Transcript Patients Are Care Managers

Patients Are Care Managers
Date
presenter
Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
Self-Management Support
• Emphasize the patient’s central role in
managing their illness
• Assess patient’s beliefs, behavior and
knowledge.
• Advise patients by providing specific
information about health risks and
benefits of change.
Self-management support, cont.
• Assist patients with problem-solving by
identifying personal barriers, strategies,
and social/environmental support.
• Arrange a specific follow-up plan.
What is self-management?
“The individual’s ability to manage the
symptoms, treatment, physical and
social consequences and lifestyle
changes inherent in living with a
chronic condition.”
Barlow et al, Patient Educ Couns 2002;48:177
What is self-management support?
Making and refining the health care
system to facilitate patient selfmanagement. This includes at the
level of patient-provider, patienthealth care team, patient-health
care system and the community.
Glasgow et al, in submission
Patient educ. vs. SMS
• Information and skills are
taught
• Usually disease-specific
• Assumes that knowledge
creates behavior change
• Goal is compliance
• Health care
professionals are the
teachers
• Skills to solve pt.
Identified problems are
taught
• Skills are generalizable
• Assumes that confidence
yields better outcomes
• Goal is increased selfefficacy
• Teachers can be
professionals or peers
What self-management support isn’t...
• Didactic patient education
• Sage on the stage
• You should…
• Finger wagging
• Lecturing
• Waiting for patients to ask for help
Why is self-management so important?
What is different?
• Clinical outcomes are dependent on
patient actions.
• Patient self-management is inevitable.
• The provider’s role is to be in partnership
with the patient
• Professionals are experts about diseases,
patients are experts about their own lives.
Self-Management Tasks in
Chronic Illness
• To take care of the illness
• To carry out normal activities
• To manage emotional changes
Based on work by Corbin and Straus
Emphasizing the patient role
Collaborative care
“If physicians view themselves as experts
whose job is to get patients to behave in
ways that reflect that expertise, both will
continue to be frustrated…Once
physicians recognize patients as experts
on their own lives, they can add their
medical expertise to what patients know
about themselves to create a plan that
will help patients achieve their goals.”
Funnell & Anderson JAMA 2000;284:1709
How to emphasize the patient’s role
• Simple messages from the primary care
provider: “Diabetes is a serious condition. There
are things you can do to live better with diabetes and
things the medical team can do to assist you. We are
going to work together on this.”
• Consistent approach
• Culturally and linguistically appropriate
Self-Management in CCM
ASSESS :
Beliefs, Behavior & Knowledge
ARRANGE :
Specify plan for
follow-up (e.g., visits,
phone calls, mailed
Personal Action Plan
reminders
1.
2.
3.
4.
ADVISE :
Provide specific
Information about
health risks and
benefits of change
List specific goals in behavioral terms
List barriers and strategies to address barriers
Specify Follow-up Plan
Share plan with practice team and patient’s social
support
ASSIST :
Identify personal
barriers, strategies, problem-solving
techniques and
social/environmental
support
Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87
AGREE:
Collaboratively set
goals based on patient’s
interest and confidence
in their ability to change
the behavior
ASSESS
Risk factors, Beliefs, Behavior and
Knowledge
Standardizing Assessment
• Knowledge
• Skills
• Confidence
• Supports
• Barriers
• Risk Factors
How confident are you that you can control any symptoms
or health problems you have so that they don’t interfere with
the things you want to do?
Not at all
confident
1 2 3 4 5 6 7 8 9 10
Totally
confident
Lorig et al Outcome Measures for Health
Education and other Health Care Interventions,
SAGE Publications, 1996
Tips on assessing patients
• Use brief standardized assessments
• Provide feedback to patient and care
team
• Assess patient’s view of progress and
how choices relate to goals
ADVISE
Provide specific personalized information
about health risks and benefits of change
Tips on providing advice
• Make the source of advice clear (medical
knowledge or from similar patients)
• Personalize lab values, health status and
how choices affect outcomes
• Provide patient-determined level of
information to make decisions
Tips on providing advice (cont.)
• Tailor information to person and their
environment
• Listen more than you talk
• Have a key message for each condition
or symptom
AGREE
Collaboratively select goals and treatment
methods based on patient’s interest and
confidence in their ability to change the
behavior
Importance Ruler
1 2 3 4 5 6 7
8 9 10
Not
Unsure
Somewhat
Very
Important
Important
Important
Self-Management in CCM
ASSESS :
Beliefs, Behavior & Knowledge
ARRANGE :
Specify plan for
follow-up (e.g., visits,
phone calls, mailed
Personal Action Plan
reminders
1. List specific goals
in behavioral terms
2. List barriers and strategies
to address barriers
3. Specify Follow-up Plan
4. Share plan with practice
team and patient’s social
support
ASSIST :
Identify personal
barriers, strategies, problem-solving
techniques and
social/environmental
support
Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87
ADVISE :
Provide specific
Information about
health risks and
benefits of change
AGREE:
Collaboratively set
goals based on patient’s
interest and confidence
in their ability to change
the behavior
Personal Action Plan
1. Something you WANT to do
2. Describe
How
Where
What
Frequency
When
3. Barriers
4. Plans to overcome barriers
5. Confidence rating (1-10)
6. Follow-Up plan
Confidence Ruler
1 2 3 4 5 6 7
8 9 10
Not
Unsure
Somewhat
Very
Confident
Confident
Confident
Tips to create agreement
• Base goals on patient priorities
• Goals are something to achieve in 3-6
months
• Plans are specific steps to help achieve
goals
• Plans must be behavior-specific
ASSIST
Using behavior change techniques (selfhelp, counseling, etc.) aid the patient in
achieving agreed-upon goals by acquiring
skills, confidence, and developing
social/environmental supports.
