Transcript Document

Group Medical Visits
Health Literacy
Patient Self-Management
Learning Session 1
<To be run in combination with GMV content>
<Insert GMV slides here>
2
Stepped Care for Self-management Support
Expert
Techniques
Advanced Techniques
(MI, PST, Care Mgr, etc.)
Self-management Support Basics:
Goal Setting, Action Planning,
Problem solving, Follow up
Patient Role in Self-management
Cultural Humility
Health Literacy
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Health Literacy
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Health Literacy is:
“The degree to which individuals
have the capacity to obtain,
process, and understand basic
health information and services
needed to make appropriate
health decisions” (I.O.M, 2004)
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But there is another important component:
“The ability of professionals and institutions to
communicate effectively so that community
members can make informed decisions and take
appropriate actions to protect and promote their
health.”
adapted from Rootman and Gordon-El-Bihbety, 2008 and Health and Literacy
Partnerships, Focus on Basics, World Education, Vol. 9, Issue B, September, 2008.
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Why should you care about health literacy?
• Affects large numbers of patients
• Contributes to improved health outcomes
• Decreases incidence of chronic disease
• Decreases health care costs
Dr. Irving Rootman
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The Patient’s Perspective…
I had a pain in my stomach. The doctor did some tests.
He said I had a blgrkrdmr.
I didn’t understand the word he used.
I asked him, “What is a blgrkrdmr?”
He said it was a grtiytuhr of the ptorjfmbtgbba.
I still didn’t understand.
He asked me, “Do you understand?”
I just said yes.
Literacy Manitoba
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Health Literacy Video Clip
• Tiny.cc/k5h8d
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Health Literacy Tools
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•
•
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Health literacy office practice survey
Teach Back (video)
Plain Language check list
Brown Bag medication review
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Easy to Use Patient Survey to Determine Patient Understanding
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Plain Language-Checklist
Literacy Partners of Manitoba
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Brown Bag Medication Review
• All meds, herbals, traditionals,
OTC to visit in a bag
• Ask
 How do you take this medication?
 What is it for?
• Check refill dates
• Do you use any aides?
(mediset, blisterpack, etc.)
Ohio Patient Safety Institute
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Try Teach Back
• After information or instruction has been given, say:
• “Could you tell me back what we just talked about to see if
I was able to make it clear?”
• “After you leave this appointment a family member or
friend might ask you what happened today. What are you
going to tell them about what you are going to do?”
• If teaching a skill, use “Show me.”
• “Show me how you are going to do this at home so I know
if I was clear.”
American Medical Association
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Table Discussions: Health Literacy tools
•
•
•
•
•
At your tables decide how you will use the tools.
Reflective questions:
Who will do what? When? and How?
Make a plan
Report back about each tool
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How Will I Recognize People Who Have
Literacy Problems?
“Treat every person as if they might have health
literacy problems.”
Dr. Darren DeWalt
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Health Literacy Universal Precautions Toolkit
http://www.ahrq.gov/qual/literacy/
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For more information......
• Additional resources can be found at
www.gpscbc.ca/psp/practice-support-program
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Patient Self-Management
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What is Self-Management?
Self-management relates to the tasks that an individual must
undertake to live well with one or more chronic conditions.
These tasks include gaining confidence to deal with medical
management, role management, and emotional
management.
Adams, Greiner, and Corrigan (2004)
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Self-Management
Key Concepts:
• Partner with patients to make sure they understand the
central role as a partner in their own care
• Make sure patients have and UNDERSTAND their own
health information
• Find out what it is that the PATIENT wants to change
• Help patients build the confidence to deal with their
conditions the other 364.5 days of the year (when they’re
not in your office)
• Follow-up with patients to make sure they’re on track –
see if they’re running into barriers, provide
suggestions
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Literature – Kate Lorig
.
Results
show:
• Self-management improves elements of health status
• ED/outpatient visits and health distress were reduced
• Self-efficacy improved
Kate Lorig, et al., 2001. Chronic disease self-management program: 2-year health status
and health care utilization outcomes
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What is Self-Management Support?
