Appendix E

How Evidence-Based Self-ManagementPrograms Can Improve Your Patient Outcomes

MAC, Inc. Living Well Center of Excellence

Why refer clients/patients, especially older adults, to evidence-based self-management and behavior change programs?

What is the prevalence of chronic conditions, falls and/or depression among older adults?

How you can increase engagement/empowerment of older adults and improve their skills for managing their health.

How to link/refer individuals to community programs.

Session Discussion Topics

Since January 1, 2011 every day for the next 19 years, 10,000 baby boomers turn 65. The aging of this huge cohort of Americans dramatically changes the composition of the country.1

70% of physical and mental decline associated with aging is due to poor lifestyle behavior.2

Older adults at any age can and do learn to make healthy behaviors and even modest lifestyle changes can produce big results when people are empowered and supported to cultivate health and longevity.3

Why Prevention and Behavior Change Strategies Matter

1 in 3 people over 65 fall every year; falls are the leading cause of fatal and non-fatal injuries for older Americans.

Every 13 seconds, an older adult is treated in the emergency room for a fall; every 20 minutes, an older adult dies from a fall.

Almost 27% of older adults have mild depression and 2% suffer with clinical depression.

People with a chronic disease are more likely to suffer from depression.

Why These Programs Are Important

91% of people over 65 have one or more chronic conditions; 73% of 65+ have 2 or more chronic conditions.

Over 1.7 million Americans die of a chronic disease each year.

In 2009, the federal and state governments spent over $250 billion on health care benefits for 9 million low-income elderly or disabled people jointly enrolled in Medicare and Medicaid.4

4Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies, Congressional Budget Office, June 2013

Impact of Baby Boomers and the Elderly on the Health Care System

1 in 3 people over 65 fall every year and falls are the leading cause of fatal and non-fatal injuries for older Americans.

Every 13 seconds, an older adult is treated in the emergency room for a fall; every 20 minutes, an older adult dies from a fall.

Almost 27% of older adults have mild depression and 2% suffer with clinical depression.

People with a chronic disease are more likely to suffer from depression.

Why These Programs Are Important

27

Statewide License for Stanford University Chronic Disease Self-Management Education (CDSME) programs

Training and technical assistance for CDSME evidence-based programs

Centralized referral, certified workforce, community-based locations, quality assurance measures, HIPAA compliant

Statewide calendar, quarterly reporting to partners, feedback on patient activation, engagement and long-term goals

MAC Inc. Living Well Center of Excellence: Delivering Evidence-Based Programs and

Services Across the Continuum

Workshops: 302 Average participants per workshop: 10.3 Completers - attended 4 or more sessions: 1,424 (77%) Race/Ethnicity: White/Caucasian 53% (870), Black or African

American 43% (716), Asian 4% (60), Hispanic/Latino 3% (43) Insurance Type: 63% Medicare (744), 63% Private Insurer (754)

15% Medicaid (176)

Living Arrangement: 37.9% Live alone (536), 62% Live with someone (877), 24.6% Unknown (460)

Maryland CDSME 1,859 Participants September 1 2015 – August 31 2016

Hypertension 989

Diabetes 932

Arthritis 591

Depression/Mental Illness 309

Chronic Pain 305

Lung Disease 300

Heart Disease 252

Cancer 230

Osteoporosis 134

Stroke 104

None 432

Hypertension

Diabetes

ArthritisDepression

ChronicPain

LungDisease

62% Reported Multiple Chronic Conditions (N= 1,308)

People with chronic conditions have similar concerns and problems.

People must deal not only with their disease, but also the impact these have on their lives and emotions.

People with chronic conditions are more likely to identify with and trust leaders who have had similar experiences.

Caregivers can be active participants

Why These Programs Work

Patients accept responsibility to manage or co-manage their own disease conditions.

