Transcript Self-Management Support: The Key Ingredients Connie Sixta, RN, PhD, MBA Robert A. Gabbay, MD, PhD.

Self-Management
Support: The Key
Ingredients
Connie Sixta, RN, PhD, MBA
Robert A. Gabbay, MD, PhD
Ancient Greeks described three
basic tools of medicine:
• The herb
• The knife
• The word
How many of you need
to deal with changing
patient behavior in your
practice?
How successful are you
in getting patients to
change their behavior?
The 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
Info
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
NCQA PCMH Standard #4
Provide Self-Care Support and
Community Resources
The practice acts to improve patients’ ability to
manage their health by providing a self-care plan,
tools, educational resources and ongoing support.
What determines positive change
in self-care behavior?
Clinician counseling style!!
Sources: Rost et al, 1991; Glasgow et al., 1999; Anderson & Funnell,
2000; Doherty et al., 2000), and many, many other studies.
Our Traditional Style:
Directive
• Expert Advice Giving
• Promotes passive, uninvolved patient.
• Lack of fit between clinician agenda and patient
agenda.
• Look how well it works!
• Two components
• Information exchange
• Persuasion
• Can lead to resistance
Patient Centered Approach
• Goals and agenda are negotiated.
• Patient values are examined.
• Outcomes are superior!
Greenfield et al., 1988; Kaplan et al., 1989; Greenfield et al., 1988;
Uhlmann et al., 1988; Roter & Hall, 1989; Golin et al., 1996 and
many, many more.
To Support Patient SelfManagement, the Provider Must:
Give up the agenda.
Let the patient take control of his life.
Help the patient feel success.
Remember that the management of a
chronic illness is a lifetime proposition.
Our job is to guide patients
appropriately over time based on
patient interest and needs.
But How?
Ask open-ended questions to:
• ASSESS what the patient knows, feels, and believes
about diabetes.
• Determine what ADVICE the patient is interested in
receiving and ready to learn.
• Help the patient decide and AGREE on a behavior
he/she is interested in changing/improving.
• ASSIST the patient with problem solving.
• ARRANGE follow-up with the patient to reinforce
the change in behavior.
The 5 As:
Self-Management in the Chronic Care Model
ASSESS
Knowledge, Beliefs, and Behaviors
PERSONAL ACTION PLAN
ARRANGE FOLLOW UP
Specify plan for follow up
List specific goals in behavioral terms.
ADVISE
List barriers and strategies to address barriers.
Specify follow-up plan.
Provide information on health
risks and benefits of change
Share the plan with the patient’s practice team and
social support.
ASSIST
Identify personal barriers and
strategies for problem solving
Adapted from Glasgow RE, et al. (2002)
AGREE
Collaboratively set behavioral goals
based on patient interest and
confidence
Assess Patient/Family Knowledge,
Beliefs, and Behaviors
• Use open-ended questions to assess knowledge
and beliefs:
• What experiences have either you or your family had
with diabetes?
• What do you know about diabetes?
• Tell me about your friends and family that have
diabetes.
• Use open-ended questions to assess behaviors:
• What do you usually eat each day? Tell me what you
had to eat yesterday.
• How much activity do you usually get each day?
• Tell me about your schedule for taking your
medications.
Open-Ended Questions
• Closed question: Do you always take your
insulin?
• Open ended question: Tell me a little
about how it’s going with taking your
insulin?
• If you strongly suspect adherence issues:
• Many people find it challenging to take
their insulin daily. How is it going for
you?
Good Question or Not?
• How do you think it might be helpful if you
check your blood sugars more often?
• Why don’t you check your blood sugars?
• What do you think is the value of taking your
medications each day?
• How can you put your life at risk by not taking
your insulin?
• Don’t you know you that by not taking your
statin you are going to die of a heart attack?
Advise the Patient/Family
• Use Open-Ended Questions to determine
what information the patient needs right
now, is ready to hear, and will address
areas of concern.
• LISTEN TO WHAT THEY SAID IN ASSESS!
• If they said they didn’t know why checking
blood sugars was important, explain it to
them.
• If they said they were worried about an
amputation or afraid of starting insulin,
explore and give needed information.
Rules to giving advice:
• Ask the patient what his/her questions are, what
he/she wants to know.
• Keep the advice as clear and simple as possible.
• Start by asking the patient what he/she already
knows.
• Give advice in small doses to avoid overwhelming
the patient with too much information.
• Help the patient connect the advice to his/her
areas of concern.
Agree on a Behavioral Goal
• Use open-ended questions to help the patient
set a behavioral goal.
• What’s the most important thing you can do to
control your diabetes?
• What part of managing your diabetes is most on your
mind?
• What would you like to do to better manage your
diabetes?
• What do you want to work on?
Helping Patients Set
Self-Management Goals
1. Ask what “overall goal” the patient would like to work on.
• Such as “get more exercise,” “eat better,” “remember to take
my medicines,” “manage stress better.”
2. Ask “how” the patient would like to move toward
achieving that overall goal.
• How would you like to go about getting more exercise?