Self-management support is defined as the
systematic provision of education and supportive
interventions by health care staff to increase
patients’ skills and confidence in managing their
health problems, including regular assessment or
progress and problems, goal setting, and
problem-solving support.
Adams et. Al. (2004)
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Self-Management Support
Key Concepts:
• Two-way communication process that encourages
interaction between the patient and members of the
health care team
• Self-management support is not the same as patient
education.
• Helps the patient learn how to adopt healthy behaviours
and problem-solve.
• Overall goal of self-management support is to increase
the patient’s self-confidence in their ability to
change their own behaviours.
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What is an informed, activated patient?
An informed, activated patient is able to:
• Identify personal priorities, values, problems, strengths
and supports
• Accept some responsibility for making choices
• Establish personal goals
• Identify possible actions/choices
• Stay in touch and ask for help when needed
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Patient Self-Management Video
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Motivational Interviewing and Brief Action
Planning
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What is Motivational Interviewing?
“a person-centered counseling method
for addressing the common problem of
ambivalence about change.”
William Miller, Stockholm International MI conference, 2010
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Spirit of Motivational Interviewing
• Collaboration
Health care professional and patient are equal
• Evocation
Ideas for change come from the patient
• Respect for Autonomy
Patient has the right to change or not
• Compassion
Interaction is grounded in caring
Dr Bill Miller, Nov 2010 updated from Miller & Rollnick,
Motivational Interviewing, 2002
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Brief Action Planning
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9 Core Principles & the Evidence Base
1.
2.
3.
4.
5.
6.
7.
8.
9.
Individual-centered
Collaborative
Respects right of not changing
SMART
Commitment statement
Behavioral menu
Measure confidence
Follow-up
Occurs in every interaction
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Core Principle #1
Action planning is individual-centered, i.e. what
the person wants, not what he/she is told to do.
“Spirit” of Motivational Interviewing: Evocation
Miller W, Rollnick S. Motivational Interviewing: Preparing People
for Change, Guilford Press, 2002
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Core Principle #2
Action planning is collaborative.
“Spirit” of Motivational Interviewing: Collaboration
Miller W, Rollnick S. Motivational Interviewing: Preparing People
for Change, Guilford Press, 2002; Heisler et al, JGIM, 2002
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Core Principle #3
Action planning respects the right of the individual
to change or not to change.
“Spirit” of Motivational Interviewing: Autonomy
Miller W, Rollnick S. Motivational Interviewing: Preparing People
for Change, Guilford Press, 2002
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Core Principle #4
Action planning is
‘SMART’
Specific
Measurable
Achievable
Relevant
Timed
Based on the work of Locke (1968) and Locke &
Latham (1990, 2002); Bodenheimer, 2009
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Core Principle #5
After the plan has been formulated, the
clinician/coach elicits a final “commitment
statement.”
Strength of the commitment statement predicts
success on action plan.
(Aharonovich, 2008; Amrhein, 2003)
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Core Principle #6
Offer a behavioral menu when needed or requested.
“Spirit” of Motivational Interviewing: Autonomy
Rollnick, Miller & Butler, 2008. Motivational Interviewing in Health Care
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Behavioral Menu
“Here are the things we have talked about. Which
one is most important to work on right now?”
Smoking
(write others
here)
Exercise
Avoiding
triggers
Taking meds
Adapted from Stott et al, Family Practice 1995; Rollnick et al, 1999, 2010
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Behavioral Menu Examples
Gerald L. Ignace Indian Health Center, Milwaukee, WI
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Core Principle #7
Confidence levels are evaluated and problemsolving utilized for confidence levels less than 7.
Higher self-efficacy is associated with healthier
behaviors and better outcomes.
(Bandura, 1983; Lorig et al, Med Care 2001; Bodenheimer
review, CHCF 2005; Bodenheimer, Pt Ed Couns 2009.)
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Core Principle #8
Action planning includes arranging follow-up or other
accountability.
(Resnicow, 2002; multiple condition specific studies)
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Core Principle #9
Action planning is considered in all chronic, planned,
or preventive visits.
