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Patient as PartnersPatient as PartnersImproving Health and Cost Improving Health and Cost
Outcomes with Self-Care and Outcomes with Self-Care and Chronic Disease Self-ManagementChronic Disease Self-Management
NatPaCT Conference ProgrammeNatPaCT Conference ProgrammeLearning from Kaiser Permanente Learning from Kaiser Permanente
– How can the NHS make better use of its resources – How can the NHS make better use of its resources and improve patient care?and improve patient care?
Tuesday 4 November 2003 – The Brewery, LondonTuesday 4 November 2003 – The Brewery, London
David S. Sobel, MD, MPHDavid S. Sobel, MD, MPHDirector, Patient Education and Health PromotionDirector, Patient Education and Health Promotion
Kaiser Permanente Northern CaliforniaKaiser Permanente Northern California1950 Franklin Street., 13th Floor, Oakland, CA 946121950 Franklin Street., 13th Floor, Oakland, CA 94612
Phone: 510-987-3579Phone: 510-987-3579Fax: 510-873-5379Fax: 510-873-5379
E-mail: [email protected]: [email protected]
Strategy for Changing Strategy for Changing Culture and PracticeCulture and Practice
Look forLook for inefficiencies, mismatches, and capacityinefficiencies, mismatches, and capacity overlooked evidence and dataoverlooked evidence and data ““win, win, win” opportunitieswin, win, win” opportunities
Strategy for Changing Strategy for Changing Culture and PracticeCulture and Practice
Rethink CareRethink Care
1.1. Patients as primary providers of acute illnessPatients as primary providers of acute illness
2.2. Self-management of chronic illnessSelf-management of chronic illness
3.3. Behavioral interventions to address psychosocial Behavioral interventions to address psychosocial needsneeds
Restructure CareRestructure Care Telephone, group appointments, web-based careTelephone, group appointments, web-based care
Retrain for Collaborative CareRetrain for Collaborative Care
Enhance understanding, skills, and confidence of Enhance understanding, skills, and confidence of members and professional staff as partners in caremembers and professional staff as partners in care
Rethinking Care 1: Rethinking Care 1: Self-Care for Acute IllnessSelf-Care for Acute Illness
PatientPatientas Consumeras Consumer
PatientPatientas Provideras Provider
Hidden Health Care SystemHidden Health Care System
Self-CareSelf-Care80%80%
Professional CareProfessional Care20%20%22
11
33
Self-Care: Self-Care: Patients as ProvidersPatients as Providers
Over 80% of all medical symptoms are self-Over 80% of all medical symptoms are self-diagnosed and self-treated without diagnosed and self-treated without professional care.professional care.
Patients are the true primary care providers Patients are the true primary care providers of medical care for themselves and their of medical care for themselves and their families.families.
How can health care systems educate, How can health care systems educate, equip, and empower the true primary care equip, and empower the true primary care providers… providers… patientspatients??
Kaiser PermanenteKaiser Permanente Self-Care ProgramSelf-Care Program
Vision: “Partners in Health”Vision: “Partners in Health” A system intervention that changes the culture A system intervention that changes the culture
of care and supports members making safe, of care and supports members making safe, appropriate, and informed health care choicesappropriate, and informed health care choices
KP Healthwise HandbooksKP Healthwise Handbooks distributed to all distributed to all membersmembers
Provider training and reinforcementProvider training and reinforcement Continuing systemwide reinforcementContinuing systemwide reinforcement
Kaiser PermanenteKaiser Permanente
Healthwise HandbookHealthwise Handbook
Kaiser PermanenteKaiser Permanente Self-Care ProgramSelf-Care Program
ResultsResults High use of the KP Healthwise HandbookHigh use of the KP Healthwise Handbook
70% in previous 6 months70% in previous 6 months Improved member self-care confidenceImproved member self-care confidence
71% more confident71% more confident Increased member satisfactionIncreased member satisfaction
60% more positive about Kaiser Permanente60% more positive about Kaiser Permanente More appropriate utilization & improved accessibilityMore appropriate utilization & improved accessibility
50% report saving a call or visit to MD50% report saving a call or visit to MD 6% medical visits and 6% medical visits and 5%telephone calls5%telephone calls
Improved provider and staff satisfactionImproved provider and staff satisfaction
Rethinking Care 2: Rethinking Care 2: Self-Management of Chronic IllnessSelf-Management of Chronic Illness
PatientPatientas Consumeras Consumer
PatientPatientas Provideras Provider
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model
E. WagnerE. Wagner
Living with Chronic DiseaseLiving with Chronic Disease
Managing the IllnessManaging the Illness Taking medicationsTaking medications Changing diet and exerciseChanging diet and exercise Managing symptoms of pain, fatigue, insomnia, Managing symptoms of pain, fatigue, insomnia,
shortness of breath, etc.shortness of breath, etc. Interacting with the medical care systemInteracting with the medical care system
Managing Daily Activities and RolesManaging Daily Activities and Roles Maintaining roles as spouse, parent, worker, etc.Maintaining roles as spouse, parent, worker, etc.
