Clinical Tools and Strategies for Supporting Self-Management Michael G. Goldstein, MD Chief, Mental...

Clinical Tools and Strategies for Supporting Self-Management

Michael G. Goldstein, MDChief, Mental Health and Behavioral Sciences Service

Providence VA Medical CenterProfessor, Psychiatry and Human Behavior, Alpert Medical School of Brown University

IBHP WebinarMarch 18, 2009

Objectives

By the end of the session, participants will be able to:

• Describe the key concepts and principles of self-management and self-management support

• Identify specific strategies, tools and resources for engaging and activating patients and families in chronic illness care

• Describe strategies for redesigning care to enhance the efficient delivery of self-management support

Outline• Self-ManagementSelf-Management

• Self-Management Support (SMS)Self-Management Support (SMS)

• Key Components of SMS Key Components of SMS • Core Clinical Competencies/Tools & Core Clinical Competencies/Tools &

Resources Resources

• Health Care System RedesignHealth Care System Redesign

• Community LinkagesCommunity Linkages

• Questions and DiscussionQuestions and Discussion

Self-Management Tasks

(Corbin & Strauss, 1998 Bodenheimer et al, 2002; Lorig et al, 2003)

• To take care of the illness To take care of the illness (medical management)(medical management)

• To carry out normal activities To carry out normal activities (role management)(role management)

• To manage emotional changes To manage emotional changes (emotional management)(emotional management)

• Blood glucose monitoringBlood glucose monitoring

• Managing high/low blood sugarsManaging high/low blood sugars

• DietDiet

• Physical activity/exercisePhysical activity/exercise

• Medication takingMedication taking

• Medical monitoring/visitsMedical monitoring/visits

• Coping with emotionsCoping with emotions

• Foot careFoot care

• Eye careEye care

• Dental careDental care

Self-Management Tasks for Diabetes

What is Self-Management Support?

Institute of Medicine Definition:Institute of Medicine Definition:• “The systematic provision of education and

supportive interventions

• 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, 2003)

• Addressing knowledge is necessary but not Addressing knowledge is necessary but not sufficient sufficient to produce changes in chronic illness care to produce changes in chronic illness care outcomesoutcomes

• Key strategies for improving outcomes of Key strategies for improving outcomes of educational and behavior change interventionseducational and behavior change interventions:

• assessment of patient-specific needs and barriers

• goal setting

• enhancing skills, problem-solving

• follow-up and support

• increasing access to resources

(Bodenheimer et al, 2002 ; Glasgow et al, 2003; Fisher et al, 2005)

What Works – Research Evidence?

What are the Desired Outcomes of Self-Management Support?

People with chronic conditions (and their families) are more:

• Aware and Informed

• Engaged

• Activated

• Empowered

• Confident they can self-manage

• Partners with health care providers

What is Self-Management Support?

A collaborative process to help people to:

• Understand

• Choose among treatments

• Identify and set goals

• Adopt and change behaviors

• Cope and overcome barriers

• Follow-through

Self-Management Support is NOT

• Didactic Patient EducationDidactic Patient Education

• LecturingLecturing

• Inducing fearInducing fear

• Finger-waggingFinger-wagging

• ““You should”You should”

• ShamingShaming

• Waiting for a patient to askWaiting for a patient to ask

Assumes knowledge drives Assumes knowledge drives changechange

Clinician sets agenda Clinician sets agenda

Goal is complianceGoal is compliance

Decisions made by caregiverDecisions made by caregiver

Assumes knowledge + Assumes knowledge + confidence drives changeconfidence drives change

Patient sets agendaPatient sets agenda

Goal is enhanced confidenceGoal is enhanced confidence

Decisions made Decisions made collaborativelycollaboratively

Self-Management SupportA Fundamental Shift in the Process of Care

Traditional CareTraditional Care Collaborative CareCollaborative Care

(Bodenheimer et al, CA Health Care Foundation, 2005)(Bodenheimer et al, CA Health Care Foundation, 2005)

SMS: Key Components

• Core Clinical Competencies and Tools and Resources for Teams, Patients & Families

• System redesign to efficiently deliver SMS within the context and flow of clinical care

• Meaningful links to community resources and community-based programs and campaigns(New Health Partnerships: www.newhealthpartnerships.org)

(New Health Partnerships, 2007)

SMS: Core Clinical Competencies

• Relationship Building

• Exploring patients’ needs, expectations and values

• Information Sharing

• Collaborative Goal Setting

• Action Planning

• Skill Building & Problem Solving

• Follow-up on progress

“a skillful clinical style for eliciting from patients their own motivation for making changes in the interest of their health.”

