Transcript HIV Patient Self-Management Support

HIV Patient SelfManagement Support
Making Sure That Patient Self-Management Works
A New Provider Training Curriculum
Joseph Rukeyser, PhD
Introducing a New Provider Training
Curriculum
► Overview
of patient self-management
evidence base
► The role of proactive provider team in
supporting patient self-management
► The training curriculum
 Rationale/goals
 Activities/experiences/practice
 Action planning for program development
► Integrating
training into practice settings
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
Wagner EH (1998) Effective Clinical Practice,
1;2-4
Defining Patient Self-management
“I can’t define it, but I know it when I see it.”
Justice Potter Stewart
Jacobellis v Ohio, 1964
Describing the Elephant
► People
can focus on very different aspects of
something, all being right.
► You can describe the essential elements of
something without being able to define the whole
 A wall
 A snake
 A tree
► The
whole may be greater than the sum of its
parts.
Activity 2: Defining Self-management
► Health
care self-management continuum
► Share personal experiences with managing
health and health care
► Develop an operational definition of selfmanagement
Patient Self-Management
The ability of patients, 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 are a part of living
with chronic diseases.
A composite of definitions in the literature
The Self-management Elephant
► Essential

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




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parts of patient self-management
Learning about disease
Developing effective communication skills
Action-planning, decision-making, problem solving
Record keeping
Seeking expert medical care and advice
Using family and peer support and community resources
Maintaining emotional and psychological balance
Practicing health-enhancing behaviors
Self-management is more than the
sum of its parts
► Recognizes
the reality of patient responsibility for
the majority of decisions and behaviors that affect
their health
► Respects and supports patient autonomy
► Affirms provider responsibility “to” and not “for”
patients
► Acknowledges that effective medical management
requires collaboration between providers and
patients
Activity 3: Patient Case Study
► Andy
and Zeke
 Brothers with similar health challenges
 Different degrees of success with selfmanagement
 Different health outcomes
 Different concerns
Case study based upon Bodenheimer et al, JAMA 2002
Andy
Active 45-yr old man
► Family history of MI
► Hypertension
► Dyslipidemia
► Glucose intolerance
► Former smoker
► Married with a child
► Employed and doing well
►
Zeke
Less active 42-yr old man
► Family history of MI
► Hypertension
► Dyslipidemia
► Glucose intolerance
► 15 lb over weight
► Smoker
► Divorced
► Developmentally disabled
son
►
Activity 3: An Evolving Case Study
 A focus on Zeke
►His
concerns
►How to support him in improving his selfmanagement skills
►What factors contribute to a patient’s ability to
manage their health and health care?
Activity 4: The To-do List
► Small
group activity to brainstorm 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?)
Supporting Patients in
Self-management
► What
can we provide to the patient to use
in improving their self-management?
► What do providers need to help them help
patients?
► What system supports will help both
providers and patients?
Activity 5: Patient Self-management
Supports
► Identifying
the need for patient selfmanagement supports
► Brainstorming the most appropriate
supports for individual tasks
► Review of patient self-management
supports
 Patient-centered
 Provider-centered
 System-centered
Sample Self-management Supports
Patient education (peer-lead; disease-management)
► Materials for action-planning, information organization, and
decision-making
► Collaborative communication, information sharing, and
resource development
► Collaborative goal-setting, action-planning, and problem
solving
► System supports (group visits; visit planning; pre-MD visit,
open medical records, coordinated provider team)
► Clinical indicator self-monitoring
► Ongoing assessment and adjustment to changing
circumstances
►
Activity 6: Action Planning Role Play
► Triad
 Provider
 Patient: Zeke
 Observer
► Focus
on developing collaborative goalsetting and action-planning skills
Action Planning Worksheet
Patient Name:______________
Physician Name:______________
Assess patient’s primary concern or problem:
(e.g., “What is your greatest concern now?”; “What one thing would you most like to change?”)
_________________________________________________
Explore patient’s feelings about the problem:
(“What do you think makes this so hard for you?”; “How will you feel if things don’t change?”)