Managing the EmotionsManaging the Emotions Managing anger, fear, depression, isolation, etc.Managing anger, fear, depression, isolation, etc.
Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M: Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M: Living a Healthy Living a Healthy Life with Chronic ConditionsLife with Chronic Conditions, Palo Alto, CA: Bull Pub. Co., 2000, Palo Alto, CA: Bull Pub. Co., 2000
Healthier Living with Healthier Living with Ongoing Health Conditions*Ongoing Health Conditions*
Lay-led, small interactive groups Lay-led, small interactive groups (2 hours/week for 7 weeks)(2 hours/week for 7 weeks)
Mixed chronic disease and co-morbiditiesMixed chronic disease and co-morbidities ContentContent
Goal setting and problem-solvingGoal setting and problem-solving Cognitive symptom managementCognitive symptom management Design of exercise programsDesign of exercise programs Management of fatigue, sleep, pain, anger, Management of fatigue, sleep, pain, anger,
depressiondepression Appropriate use of medicationsAppropriate use of medications Patient/physician communicationPatient/physician communication Use of advanced directivesUse of advanced directives
Lorig K et al Lorig K et al Medical CareMedical Care 1999;37:5-14. 1999;37:5-14. http://patienteducation.stanford.edu/http://patienteducation.stanford.edu/
*aka Chronic Conditions Self-Management *aka Chronic Conditions Self-Management Program, Expert Patient Programme Program, Expert Patient Programme
Healthier Living with Healthier Living with Ongoing Health ConditionsOngoing Health Conditions
Improves health behaviors and health statusImproves health behaviors and health status Cost effective (estimated 5:1 to 10:1 ROI)Cost effective (estimated 5:1 to 10:1 ROI) Outcomes are long-lasting and robust (2+yrs.)Outcomes are long-lasting and robust (2+yrs.) Replicable and dissemination can yield outcomes Replicable and dissemination can yield outcomes
as good, or better.as good, or better.
Lorig KR, Sobel DS, Lorig KR, Sobel DS, Effective Clin PracticeEffective Clin Practice 2001;4:256-262 2001;4:256-262Lorig KR, Lorig KR, Medical CareMedical Care 2001;39:1217-1223 2001;39:1217-1223
Chronic Disease Chronic Disease Self-Management ProgramSelf-Management Program
LESSONSLESSONS General coping skills education for heterogeneous General coping skills education for heterogeneous
conditions complements disease specific informationconditions complements disease specific information Patients are the “experts” in living and coping with Patients are the “experts” in living and coping with
chronic illnesschronic illness Modeling more effective than “save and rescue”Modeling more effective than “save and rescue” No significant difference in participants’ outcome with No significant difference in participants’ outcome with
lay vs professional leaderslay vs professional leaders Confidence predicts improvement in health outcomesConfidence predicts improvement in health outcomes People benefit themselves from helping other peoplePeople benefit themselves from helping other people Process is more important than contentProcess is more important than content
Rethinking Care 3: Rethinking Care 3: Behavioral MedicineBehavioral Medicine
BodyBodyas Machineas Machine
MindMindas HMOas HMO
Sobel DS: The cost-effectiveness of mind-body medicine interventions. In The Biological Basis for Mind Body Interactions, Progress in Brain Research, Vol 122, EA Mayer and CB Saper (Eds.), Elsevier, 2000:393-412.