Motivational Interviewing

(Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

“Definition”

The “Spirit of MI”The “Spirit of MI”


• Collaborative

• Partnership, shared decision making

• Evocative

• Understand patient goals; evoke arguments for change

• Honoring patient autonomy

• Patients ultimately decide what to do

Motivational Interviewing“Principles”

• Resist the Righting Reflex (Directing)

• Understand Patient Motivations

• Listen to Your Patient with Empathy

• Empower Your Patient


A refined form of A refined form of guidingguiding, rather than directing or following……, rather than directing or following……helping the patient make his or her own decision about behavior changehelping the patient make his or her own decision about behavior change

MI Style


Motivational Interviewing

• Asking

• Listening

• Informing

Guiding - balancing skills, flexibly applied


Explore: Agenda, Needs, Expectations

• “What are you hoping to accomplish today?”

• “What do you think is most important for us to talk about?”

• What concerns do you have about your health?

• What reasons do you have to change?

• Where would you like to start?

If you have DIABETES, here are some things you can talk about with your health care provider

Choose to talk about changing any of these and add other concerns in the blank circles.

Blood glucose monitoring

Taking medications to help control blood sugar

Losing weight

Daily foot care

Depression

Smoking

Skin careTaking insulin

Diet

(RI Dept of Health Chronic Care Collaborative)

“How convinced are you that it is important to monitor your blood sugars?”

Not at all convinced

Totallyconvinced

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10

Explore Conviction/Importance

“What makes you say 4?”

“What leads you to say 4 and not zero?”

“What would it take (or have to happen) to move it to a 6?”

(From Keller and White, 1997; Rollnick, Mason and Butler, 1999)

Share InformationShare Information

AskAsk Permission Permission

AskAsk Understanding Understanding

TellTell (Personalize)(Personalize)

AskAsk Understanding Understanding

Benefits of

Physical

Activity

Collaboratively Set Goals

• Share clinician priorities

• Offer options

• Agree on something to work on

• Negotiate a specific action plan







• Action Planning



Action Planning – Starts with SMART Goals

• Specific and behavioral

• Measurable

• Attractive

• Realistic

• Timely

Action Plan1. Goals: Something you WANT to do1. Goals: Something you WANT to do

2. 2. Describe Describe

HowHow WhereWhere

WhatWhat FrequencyFrequency

WhenWhen

3. Barriers -3. Barriers -

4. Plans to overcome barriers -4. Plans to overcome barriers -

5. Conviction and Confidence ratings (0-10) -5. Conviction and Confidence ratings (0-10) -

6. Follow-Up:6. Follow-Up:

Action Plan1. Goals: Something you WANT to do 1. Goals: Something you WANT to do Begin ExerciseBegin Exercise

2. 2. Describe Describe

HowHow WalkingWalking Where Where NeighborhoodNeighborhood

WhatWhat 20 min20 min Frequency Frequency 3x/week3x/week

When When After dinnerAfter dinner

3. Barriers - 3. Barriers - Dishes, safety (no sidewalks)Dishes, safety (no sidewalks)

4. Plans to overcome barriers - 4. Plans to overcome barriers - get kids to clean up, ask get kids to clean up, ask neighbor or husband to join me, wear reflective neighbor or husband to join me, wear reflective vestvest

5. Conviction and Confidence ratings (0-10) - 5. Conviction and Confidence ratings (0-10) - 9/89/8

6. Follow-Up: 6. Follow-Up: Will keep log and bring to next visit in 1 Will keep log and bring to next visit in 1 monthmonth

• Review past experience - Review past experience - especially successes especially successes

• Define small steps that Define small steps that are likely to lead to are likely to lead to successsuccess

Action Planning

“How confident are you that you can meet your goal of exercising 5 days a week?

Not at all confident

Totallyconfident

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10

Action Planning:Assess and Enhance Confidence

“What makes you say 6?

“What might help you to get to a 7 or 8?”

“What could I do to help you to feel more confident?”