________________________________________________
Identify patient’s goals:
(“How would you like the situation to change?” “What one thing do you want to change?”)
________________________________________________
Brainstorm solution ideas:
(“What do you think might work or help you to reach that goal?”; How do you think you might solve this
problem?”; ”What have you tried in the past?”; “How might I or someone else help you to do this?”)
________________________________________________
Choose a solution and Action Steps to try:
(“What do you think you could do?”; “When would you do it?”; How often do you think you could do that?”;
What will you do to get started?”)
________________________________________________
Estimate self-efficacy [Use the “Getting to 7” Scale]:
(“Does this sound like something you can do?” ”Are you sure this is something you want to do?” “On a scale
of 1 to 10 how likely is it that you will actually be able to do that?” )
“Getting to 7”
Use the scales below to estimate how likely it is that you will be able accomplish the goal
you have set.
Write the goal on the line above the first 1-to-10 scale. The goal should be “what you will do
by when.” Then circle the number, on a scale of 1 to 10, which shows how likely you
think it is that you will actually accomplish the goal.
Goal: ___________________________________________________.
Not Likely
1
2
3
4
5
6
7
8
Very Likely
9
10
If you selected a number below 7, try to revise your goal to make it more realistically fit
what you think you can actually accomplish.
Revised Goal: ____________________________________________.
Not Likely
1
2
3
4
5
6
7
8
Very Likely
9
10
Barriers to Initiating Patient Selfmanagement Support Programs
► Comfort
with traditional model of care
► Reluctance to lose “control”
► Time constraints
► Unpreparedness for dealing with “nonmedical” issues
► Reimbursement
► Lack of skills training
Activity 7: Program Action Planning
► Identifying
concerns and barriers to patient
self-management program development
► Personal action-planning for program
development or implementation
► Group feedback and program discussion
Self-management Support Improves
Patient Involvement and Self-efficacy
► Growing
evidence that supporting patient selfmanagement:
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Reduces hospitalizations
Reduces ER visits
Reduces overall managed care costs
Increases patient satisfaction with care
Improves health outcomes
► Glycemic
control
► Nocturnal asthma symptoms
► Blood pressure control
Coleman and Newton, Am Fam Physician, 2005
Self-management Support Improves
Patient Involvement and Self-efficacy
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NYS HIV Center interviews with providers and patients
 Patient involvement in decision-making increases patient
“ownership” of care
 Patients who feel more in control of their care tend to
have better long-term health outcomes
Good Doctors, Good Patients: more involved HIV patients
do better (even in pre-HAART era) (Rabkin, Remien, and Wilson, 1994)
New UK Good Medical Practice guidelines on working in
partnership with patients (Moszynski, BMJ, 2006)
Curriculum Summary
► Training
curriculum goals:
To meet the needs of providers in developing individual
expertise in patient self-management support
To assist providers in initiating or further developing
practice-based patient self-management support programs
To improve the quality of HIV/AIDS health care by
fostering collaborative interaction between patients and
their providers in support of increased patient self-efficacy
and self-management
Curriculum Summary
► Targeted
toward a range of care providers
► Modular
► Interactive
► Experiential
► Learner-centered
► Brief
(~4 hours)
► Model for collaborative approach
Discussion
► Pilot
training and curriculum revision
► Potential utilization of provider training
► Hurdles to overcome in initiating trainings
► Resources to utilize
Selected References
Anderson R. Patient Empowerment and the Traditional Medical Model.
Diabetes Care. 1995;18(3):412-5.
Bodenheimer T, Lorig K, Holman H, et al. Patient Self-management of
Chronic Disease in Primary Care. JAMA.2002;288(19):2463-2475.
Coleman M and Newton K. Supporting Self-management in Patients with
Chronic Illness. Am Fam Physician 2005;72:1503-10.
Glasgow R, Davis C, Funnell M, et al. Implementing practical interventions
to support chronic illness self-management. Jt Comm J Qual Saf.
2003;29(11):563-74.
Gifford A, Laurent D, Gonzales V, et al. Pilot Randomized Trial of Education
to Improve Self-Management Skills of Men with Symptomatic
HIV/AIDS. JAIDSHR. 1998;18:136-144.
HRSA HIV AIDS Bureau. Self-Management and the Chronic Care Model.
HRSA CARE Action. January 2006.
Warsi A, Wang P, LaValley M, et al. Self-management Education Programs
in Chronic Disease. Arch Intern Med. 2004;164:1641-1649.