Patients become active participants in a systemof coordinated health care, intervention and communication

Patients gain confidence (self-efficacy) to perform tasks and focus on improved health status and appropriate health care utilization

Self-Management Goals

Risk Assessment Questions

Chronic Disease Assessment: 1) Do you have 2 or more chronic medical

conditions?; 2) Are you taking more than 5 medications?; 3) Do you have difficulty managing your condition(s)?

Falls Risk Assessment for patients over 65: 1) Have you fallen in the

past year?; 2) Do you feel unsteady when standing or walking?; 3) Do you worry about falling?

Depression Screen: Over the past two weeks, how often have you been

bothered by any of the following problems? 1) Little interest or pleasure in doing things; 2) Feeling down, depressed or hopeless

Malnutrition : 1) Have you recently lost weight without trying?; 2) If yes,

how much weight have you lost? (MST – Malnutrition Screening Tool)

Living Well Disease Management Programs

Living Well Stanford University Self-Management Programs Living Well with Chronic Conditions Living Well with Diabetes Living Well with Chronic Pain Living Well: Cancer - Thriving and Surviving Living Well: Spanish Diabetes Program Living Well Home study chronic disease toolkit

Living Well with Hypertension (Recruitment session)

What goes on in Living Well?

Programs are open to individuals over 18 and caregivers 6-week workshop, 2.5 hours per session Interactive peer-led groups of 10-16 people Facilitated by 2 trained peer leaders, non-health

professionals with chronic diseases or caregivers Standardized materials and training for leaders Highly scripted to maintain fidelity to original program Free or low cost to participants Participants become active in managing their care DOES NOT replace existing programs or treatments

Living well workshop topicsCDSMP

Nutrition Appropriate exercise for strength, flexibility, and

endurance Communicating effectively with family, friends

and health care providers Appropriate use of medications Techniques to deal with pain, fatigue, frustration Decision Making Action Planning and Goal Setting

Stanford Self-Management ProgramsNational Study 2012 and the Triple AimTriple Aim

GoalOutcome Measure

Base-line

Mean

12-Month Mean

% Change

Better Care Communication with MD IMPROVED 2.6 2.9 9%

Medication Compliance IMPROVED .25 .21 12%

Health Literacy IMPROVED 3.0 3.1 4%

Better Outcomes

Self-assessed Health IMPROVED 3.2 3.0 5%

PHQ Depression REDUCED 6.6 5.1 21%

Quality of Life IMPROVED 6.5 7.0 6%

Unhealthy Physical Days REDUCED 8.7 7.2 15%

Unhealthy Mental Days REDUCED 6.7 5.6 12%

Lower Health Care Costs

% w/ ED Visits in the Past 6 Months REDUCED

18% 13%ratio .68

An upward arrow indicates a higher value is desirable, a downward arrow that a lower value is desirable.

Financial Impact

HOSPITALIZATIONS REDUCTION AT 6 MONTHS

EMERGENCY ROOM VISITS ODDS REDUCED BY 32%

NET COST SAVINGS PER PERSON

$390 PER PERSON

Living well workshop topicsDiabetes Self-Management (DSMP)

Key self-management strategies same as CDSMP (Decision Making, Problem Solving, Action Planning, Physical Activity)

What is Diabetes?

Monitoring

Formula for a Healthy Eating Plan

Preventing Low Blood Sugar

Preventing or Delaying Complications

Strategies for Sick Days

Foot Care

This interactive 2-1/2 hour session used as a recruitment strategy for Chronic Disease and Diabetes Self-Management Programs to help individuals learn to better manage hypertension

Module activities/topics include: What is High Blood Pressure Problems with Salt/Sodium Intake Home Monitoring Tips Where’s the Salt Knowing Your Numbers