Somatic Symptom SuperhighwaySomatic Symptom Superhighway
Medical IllnessMedical Illness
Psychiatric DisorderPsychiatric DisorderEmotional Emotional DistressDistress
Somatic SymptomsSomatic Symptoms
Final Common PathwayFinal Common Pathway
Psychological Status of Psychological Status of Primary Care PatientsPrimary Care Patients
0
10
20
30
40
50
60
70
80
90
Psychiatric Disorder Psychological Distress
Causes of Common Symptoms Causes of Common Symptoms in Primary Care Medicinein Primary Care Medicine
Kroenke, Kroenke, Am J MedAm J Med 1989:86:262-6 1989:86:262-6
Psychological10%
Organic16%
Unknown74%
Chest pain, fatigue, dizziness, headache, back pain, Chest pain, fatigue, dizziness, headache, back pain, edema, dsypnea, insomnia, abdominal pain, numbnessedema, dsypnea, insomnia, abdominal pain, numbness
Depressive SymptomsDepressive Symptoms
Depressive Depressive symptomssymptoms more debilitating in more debilitating in terms of physical and social functioning terms of physical and social functioning than:than:
diabetesdiabetes arthritisarthritis gastrointestinal disordersgastrointestinal disorders back problemsback problems hypertensionhypertension
Wells et al. Wells et al. JAMAJAMA 1989;262:914-930 1989;262:914-930
Psychosocial DysfunctionPsychosocial Dysfunctionin Medical Carein Medical Care
Common Common Undiagnosed or inadequately treatedUndiagnosed or inadequately treated Significant impact on:Significant impact on:
functional status and disabilityfunctional status and disability medical utilization and costsmedical utilization and costs medical morbidity and mortalitymedical morbidity and mortality
Health Care services mismatched to needsHealth Care services mismatched to needs Need to develop integrated behavioral health Need to develop integrated behavioral health
education serviceseducation servicesSobel DS: Rethinking medicine: Improving health outcomes with cost-effective Sobel DS: Rethinking medicine: Improving health outcomes with cost-effective psychosocial interventions. psychosocial interventions. Psychosomatic MedicinePsychosomatic Medicine 57:234-244, 1995. 57:234-244, 1995.
Mind/Body Medicine Program EvaluationMind/Body Medicine Program EvaluationPre- and Post-Class Pre- and Post-Class
SCL-90 Sub-scale MeasuresSCL-90 Sub-scale Measures
% C
lass
ife
d a
s P
sy
ch
% C
lass
ife
d a
s P
sy
ch
Ou
tpa
tien
t C
ase
s o
n S
CL
-90
Ou
tpa
tien
t C
ase
s o
n S
CL
-90
Nancy Gordon - DOR (June, 2000)Nancy Gordon - DOR (June, 2000)
12 NCal Facilities12 NCal Facilities
0%0%
10%10%
20%20%
30%30%
40%40%
50%50%
60%60%
70%70%
DepressionDepression(n=124)(n=124)
SomatizationSomatization(n=120)(n=120)
AnxietyAnxiety(n=121)(n=121)
62.1% 61.2% 60.0%
28.2%21.5%
31.7%
Intake Post-Program
00
500500
10001000
15001500
20002000
25002500
30003000
ADPADP+34%+34%
ERER- 45%- 45%
MedMed-37%-37%
UrgUrg-22%-22%
PsyPsy- 41%- 41%
Utilization Change for Utilization Change for Mind/Body Medicine ParticipantsMind/Body Medicine Participants
TotalTotalVisitsVisits
Ngissah, Levine, & Walsh (1998 - N. Valley) Ngissah, Levine, & Walsh (1998 - N. Valley)
N=609N=609
6-Mo. Pre 6-Mo. Post
RethinkingRethinking Health Improvement InterventionsHealth Improvement Interventions
HealthHealthOutcomesOutcomes
AttitudesAttitudesBeliefsBeliefsMoodsMoods
Health Health BehaviorBehaviorChangeChange
Lorig K, Arthritis and Rheumatism. 1989;32:91-95
Confidence CountsConfidence Counts
Psychosocial Psychosocial SkillsSkills
