different in the two groups.

No follow-up of this pilot study reported to date. Gifford A, Pilot Randomized Trial of Education to Improve Self-Management Skills of Men with Symptomatic HIV/AIDS.

JAIDSHR

. 1998;18136-144 .

National Quality Center (NQC)

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Limitations of Patient Self-Management Education

In a meta-analysis of 71 trials of self-management education across several chronic disease states the authors concluded that… •  While self-management education programs are conceptually appealing, the findings of this review suggest that not all self management education programs for all diseases or for all patients are effective.

Patient self-management programs which tailor educational content and methodology to individual patients and which are integrated into medical care may prove to be more effective than structured self management education courses, for which only specific patient subgroups may be ready.

Warsi A, et al. Self-management Education Programs in Chronic Disease.

Arch Inter Med

. 2004;164:1641-1649.

National Quality Center (NQC)

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In summary Helping patients be better self managers can… •     Improve  Patient health outcomes  Patient health-promoting behaviors  Patient self-efficacy Communication with providers Utilization of community resources Containment of health care costs The quality and efficacy of HIV care National Quality Center (NQC)

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Activity 2: Patient Case Study

• • 9:50am Andy and Zeke   Brothers with similar health challenges Different degrees of success with self-management  Different health outcomes  Different concerns Small group brainstorming activity Case study based on Bodenheimer et al,

JAMA

2002 National Quality Center (NQC)

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Activity 3: The To-Do List

• • • • 10:20am Small group activity to plan an approach to collaborative care with Zeke Primary care issues Assessing Zeke’s concerns, needs, strengths and priorities Zeke is HIV-positive  How does this affect his care?

 What are the key management tasks?

 Whose responsibility? (Zeke, providers, both?) National Quality Center (NQC)

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Activity 4: Patient Self-Management Supports

• • • 10:50am Identifying the need for patient self management supports Brainstorming the most appropriate supports for individual tasks Review of patient self-management supports   Patient-centered Provider-centered  System-centered National Quality Center (NQC)

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Integrating Patient Self Management into Clinical Practice Harlem Hospital New York City

Jenny Knight, FNP Harlem Hospital Center, NY

[email protected]

National Quality Center (NQC)

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Harlem Hospital

• • • Our team was part of a one-year national learning community sponsored by the Institute for Healthcare Improvement on patient self management (included 20 sites, 2 other HIV) The Family-Centered Care Program (FCP) was our target population Participated in extended follow-up project to measure sustainability of change National Quality Center (NQC)

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Population of Focus

• • • • 25% of FCP patients are recent immigrants from West Africa The remaining 75% of FCP patients are predominantly African-American or Hispanic Many face legal, linguistic and cultural barriers to care The self-management model is well-suited to assist these patients in overcoming barriers and achieving better health outcomes National Quality Center (NQC)

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Introducing Self-Management

• • Developed a goal setting tool to set a patient driven healthcare goal and develop an action plan during the clinic visit Developed a model to accomplish this within the time constraints of the clinic setting National Quality Center (NQC)

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My Action Plan for Better Health Harlem Family Center This month I will: Improve my food Choices Reduce my stress Describe it: (How, where, what, when, how often) Take my meds everyday Barriers (what might get in the way): Attend a support group Exercise more often Plans to over come barriers (what could you do to handle the barriers?): Follow up with a medical appointment (go to the dentist) Cut down or stop smoking (or drinking or drug use) Other: On a scale of 1 – 10: How important is this goal: ________ (1 = Not important at all, 5 = somewhat important, 10 = the most important) On a scale of 1 – 10: How sure am I that I can make this goal: ______ (1 = Not sure at all, 5 = somewhat sure, 10 = 100% sure) Follow up Plan: Signature: Clinician Signature: National Quality Center (NQC)

Refine Goal Setting Delivery

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Optimize Goal setting in Mom/Baby Clinic Implement – Goal Setting Delivery Design