Living Well with Hypertension

Participant Action Plan and Blood Pressure Protocol

0

50

100

150

200

250

Participants Blood PressureScreening

>140/>90 >160/>100

Blood Pressure Screening (N = 196)• 34% of individuals had hypertension

• 21% were poorly controlled: counseled to check with their health care provider

• 10% uncontrolled: referred to provider or community health worker

Hypertension Education/BP Screen Identified At Risk Individuals

0

10

20

30

40

50

60

70

80

90

Participants Week 1 and Week 7BP

Week 7 ImprovedBP

Week 7 Noimprovement

Week 7 Worse BP

• 58 had hypertension• 40 had diabetes• 39 had week 1 and 7 BP • 24 (62%) improved BP• 11 (28%) same BP • 7 (18%) were healthy zone both times• 5 (13%) had higher BP

Change in BP at 7 weeks for 79 Workshop Participants

CDSMP/DSMP Workshops

Referral tracking and follow-up (standard 5)

Care plans (standard 4)

Self-management goals (standard 4)

Continuous Quality Improvement (standard 6)

Linkage to EHR/EMR

CDSME Meets NCQA Expectations

Adherence to workshop size requirements Workshop retention rates Reach to underserved populations Fidelity monitoring and adherence to certification

requirements Non-disclosure agreements and Privacy Protection Training Peer leaders made me feel welcome and a part of the group Peer leaders shared teaching responsibilities Peer leaders were prepared when they came to class Peer leaders were able to manage the group very well Peer leaders got along well together My opinions and contributions to the group were valued by

the peer leaders

Quality Assurance Measures

I have more self-confidence in my ability to manage my health than I did before taking this workshop

I learned how to set an action plan and follow it

I now have a better understanding of how to manage the symptoms of my chronic health condition(s)

I feel more motivated to take care of my health since I took this workshop

New Question for 2017: On a scale of 0 to 10, After taking this workshop, how confident are you that you can manage your chronic condition(s)

Patient Activation and Self-Efficacy Measures

Participant Satisfaction Scores September 1 2015 – August 31

2016 N=770

0

10

20

30

40

50

60

70

80

Leader Skills Opinionsvalued

Self confidence Set and followplan

Moremotivated

Understandhow to manage

Strongly Agree Agree Disagree Strongly Disagree

Other Healthy Aging/Disease Management Programs for Older Adults

Living Well Evidence-based Programs

Stepping On (Falls Prevention) OTAGO (home-based Falls Prevention)

EnhanceFitness (Exercise)

PEARLS (Depression Screening)

DPP (Diabetes Prevention Program)

Stepping On Falls Prevention Program: Seven week, 2 hours/session workshop: strategies and exercises to reduce falls and increase self-confidence and behavioral change in situations where older adults are at risk of falling.

Outcomes: 31% reduction in falls. The program participants maintained their confidence in their ability to avoid a fall during a variety of functional daily living tasks.

Falls Prevention

Prescription for Evidence-Based Program

Fax, phone, in-person office visits

Online HIPAA-Compliant Auto fill http://www.macinc.org/lwcd-referral-form.html

Access to Client referral, follow-up and enrollment system

Tracking of participation/engagement/program completion

Feedback to referring provider

3 to 6 month goal and action plan to attain the goal

Patient Satisfaction and Self-efficacy measures of increased ability to self-manage

How to Refer – MAC, Inc. Living Well Center of Excellence

References

Lorig, Kate (November 1, 2011). Chronic Disease Self-Management Program: What is It.

Whitelaw, N., Lorig, K., Smith, M. L., & Ory, M. G. (March 19, 2013). National Study of Chronic Disease Self-Management Programs (CDSMP). Retrieved April 8, 2013, from www.ncoa.org/cha

Maryland State Health Improvement Process (SHIP) 2011 – 2014, Racial/Ethnic Disparities Measures, 2011. Retrieved from http://dhmh.maryland.gov/ship/PDFs/SHIP%20FRAMEWORK%20with%20Racial%20Ethnic%20Dis

parities%207-24-12.pdf

Chronic Disease in Maryland: Facts and Figures, March 2011, DHMH Office of Chronic Disease Prevention

Diabetes Educ. 2009 Jul-Aug;35(4):641-51. doi: 10.1177/0145721709335006. Epub 2009 Apr 30.