Targeting CoreTargeting Core Attitudes, Beliefs, and MoodsAttitudes, Beliefs, and Moods
CORECOREAttitudesAttitudesBeliefsBeliefsMoodsMoods
Problems Problems in Livingin Living
Behavioral Behavioral Risk Risk
ReductionReduction
Mental Mental IllnessIllness
Quality of LifeQuality of Life
Medical Medical ConditionsConditions
Ornstein R, Sobel D: Ornstein R, Sobel D: Healthy PleasuresHealthy Pleasures. Addison-Wesley, 1989. Addison-Wesley, 1989
Restructuring CareRestructuring Care
Group Group AppointmentsAppointments
andandWeb-basedWeb-based
CareCare
Medical Medical Office VisitsOffice Visits
Medical Group AppointmentsMedical Group Appointments(Group Visits, Cluster Visits, etc.)(Group Visits, Cluster Visits, etc.)
Scheduled or ‘drop-in’ visit for group of patients with similar Scheduled or ‘drop-in’ visit for group of patients with similar or mixed health conditionsor mixed health conditions
Under direction of physician or other licensed health care Under direction of physician or other licensed health care professionalprofessional
Provision of individualized clinical servicesProvision of individualized clinical services Medical Assessment Medical Assessment
history, physical assessment, triage, referralhistory, physical assessment, triage, referral Medical InterventionMedical Intervention
medication prescription/adjustment, lab testsmedication prescription/adjustment, lab tests
Diabetes Cooperative Care ClinicDiabetes Cooperative Care Clinic
Randomized clinical trial, n=185, f/u 1yr, 2hr group monthly x 6Randomized clinical trial, n=185, f/u 1yr, 2hr group monthly x 6
OutcomesOutcomes lower HgbA1C (lower HgbA1C ( 1.3% vs. 1.3% vs. 0.22% controls, p<0.0001)0.22% controls, p<0.0001) more home blood glucose monitoringmore home blood glucose monitoring reduced hospital and outpatient utilization reduced hospital and outpatient utilization
hospitalizations 80% more frequent in controlhospitalizations 80% more frequent in control fewer physician and nonphysician visits fewer physician and nonphysician visits
increased self-efficacy increased self-efficacy diet, management of low BG and BG when sickdiet, management of low BG and BG when sick
increased satisfactionincreased satisfaction
Sadur CN, Diabetes Care, Sadur CN, Diabetes Care, 1999;12:2011-20171999;12:2011-2017
Restructure Care:Restructure Care:Web-Based Care at kp.orgWeb-Based Care at kp.org
www.kaiserpermanente.org
Get Health AdviceGet Health Advice
Appointment/Rx RefillsAppointment/Rx Refills
Physician Personal
Home Page:A Personal
Portal to Kaiser
Permanente Online
Services
Retraining for Retraining for Collaborative CareCollaborative Care
Traditional, Traditional, PaternalisticPaternalistic
CareCare
CollaborativeCollaborativeCareCare
How Traditional Care Differs How Traditional Care Differs from Collaborative Carefrom Collaborative Care
IssueIssue Traditional Care/Traditional Care/Patient EducationPatient Education
Collaborative Care/Collaborative Care/Self-Management EducationSelf-Management Education
RelationshipsRelationships Professional are expert. Professional are expert. Patients are passive.Patients are passive.
Shared expertise with active Shared expertise with active patients. Patient expert in their patients. Patient expert in their experience of diseaseexperience of disease
Needs Needs AssessmentAssessment
Provider defines what Provider defines what patients need to know. patients need to know.
