but we provide great healthcare! why do we have to worry...
TRANSCRIPT
But We Provide Great Healthcare! Why do we have to worry about self-management support?
Kathy Reims, MD, FAAFP
January 20, 2017
Objectives:
1. Define self-management and self-management support
2. Explain the Stepped Care Model and the associated self-management interventions
3. Describe the evidence for self-management support
4. Describe the link between self-management support and improvement initiatives
What comes to mind?
One Definition
“The individual’s ability to manage the
symptoms, treatment, physical and social
consequences and lifestyle changes inherent in
living with a chronic condition.”
1Barlow et al, Patient Educ Couns 2002;48:177
Individuals with Diabetes Mellitus provide about 95% of their own care.
Anderson RM, Funnell MM, Butler PM, et al. Patient empowerment. Results of a randomized controlled trial. Diabetes Care 1995;18(7):943-9
Self-Management Support (SMS): What is it?
“Self-management support” is “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 of progress and problems, goal setting, and problem-solving support.”
IOM 2002
Medical Professionals often Confuse SMS with Education
Education
Begins with provider
determination of need
Information and technical skills
are taught
Usually disease-specific
Assumes knowledge leads to
behavior change (false)
Goal is compliance
Teachers are always
professionals
SMS
Begins with the patient’s self-
identified problems
Problem-solving skills are
taught
Skills are “generalizable”
Assumes self-efficacy leads
to change (true)
Goal is more self-efficacy
Teachers can be
professionals or peers
Bodenheimer et al JAMA 2002;288:2469
Thinking about SMS is Evolving…
“Self-Management Support is the assistance caregivers give patients and their self-defined circle of support so patients can manage their conditions on a day-to-day basis and develop the confidence to sustain healthy behaviors for a lifetime.”
T Bodenheimer, et al. Helping Patients Manage their Chronic Conditions.
Available at http://www.chcf.org
Who benefits from self-management support?
Perspective of Health vs Health CARE
Framing
When we engage people in their healthcare and health, we are often asking them to make a change or do something differently.
Lose weight
Start a
medication
Get more
exercise
Get health
advice
when you
need it
Eat at least 5
fruits and
vegetables per
day
Get your
mammogram
Follow up in
3 months
Immunize
your baby
What influences health behavior change?
Basic needs met
Competing priorities
Personal resilience and personality traits
Family of choice and community support
Readiness, ability and willingness to change
Advice from a trusted person or professional
Importance of the change
Confidence that you can make the change
Even once you decide to make a change, it is sometimes challenging to follow through.
Self-confidence
People’s beliefs about their capabilities to perform specific behaviors and their ability to exercise influence over events that affect their lives. Self-confidence beliefs determine how people feel, think, motivate themselves and behave.
- Albert Bandura
Mt Frosty, BC by C. Davis
Stepped Care Self-management Support
adapted from Health Council of Canada: Self-management Support for Canadians with Chronic
Conditions, May 2012
Patients vary in
what type and
how much
SMS they need
over time.
Evidence for SMS Programs
Evidence for SMS
Evidence is emerging that self-management support programs improve a variety of outcomes for different chronic conditions 10 - 28
Patient’s sense of engagement and self-efficacy are strong predictors of outcomes.29
Quality improvement interventions that have attempted to improve the outcomes of chronic care without a component that supports patient self-management have not been found to affect patient outcomes.30
Reporting, and pay-for-performance programs encourage the provision of self-management support
Debra DeSilva
“The literature shows that proactive, behaviorally focused self-management support designed to increase self-efficacy can have a positive impact on people’s clinical symptoms, attitudes and behaviors, quality of life and patterns of healthcare resource use.”
Natalie Grazin, p iv
Conclusions
1. Some interventions are more effective than others
If combine studies, dilutes effectiveness
“One off” efforts unlikely to make a difference, so make it part of wider initiatives and system redesign
2. Proactive SMS and focusing on behavior change can impact clinical outcomes and emergency service use.
DeSilva, 2011, “Helping People Help Themselves”
General components that work
Involving people in decision making
Emphasizing problem solving
Developing care plans as a partnership between patient and professional
Setting goals and following up on them
Promoting healthy lifestyles, educating people about their conditions and how to self-manage
DeSilva, 2011, “Helping People Help Themselves”
Components, cont.
Motivating people using targeted approaches and structured information and support
Helping people to monitor their symptoms and know when to take action
Helping people manage social, emotional and physical impacts of their conditions
Proactive follow-up
Providing opportunities to share and learn from others
DeSilva, 2011, “Helping People Help Themselves”
Questions remain…
Best strategies to implement principles
Barriers and facilitators to implementation
How best to build relationships between patients and professionals
Exploring effective strategies for behavior change
Understanding skills clinicians need and barriers that prevent them from offering support
DeSilva, 2011, “Helping People Help Themselves”
Strategies
DeSilva, 2011, “Helping People Help Themselves”
How would things be different?
?
??
?
??