Problem Solving
1. Identify the problem.
2. List all possible solutions.
3. Pick one.
4. Try it for 2 weeks.
5. If it doesn’t work, try another.
6. If that doesn’t work, find a resource for ideas.
7. If that doesn’t work, accept that the problem may not
be solvable now.
Examples of Effective Interventions
• CDSMP (Lorig)
• Open Airways (Clark)
• Office Practice (Glasgow)
• Patient Empowerment (Anderson)
• Diabetes Prevention (DPP study group)
Chronic Disease SelfManagement Program
• develop and studied by Kate Lorig and colleagues at
Stanford
• lay-leaders, 6 sessions, 2 1/2 hours each
• addresses multiple conditions
• includes planning and problem solving, skill
acquisition
• “Everything you wish patients knew”
• outcomes: improved health behaviors and health
status, fewer hospitalizations some sustained for 2
yrs (Lorig, Med Care 1999;37:5, 2002;39:1217)
Open Airways
• developed by Clark and colleagues in Michigan
• for children with asthma
• 6 sessions, 1 hour each
• information, emotional support, monitoring,
problem solving, physical activity planning
• reduced asthma episodes, decreased
symptoms, improved self-efficacy (Evans, Hlth
Ed Q 1987;14:267-279)
Individual Office Practice
• developed by Glasgow and colleagues
• prior to visit: mailed reminder of self-monitoring
• waiting room: self-care form
• exam room: feedback on changes, check on goal,
elicit current self-care concern
• physical exam: message
• follow-up: negotiate goals, develop plan, anticipate
barriers, plan for support
• outcomes: decr. serum cholesterol, alt. dietary habits,
impr. satisfaction (Glasgow, Pt Ed & Couns
1997;32:175-184)
Diabetes Prevention Program
• Had IGT
• 7% wt loss, 150 minutes exercise/wk
• Diet, exercise, behavior modification 1:1 for 24 weeks
• Flexible support, culturally sensitive, individualized
• Group and individual follow-up
• After nearly 3 years, diabetes incidence decreased
by 58%
• More successful in those over 60
NEJM 2002;346:393-403
Patient Empowerment
• developed by Anderson and colleagues at University of
Michigan
• emphasis on whole patient
• patient generates options
• build on patient strengths
• failures are learning experiences
• diabetes outcomes: reduced HbA1c, improved selfefficacy (Anderson, Diabetes Care 1995;18:943-949)
Techniques
• Motivational Interviewing
• Problem Solving
• Peer Support
• Empowerment
• Skill Acquisition
• Modeling
• Reinterpreting symptoms
Thoughts on reading level
• Developed to put school children into ability
groups for educational purposes
• Adults can read above their level on topics that
interest them
• Families and friends are often willing to read to
their loved ones
• Patients are very sensitive about being talked
down to.
Source: Kate Lorig, RN, DrPH
ARRANGE
Schedule follow-up contacts to provide
ongoing assistance and support to adjust
the plan as needed, including referral to
more intensive treatment
Tips for follow-up
• Try a wide variety of methods, whichever
patient prefers (in person, phone, email)
• Make sure follow-up happens, patient
trust can be destroyed by missed followup
• Use outreach and community
opportunities
Opportunities for SMS
• Before the Encounter
• During the Encounter
• After the Encounter
Opportunities for SMS
Before the Encounter
• Pre-visit contact (phone,
mail or e-mail)
• Waiting room assessment
• Patient education material
• Posters
• Pamphlets on “Talking to
Your Provider”
• Community outreach
Opportunities for SMS
During the Encounter
• Review assessments
• Feedback on
achievements vs. goals
• Identifies priorities for visit
• 5 “A”s Counseling
• Targeted patient education
materials
• Referral for more SMS
Opportunities for SMS
After the Encounter
• Referrals (Health Education,
etc)
• Further 5 “A”s counseling
• Phone calls follow-up
• Mailed patient education
• Peer support
• Newsletters
• Follow-up visits
• e-mail/Internet sites
What about effectiveness?
• The effects of behavioral interventions cannot
be compared to drug trials.
• Generally 5-15% will make clinically significant
behavior change
• When viewed at the level of a population, this
does benefit the health of the population.
• A more relevant outcome than behavior change
may be improved self-efficacy, which translates
into better quality of life and decreased
utilization.
Who can do this?
• Natural helpers
• Trained peers
• Health educators
• Nurses
• Physicians
• Any caring person...
A philosophical shift
Professional
-
Professional
Patient
Patient
Person
patient
-
Patient
-
Professional
-
professional
professional
Person-Person
Adapted from Tom Janisse, Kaiser NW
Web resources
• www.bayerinstitute.com provides provider
training in “Choices and Changes”
• www.motivationalinterview.org has books,
videos and training
• www.stanford.edu/group/perc home of
Chronic Disease Self-Management
Program
Contact us:
•www.improvingchroniccare.org
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