(From Keller and White, 1997; Rollnick, Mason and Butler, 1999)

• Provide tools, strategies, Provide tools, strategies, resources, skillsresources, skills

• Address barriersAddress barriers

• Attend to progress and to Attend to progress and to perceive slips as occasions perceive slips as occasions for problem solving for problem solving rather than as failurerather than as failure

Enhancing Confidence

Enhancing Confidence:Identifying Barriers & Problem-Solving

• What will get in the way?

• Anything else?

• What might help you to overcome that barrier?

• Anything help in the past?

• Here is what others have done...

• Ok, now what is your plan?

• Reassess confidence

Self-Management Support Cycle

Adapted from: Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87

EXPLORE :Needs, Expectations, Values,

Behavior, Progress SHARE :Provide specific

Information about

health risks,benefits of

change, and strategies to self-manage

SET GOALS:Collaboratively set

goals based on patient’s

conviction and confidence

in their ability to change

BUILD SKILLS :Identify personal

barriers, strategies, problem-solving

techniques and social/environmental

support

ARRANGE :Specify plan for

follow-up (e.g., visits,phone calls, mailed

reminders Personal Action Plan1. List specific goals

in behavioral terms2. List barriers and strategies

to address barriers3. Specify follow-up plan4. Share plan with practice

team and patient’s socialsupport

SMS: Key Components




Prepared,Proactive

Practice Team

Informed,Informed,ActivatedActivated

PatientPatient

Productive Interactions

Functional and Clinical Outcomes*E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound

Health SystemOrganization of Health Care

Self-Management

Support

DecisionSupport

DeliverySystemDesign

ClinicalInformation

Systems

CommunityCommunityResources and PoliciesResources and Policies

A Model for Planned Care*

Delivery System Redesign

• Determine process and define roles for Determine process and define roles for delivering SMS among members of the care delivering SMS among members of the care teamteam

• Planned Care visitsPlanned Care visits• Medical Group visitsMedical Group visits• Chronic Disease Self-Management groupsChronic Disease Self-Management groups• Planned peer interactionsPlanned peer interactions• Provide support and coordination according to Provide support and coordination according to

level of needlevel of need

Opportunities for SMS:Opportunities for SMS:When, Where and By WhomWhen, Where and By Whom

• Before the EncounterBefore the Encounter

• During the EncounterDuring the Encounter

• After the EncounterAfter the Encounter

Chronic Disease Self-Management Program

• Developed and studied by Kate Lorig and colleagues Developed and studied by Kate Lorig and colleagues at Stanford at Stanford

• Lay-leaders, 6 sessions, 2 1/2 hours eachLay-leaders, 6 sessions, 2 1/2 hours each• Single or multiple conditionsSingle or multiple conditions• Focus on collaborative goal-setting, personalized Focus on collaborative goal-setting, personalized

problem solving, skill acquisitionproblem solving, skill acquisition• Outcomes: improved health behaviors and health Outcomes: improved health behaviors and health

status, fewer hospitalizationsstatus, fewer hospitalizations• Limitations: limited population Limitations: limited population

(Lorig et al, Med Care 1999, 37:5-14; Lorig, et al., Med Care, 2001, 39: 1217-1223)

Clinical Information Systems

• Provide access to educational materials Provide access to educational materials and toolsand tools

• Create capacity to identify and contact Create capacity to identify and contact relevant subpopulations for proactive carerelevant subpopulations for proactive care

• Monitor and share SMS performance Monitor and share SMS performance data.data.

Community Linkages

• Identity community programs and resourcesIdentity community programs and resources

• Partner with community organizationsPartner with community organizations

• Partner with employersPartner with employers

• Raise community awareness: community Raise community awareness: community

campaignscampaigns

Implementing Health System Changes to Support Self-Management

• Quality Improvement CollaborativesQuality Improvement Collaboratives: : with focus on SMS (e.g., New Health with focus on SMS (e.g., New Health Partnerships) and Patient Activation (MN)Partnerships) and Patient Activation (MN)

• Educational Outreach Educational Outreach – QIOs, DOQ-IT, – QIOs, DOQ-IT, Voluntary AgenciesVoluntary Agencies

• Provider education and trainingProvider education and training - Core - Core Competencies, Motivational InterviewingCompetencies, Motivational Interviewing

• Incentives, rewards Incentives, rewards for provider delivery of for provider delivery of SMS, system changeSMS, system change

SMS: Key Components










• Action Planning



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