Non-clinical staff are 9 times more likely to engage
in goal-setting than clinical staff. Technology
(such as howsyourhealth.org) is an option
(Bodenheimer, 2009)
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Brief Action Planning (B.A.P.)
“Is there anything you would like to do for your health
In the next week or two?”
SMART Behavioral Contracting
Elicitation of Commitment Statement
“How confident (on a scale from 0 to 10) do you
feel about carrying out your plan?”
If Confidence >7
“When would you like to check in with me to
review how you are doing with your plan?”
Steven Cole, et. al.
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Behavioral
Menu
Brief Action Planning (B.A.P.)
“Is there anything you would like to do for your health
In the next week or two?”
Behavioral
Menu
SMART Behavioral Contracting
Elicitation of Commitment Statement
“How confident (on a scale from 0 to 10) do you
feel about carrying out your plan?”
If Confidence <7, “Problem Solve” Barriers
“When would you like to check in with me to
review how you are doing with your plan?”
Steven Cole, et. al.
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Problem solving
1.
2.
3.
4.
5.
6.
7.
Identify the problem.
List all possible solutions.
Pick one.
Try it for 2 weeks.
If it doesn't’t work, try another.
If that doesn't’t work, find a resource for ideas.
If that doesn't’t work, accept that the problem
may not be solvable now.
Source: Lorig et al, 2001
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Table Discussions for Self-Management
•
•
•
•
At your tables decide how you will use the tool.
Reflective questions:
Who will do what? When? and How?
Once you have your plan – try it in your small
group
• Report back to the bigger group
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Planning for Improvement
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The Fundamental Questions
for Improvement
1. What are we trying to accomplish? (Aim)
2. How will we know that a change is an
improvement? (Measures)
3. What changes can we make that will
result in an improvement? (Tests of change)
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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make that
will result in improvement?
Act
Plan
Study
Do
AIM
MEASURES
TESTS OF CHANGE
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Example Practice Aim For This Module
We want to have 80% of or patients living with
chronic disease with document self management
goals, within 12 months.
OR
We want to have 70% of our patients reporting
they have a confidence level of >7 out of 10 that
they will be able to achieve their self
management goal, within 12 months
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Measurement
• The purpose of measurement in the collaborative
is for learning not judgment
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Measures
Required Measures - for the practice
Target
% of patients identified to work on PSM that have a
documented self management goal and action plan
(use action plan)
80%
% patients with a PSM plan that have confidence level
of > 7 out of 10 that they will be able to achieve their
self management goal (use action plan)
90%
% of patients in GMV that answer yes to: Overall I was
satisfied with today’s appointment (use GMV patient
survey)
80%
% patients that report they agree or strongly agree: My
doctor explained things to me in a way that was easy to
understand (use the Health Literacy survey)
90%
% of providers after doing GMV that rate their
satisfaction as a 5 or greater (use GMV practice survey)
100%
Baseline
Current
results
Required Measures - for the cohort
% of GPs that have held a GMV and that have an aim
statement and measures
100%
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Example of Small Tests You Can Try:
GMV and a documented PSM action plan
AP
SD
Documented PSM
action plan =
patient
empowerment
Cycle3: Include brief action planning
in all CDM visits, explore MOA role
in facilitating completion
Cycle 2: make necessary adjustments and try with 2 more patient
of different age, diseases stage, culture, ect.
Cycle 1: work with 1 patient using Brief Action Planning to set a Self
management Goal and action plan.
Goal is 80% patients with
a self management action
plan
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Where do I start?
• What are you going to
do next Tuesday?
• What is your aim?
• Determine how you will
measure/track
improvement
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Action Period Expectations
• Try tests of change
• Measure and track your progress
Support throughout the action you can
expect: Practice visits from coordinator
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Have Fun!
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Additional Slides
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Optional: GP Champion or Guest Speaker
• Your experience: How you started, types of groups, # of
patients
• Highlight benefits for patient & provider
• Improved completion and target rates
• One stop shopping
• “others asking questions I wouldn’t think of”
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