Patient defined problemsPatient defined problems
ContentContent Disease managementDisease management Disease, role, and emotional Disease, role, and emotional managementmanagement
ProcessProcess Prescribed behavior change. Prescribed behavior change. Provider solves problems. Provider solves problems. External motivation. Didactic External motivation. Didactic presentations.presentations.
Self-defined goals. Patient Self-defined goals. Patient learns problem-solving skills. learns problem-solving skills. Focus on internal motivation Focus on internal motivation and self-efficacy. Interactive.and self-efficacy. Interactive.
OutcomesOutcomes Knowledge and behaviorKnowledge and behavior Health status and appropriate Health status and appropriate utilizationutilization
adapted from Bodenheimer, Lorig, et al JAMA 2002;288:2469.adapted from Bodenheimer, Lorig, et al JAMA 2002;288:2469.
Retraining for Collaborative CareRetraining for Collaborative Care
Thriving in a Busy Practice: Thriving in a Busy Practice: Clinician-Patient CommunicationClinician-Patient Communication
(“Four Habits of Effective Clinicians”)(“Four Habits of Effective Clinicians”) Brief NegotiationBrief Negotiation Practice Essentials for Care ManagersPractice Essentials for Care Managers Education for Health ActionEducation for Health Action Group Appointment ToolkitGroup Appointment Toolkit
Address member’s needs in 3 domains:Address member’s needs in 3 domains:1. Disease and Health Management1. Disease and Health Management2. Role Management2. Role Management3. Emotional Management3. Emotional Management
Use state-of-art communication/educational strategies:Use state-of-art communication/educational strategies: Transform didactic, information-based approaches into interactive, self-Transform didactic, information-based approaches into interactive, self-
efficacy/confidence enhancing communication that strengthens patients’ efficacy/confidence enhancing communication that strengthens patients’ skills in problem-solving, goal setting and action planning, self-tailoring, skills in problem-solving, goal setting and action planning, self-tailoring, using available resources, forming a partnership with clinician using available resources, forming a partnership with clinician
Ask questions and elicit patient perspective and engagement in action Ask questions and elicit patient perspective and engagement in action planning and problem-solving planning and problem-solving
Use nonjudgmental and positive toneUse nonjudgmental and positive tone Link back to member’s routine source of care and team care and peer Link back to member’s routine source of care and team care and peer
supportsupport
Retraining for Collaborative Care:Retraining for Collaborative Care:Key StrategiesKey Strategies
Patients as Partners: Patients as Partners: Changing Culture and PracticeChanging Culture and Practice
Rethink CareRethink Care1.1. Patients as primary providers of acute illnessPatients as primary providers of acute illness
2.2. Self-management of chronic illnessSelf-management of chronic illness
3.3. Behavioral interventions to address psychosocial Behavioral interventions to address psychosocial needsneeds
Restructure CareRestructure Care Telephone, group appointments, web-based careTelephone, group appointments, web-based care
Retrain for Collaborative CareRetrain for Collaborative Care Enhance understanding, skills, and confidence of Enhance understanding, skills, and confidence of
members and professional staff as partners in caremembers and professional staff as partners in care
AppendicesAppendices
Four Habits of Highly Effective Four Habits of Highly Effective Clinicians Clinicians
1.1. Invest in the BeginningInvest in the Beginning
2.2. Elicit the Patient’s PerspectiveElicit the Patient’s Perspective
3.3. Demonstrate EmpathyDemonstrate Empathy
4.4. Invest in the EndInvest in the End
Frankel RM, Stein T. Frankel RM, Stein T. Getting the Most out of the Clinical Encounter: The Getting the Most out of the Clinical Encounter: The
Four Habits ModelFour Habits Model. The Permanente Journal, Fall 1999, Vol 3, No. 3. The Permanente Journal, Fall 1999, Vol 3, No. 3 http://www.kaiserpermanente.org/medicine/permjournal/fall99pj/frhabits.htmlhttp://www.kaiserpermanente.org/medicine/permjournal/fall99pj/frhabits.html
2003 CMI Evidence-Linked 2003 CMI Evidence-Linked RecommendationsRecommendations
Embed Self-Mgt into Pop Mgt:Embed Self-Mgt into Pop Mgt: Lower intensityLower intensity interventions interventions ((automated
phone messages, staged mailings, videos, online) ) for for all patientsall patients
Higher intensityHigher intensity (e.g. multi-session programs)(e.g. multi-session programs) for those with higher needsfor those with higher needs
Robert Wood Johnson Foundation and Center for the Advancement of Health. Essential Elements of Self-Management Interventions, 2002.
