Transcript PATIENT SELF-MANAGEMENT DEFINITIONS Definition #1 – Self-management is how patient manages aspects of their chronic disease (s). Definition # 2 – Learning and.

PATIENT SELF-MANAGEMENT DEFINITIONS
Definition #1 – Self-management is how patient
manages aspects of their chronic disease (s).
Definition # 2 – Learning and practicing the skills
necessary to carry on an active and emotionally
satisfying life in the face of chronic illness.
SELF-MANAGEMENT TASKS
1. Managing the elements of their chronic
disease: medication adherence, diet, exercise,
treatments, self-testing and record keeping.
2. Maintaining their roles and functions in life.
3. Dealing with the emotional demands of their
lives.
THE CASE FOR SELF-MANAGEMENT SUPPORT
The role of the PCMH team is to provide
motivating support and education needed by
chronically ill patient needs . This includes
• Timely, accurate, understandable information
• Involvement in collaborative decision making
• Goal setting and problem solving
• Help managing psychosocial needs
NCQA 2011 CERTIFICATION GUIDELINES FOR PCMH
PCMH 4A: Support Self-Care Process- MUST PASS
 Requires practice to develop and document self-management plans/goals
(CRITICAL FACTOR) in at least 50% of patients/families.
 Documents self-management abilities for at least 50% of patients/families.
 Provides self-management tools to record self-care results for at least 50%
percent of patients/families.
 Counsels at least 50% of patients/families to adopt healthy behaviors.
 Provides educational resources or refers at least 50 % of patients/families to
assist in self-management.
 Uses an EHR to identify patient-specific education resources and provide them to
more than 10% of patients/families.
PATIENT TEACHING VS. SELF-MANAGEMENT SUPPORT
Patient Education
Self-Management Support
Information and skills are taught
Skills to solve patient-identified problems are taught
Usually disease specific
Assumes that confidence yields better outcomes
Goal is compliance
Goal is increased self confidence
Healthcare professionals are the teacher
Teachers can be professionals or peers
Gives information
Provides tools
Gets patient involved in
day-to-day decisions
STAGES OF CHANGE MODEL
•
Development of self-management skills means change to the patient’s life.
•
Recognizing where patient is on the continuum of change is critical to effective
support
•
The stages of changes as 1st proposed by Prochaska and DiClemente in 1983:
1. Precontemplation (not ready to change)
2. Contemplation (thinking of changing)
3. Preparation (ready to change)
4. Action (Making the change)
5. Maintenance (Staying on track)
**Added to the theory since then, is # 6 Relapse (falling of the
wagon!)
OTHER SKILLS AND TOOLS NEEDED
Open-ended and exploratory questioning- frame your communication so a simple “yes, no
or I don’t know” are not possible answers.
Reflective listening – encourages patient communication. Patient can’t/won’t talk if staff
member is “telling” them what to do.
Depression Assessment – soon to be done practice wide.
Health literacy assessment – Don’t assume people understand what they are told by the
PCP or yourself. Use the Teach-Back technique.
Engaging family members, caregivers and other signifigant social supports – should be
with patient’s agreement. Be careful of self-appointed family members who want to
become the “diabetic police”!
Goal setting, prioritizing and planning of care- use of motivational interviewing technique's
and work toward the patient’s strengths and health belief system.
Effective team membership and participation- required by NCQA. Be proactive.
Document all of the above in the EHR
SELF- MANAGEMENT AND GOAL SETTING
Step 1 - Problem identification
Impact of illness
Identify specific symptoms and signs of illness
Identify factors leading to preservation and promotion of a healthy lifestyle
Step 2 – Identifying barriers to self-management
Motivation
Knowledge of condition
Knowledge of symptom management
Comorbidities
Health beliefs
Self efficacy
Social context
SELF MANAGEMENT AND GOAL SETTING
Step 3 – Planning (setting of goals) – SMART
 Specific
 Measurable
 Achievable
 Realistic
 Timely
Goals should focus on medication adherence, smoking cessation, self-monitoring
(i.e. glucose logs), diet, exercise, foot care, managing comorbidities and continuing
to live a participative lifestyle. Once goals are set , patient should get copy and they
should be shared with team via EHR.
BRIEF NEGOTIATION ROADMAP
 Developed in 2002 by Kaiser Permanente and two psychologists, Miller and
Rollnick
 Needed a tool for practitioners to use in day-to-day patient interactions to
promote healthy behavior changes.
 Systematic way to efficiently and effectively discuss these changes with the
patient/family.
 Basic tenet of brief negotiations is that everyone has the potential for positive
change.
 Structure is a brief collaborative interaction to discuss health care changes.
FURTHER LEARNING ONLINE
http://www.kphealtheducation.org/