A P S D

Cycle 4: Expand approach to two RN/Provider teams in Adult HIV clinic

A P S D

Cycle 3: Team approach implemented in Mom/Baby Clinic. Case manager plays role in supporting plan Cycle 2: RN uses goal-setting tool with patients prior to provider Visit at one clinic session. Provider reinforces goals/plan Cycle 1: Providers use goal-setting tools with patients National Quality Center (NQC)

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Team Approach

• • • • • Piloted in Mom-Baby Clinic  Later expanded to several providers in ID Clinic Nurse sets goal with pt during triage Provider reviewed goals with pt during visit Case manager available to reinforce goals Goal and action plan filed in patients’ chart National Quality Center (NQC)

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Goal-setting was Patient-Driven

• • • Easier than expected to generate goals from patients Encouraged the patient to identify the goal themselves, come with action plan, identify barriers, come up with solution that worked for them Skills included: asking opening ended questions, reflective listening, summarizing National Quality Center (NQC)

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Impact of Goal-Setting

• • • • Can solve impasse around behavior change Gives providers deeper understanding of the patient Improves relationship between patient-nurse and patient-provider Empowers pt to make needed behavior changes, or at least think about them if they are not ready National Quality Center (NQC)

Case Study: Improving Adherence

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• • • • • 37 yr old female with AIDS, newborn at home, with recent illnesses, weight loss, and depression. Stopped taking her meds.

Goal:

“To take my medicines every morning after eating”

Barriers:

“Tired of taking pills”

Plans to overcome barrier:

“Think about tomorrow!”, “Remind myself why I am taking them”

Follow –up:

Reported 100% adherence on self-reported follow-up survey; a more positive outlook

Objective measures:

CD4 increased from 153 to 360 and VL decreased from 15,400 copies to undetectable; weight increased by 13 lbs National Quality Center (NQC)

Case Study: Substance Abuse

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• • • • • 28 yr old with HIV, relatively medically well, but with depression, active marijuana use, multiple missed clinic visits, and chaotic life circumstances. Active ACS case: all three kids in mandated foster care

Goal:

Stop marijuana use to get children back, “must have clean urines”

Barriers:

friends, depression, lack of activities

Plans to overcome barriers:

attend parenting classes, attend drug support group, take meds for depression

Follow-up:

additional barriers identified as drug supplying boyfriend and drug-infested neighborhood

Objective measures:

CD4 stable persistently positive urines; but improved compliance with follow-up visits; VL initially showed a significant decrease (though not maintained); National Quality Center (NQC)

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Case Study: Coordination of Care

• • 46 yr old male with AIDS with hx of substance use and poor adherence.

Returned to NYC 8/06 after several months of incarceration in Virginia with CD4 277 and VL <50 and reengaged in care By 11/06 CD4 180, VL > 100,000. Pt was at the hospital daily attending support programs (HATS, COBRA, HABARI, Harm Reduction, Nutrition, Hep C) National Quality Center (NQC)

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Setting a Goal

• • • • Held case management meeting with all programs, provider and patient At that meeting developed goal and action plan with pt Goal: Take medications every day Plan: Take my pills every morning at home after breakfast National Quality Center (NQC)

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Problem-Solving

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Barriers:

Forgetting/Frustration/Substance Abuse •

Plans to overcome barriers:

    Keep dose in bag/jacket Check in with HATS (adherence support daily) Continue 1:1 counseling with Habari (Housing, psych referral) Continue 1:1 counseling with Harm Reduction Program •

Follow up:

 At next medical visit, pt reported 100% adherence  1/07 CD4 233, VL 2,880 National Quality Center (NQC)

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Group Discussion

11:35am Participant exchange and discussion on activities and tools/resources for supporting patient self-management.

National Quality Center (NQC)

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Evaluation and Wrap up

11:50-12:00 noon

Thank you for your participation.

National Quality Center (NQC)