• What exercise or activity would you like to do?
• What is your usual activity? How much do you usually do?
3. Help the patient design a goal that is specific and
measurable.
• The goal statement should answer:
what, where, when, and how often?
Example Goal
I am going to walk three blocks (what) around
the neighborhood (where) in the early
morning before I go to work (when) three
days/week on Monday, Wednesday, and
Friday (how often).
Ask How Important the Goal Is
• Patients are more likely to be successful with a
change they think is important.
• Ask the patient to rate how important the goal is
to him/her on a scale of 1 to 10.
1
2
Not
Important
3
4
Unsure
5
6
7
Somewhat
Important
8
9
10
Very
Important
• If the patient rates the goal at 6 or below, ask
him/her to agree on another goal that is more
important.
Ask How Confident in Success
• Patients are more likely to be successful with a
change they think they can accomplish.
• Ask the patient to rate how confident he/she is in
being able to accomplish the goal on a scale of 1
to 10.
1
2
Not
Confident
3
4
Unsure
5
6
7
Somewhat
Confident
8
9
10
Very
Confident
• If the patient rates his/her confidence at 6 or
below, explore barriers or ask him/her to agree on
another goal he/she is more confident in
achieving.
REMEMBER TO
START SMALL
Overall behavioral objective
A small, specific, measurable goal that
moves the patient toward the overall
objective.
Weight: Lose 25 lbs.
I will lose 1 lb. by the end of this week by
limiting the number of cans of soda I drink
to one per day after dinner.
Exercise: Run 3 miles daily
I will walk 2 miles every other day in the
morning before I go to work, starting
tomorrow.
Diet: Decrease daily calories to
1500/day
I will have dessert only 2 times this week
on Saturday and Sunday after I eat dinner.
Stress management: I will walk
home from work every day to
refocus my mind and release
my tension.
I will walk home from work three times this
week on Tuesday, Wednesday, and
Thursday. My wife will take me to work on
those mornings.
Assist the Patient/Family in
Problem Solving
• Use open-ended questions to help the patient
identify barriers during goal setting.
• What is in the way of you achieving that goal?
• What could you do to succeed with that goal?
• Use open-ended questions to help the patient
problem solve when goals are not met.
• What kept you from achieving your goal?
• What could you do to help with that situation?
• What could you do to handle that differently?
Arrange Follow-up
• Can be as simple as:
• A phone call from your staff 2 weeks after the
visit to see how things are going and to help
problem-solve any barriers [CAN BE SCRIPTED IF
NEEDED].
• Remembering to ask the patient about progress
toward the goal at the next visit.
Why is Follow-Up Important?
• Shows the patient that the behavior change is
important.
• Tells the patient you are concerned about their
health and interested in helping them change
their behaviors.
• Helps the patient build skills that will help
them with behavior change and problemsolving in the future.
Let’s Practice
Scenario: Mrs. Gonzales is a 55-year-old Hispanic female who
has had type 2 diabetes for the past 20 years. She watches her
two very active grandchildren (both under age five) every day
during the week. Lately she has been having trouble keeping up
with them when they walk to the park. She has decided that if
she lost some weight she could keep up with them more easily.
Mrs. Gonzales sets a goal to lose 10 lbs. this week.
• Is this an appropriate goal for her? Why?
• What questions could you ask that would help
her develop a more appropriate goal?
• How could the goal be rewritten?
Let’s Try Another Case
Scenario: Mr. Singh is a 48-year-old Indian male who has type 2
diabetes and travels frequently for his job as a salesman. He
noticed on one of his last trips that his suit pants and suit coat
are getting very tight. He has decided that he wants to resume
his running to lose weight. Mr. Singh sets a goal to run Monday,
Wednesday, and Friday before work.
• Is this an appropriate goal for him? Why?
• What questions could you ask that would help
him develop a more appropriate goal?
• How could the goal be rewritten?
Let’s Practice It
Tonight!
One of you is the patient,
and one is the provider.
Patient’s Topic
• Something about yourself that you:
• want to change
• need to change
• should change
• have been thinking about changing but you
haven’t changed yet (i.e. – something you’re
ambivalent about)
• Something you’re comfortable discussing (no dark
secrets)
Provider
• Listen carefully with a goal of
understanding the dilemma.
• Give no advice.
• Just listen.
Provider
Ask open-ended questions to:
• ASSESS knowledge, feelings, and beliefs
about the topic.
• Determine what ADVICE the patient wants
and is ready to learn.
• Help the patient AGREE on a small, specific,
measurable goal and rate his/her importance
and confidence levels.
• ASSIST with problem solving.
• ARRANGE for follow-up.
A Change of Role Is Needed
• You don’t have to make change happen.
You can’t.
• You don’t have to come up with all the answers.
You probably don’t have the best ones.
• You’re not wrestling…
You’re dancing.
X
Conclusions
• Patient education is necessary, but not sufficient.
• People don’t change just because we tell them
to.
• We need to work with patients to help them
with behavior change.
• The counseling style is key.
• Ask open-ended questions to help patients set
their own goals.
Questions?