Von Korff M, Tiemens B. West J Med 2000; 172(2):133-137.Piette JD,e al. Am J Med 2000; 108(1):20-27.Serxner S, et al. Congestive Heart Failure; 1998. May/June:23-28.
2003 CMI Evidence-Linked 2003 CMI Evidence-Linked Recommendations, cont’d.Recommendations, cont’d.
During clinical encounter, support During clinical encounter, support member’s central role in health:member’s central role in health:
Collaborative communication (Collaborative communication (Brief Negotiation, 4 Habits)Brief Negotiation, 4 Habits)
Assess member’s self-mgt needs; provide tailored Assess member’s self-mgt needs; provide tailored feedback and behavioral advisefeedback and behavioral advise
Collaboratively set behavioral goals and action plan. Collaboratively set behavioral goals and action plan. Document and share with member.Document and share with member.
Offer self-mgt resources; refer to programsOffer self-mgt resources; refer to programs F/up to adapt plan and address relapseF/up to adapt plan and address relapseGlasgow RE et al. Ann Behav Med 2002; 24(2):80-87.Stewart MA. CMAJ 1995; 152(9):1423-1433. Petrella RJ, Lattanzio CN. Can Fam Physician 2002; 48:72-80.Rice VH. Heart Lung 1999; 28(6):438-454.Boulware LE, et al. Am J Prev Med 2001; 21(3):221-232.
2003 CMI Evidence-Linked 2003 CMI Evidence-Linked Recommendations, cont’d.Recommendations, cont’d.
Strengthen Adherence to Strengthen Adherence to Prescribed Medications:Prescribed Medications:
Anticipate nonadherence: “Have you ever missed or forgot to take your pills?”
Identify personal barriers and problem solve. Avoid assuming causes of nonadherence
Collaboratively develop a regimen pt is willing and able to follow. Praise efforts to adhere.
As needed, refer for pharmacist consultation
McDonald HP, et al. JAMA 2002; 288(22):2868-2879.Haynes RB , et al. JAMA 2002; 288(22):2880-2883.Yuan Y, et al. Am J Manag Care 2003; 9(1):45-56.
2003 CMI Evidence-Linked 2003 CMI Evidence-Linked Recommendations, cont’d.Recommendations, cont’d.
Turn didactic pt education into self-Turn didactic pt education into self-mgt education mgt education
Beyond knowledge to skills & confidence: Problem solving training (incl. medication adherence)
Goal setting and action planning Peer modeling and support Experiential exercises (relaxation session, read peak flow
meter, pick from a menu)
Forming partnership with clinician
Bodenheimer T et al. JAMA 2002; 288(19):2469-2475.Norris S et al. Diabetes Care 2002; 25(7):1159-1171.Gibson PGM et al. Cochrane Database Syst Rev 2002;2.Barlow J, et al.Patient Educ Couns 2002; 48(2):177-187.
2003 CMI Evidence-Linked 2003 CMI Evidence-Linked Recommendations, cont’d.Recommendations, cont’d.
Offer multiple options to receive self-Offer multiple options to receive self-mgt education:mgt education:
Staged mailings based on readiness to change Telephone group sessions Group visits Internet-based programs Community and work site programs
Serxner S, et al. Congestive Heart Failure 1998; May/June:23-28.Boucher, JL et al. Diabetes Spectrum 1999 12(2).121-123.Wagner EH et al. Diabetes Care 2001; 24(4):695-700.McKay HG, et al. Diabetes Care 2001; 24(8):1328-1334.Norris SL et al. J Prev Med 2002; 22(4 Suppl):39-66.Pelletier KR. Am J Health Promot 2001; 16(2):107-116.