If health care professionals provided excellent self-management
support and patients were excellent self-managers, how would things
be different?
How important is it for you to develop or expand the SMS you provide in your practice?
0 1 2 43 65 7 8 9 10
Not at all
important
Very
important
Starting or Expanding SMS as an Improvement Project
Set an aim
Select measures and calculate your baseline
Choose changes that will help you achieve your aim. These might include changes to roles and responsibilities, workflows, documentation norms, et al.
Setting an Aim
What SMS do you want to offer?
To whom?
By when?
Be specific about what success looks like
“By January 31, 2018 we will have offered 90% of our patients with diabetes the opportunity to set patient-directed self-management goals”
Who Should we Target for SMSUnderstanding our Patients
DemographicsCulturesEducational levelHealth behavior insights (how savvy is the population
about their health)Chronic disease burdenHealth outcomesTop 10 diagnosesTop 5 referral specialtiesCAHPS scores around respect, understood, listened to…. What else?
Clinical Status and Confidence Matrix
Wasson – How’s Your Health www.howsyourhealth.org
• Front desk
• iPad kiosk check in
• MA
• Nurse
• Physician or provider
• Community Health worker
• Health coach
Evaluation Metrics
Maintenance costs – structure, facility, training
Process development – education, coaching, reach
Patient self-efficacy and knowledge
Patient behavior change
Biometrics – disease parameters
Health outcomes – health status, quality of life
Utilization markers – hospitalizations, ER visits
Cost – overall costs, shared savings
Patient satisfaction and experience
CAHPS Supplemental Survey Sets
https://cahps.ahrq.gov/Surveys-Guidance/index.html
What changes do we need to make?
Consider internal capacity as well as community resources
Think about and ask staff about what requests pop up frequently
Ask patients what would be most helpful
Look to available change packages
Staff Skills for Interventions that work: Step 1
Involving people in decision making
Promoting healthy lifestyles, educating people about their conditions and how to self-manage
Helping people to monitor their symptoms and know when to take action
de Silva, 2011, “Helping People Help Themselves”
Staff skills for Interventions that work: Step 2
Setting goals and following up on them
Developing plans as a partnership between patient and professional
Emphasizing problem solving
de Silva, 2011, “Helping People Help Themselves”
Staff skills For Interventions That work: Step 3
Helping people manage social, emotional and physical impacts of their conditions
Proactive follow-up
Providing opportunities to share and learn from others
de Silva, 2011, “Helping People Help Themselves”
What can our existing staff do ?
Differentiate self-management support tasks
Look for people with different skills for different tasks (may cross roles)
Remote versus face-to face
At versus between visits
What can our community offer?
MOUs and partnerships
Ensure philosophically aligned
Coordinate approach and language
How might you expand further?
New roles – Community Health Workers, Health Coaches
Modified roles – MA role takes on action planning
Engage behavioral health or addiction specialists to provide services at your facility
Summary
Described SM, SMS and why it is an important and integral part of the care we provide
Reviewed the evidence for SMS
Discussed different ways to assess your practices’ SMS needs
Provided guidance on how to improve SMS in your practice
Online Resources
http://www.centrecmi.ca/
Stepped Care brochure
Brief Action Planning algorithm and Guide
BRAIN tool
Contact me:
References
19 Norris SL, Engelgau MM, Venkat Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 2001;24(3):561-87.
20 Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports. Br Med J 2002;325(7370):925.
21 Norris SL, Lau J, Smith SJ, et al. Self-management education for adults with type 2 diabetes: A meta-analysis of the effect on glycemic control. Diabetes Care 2002;25(7):1159-71.
22 Warsi A, Wang PS, LaValley MP, et al. Self-management education programs in chronic disease: a systematic review and methodological critique of the literature. Arch Intern Med 2004;164(15):1641-9.
References
23 Chodosh J, Morton SC, Mojica W, et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med 2005;143(6):427-38.
24 Guevara JP, Wolf FM, Grum CM, et al. Effects of educational interventions for self-management of asthma in children and adolescents: systematic review and meta-analysis. Br Med J 2003;326(7402):1308-9.
25 McAlister FA, Stewart S, Ferrua S, et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am CollCardiol 2004;44(4):810-9.
References
26 Gibson PG, Powell H, Coughlan J, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2002;3:CD001117.
27 Gibson PG, Ram FS, Powell H. Asthma education. Respir Med 2003;97(9):1036-44. 41
28 Bravata DM, Sundaram V, Lewis R, et al. Asthma care. Vol 5 of: Shojania KG, McDonald KM, Wachter RM, et al., editors. Closing the quality gap: a critical analysis of quality improvement strategies. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville (MD): Agency for Healthcare Research and Quality; 2007. AHRQ Publication No. 04(07)-0051-5.
References
29 Bandura A. Promotion from the perspective of social cognitive theory. Psych Health 1998;13:623-49.
30 Renders CM, Valk GD, Franse LV, et al. Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice. Diabetes Care 2001;24(8):1365-70.