Training Medical Students to Teach Self-Management Skills to Patients with Chronic Disease Maureen R. Gecht-Silver OTR/L, MPH Christine J. Bobek FNP UIC Department of Family Medicine STFM Predoc Conference Jacksonville January 31, 2010

Objectives By the end of the session, participants will be able to: Discuss evidence-based models and approaches useful in teaching self- management skills Demonstrate at least one self-management technique Apply Self Management Learning Lab strategies to their respective settings

Background UIC Longitudinal patient-centered medicine curriculum for medical students M1 : Patient Centered Continuity of Care M2 : Service Learning with vulnerable populations M3 : Patient Empowerment M4 : Interdisciplinary Team Self-Management Learning Lab is part of the M3 component Partially funded by IDPH and HRSA

Definition Self-Management Day-to-day decisions and actions that individuals undertake to live with one or more chronic health conditions Key Tasks Medical or Behavioral Management Role Management Emotional Management

Self-Management Support Systematic provision of education and supportive interventions by health care system to: Encourage daily decisions that improve health-related behaviors and clinical outcomes Transformation to a collaborative patient provider partnership

Overview of Evidence- Based Approaches Used to Shape this Curriculum

Chronic Disease Self-Management Program (CDSMP) Kate Lorig et al Description of this group program Structured community-based six-week program 2.5 hour sessions Designed to enhance participant’s self-efficacy Self-Management Strategies Action planning Problem-solving Phone follow-up

Chronic Care Model Edward H Wagner MD, MPH, MacColl Institute, Seattle

Motivational Interviewing Semi-directive person-centered counseling style for helping people find their own reasons to change Spirit of MI Collaborate, Evoke, Honor Autonomy Guiding principles (RULE) Resist righting reflex Understand Listen Empower Skills and Strategies Rollnick et al, Motivational Interviewing in Healthcare

Literature Review of Evidence for Self-Management Education Limitations Unclear description of interventions being studied Variability of content and outcome measures Sustainability of outcomes and/or cost reduction uncertain Limited replication of results in general population

Evidence for Effective Self-Management Education Self-management programs result in small to moderate health behavior changes Diabetes self-management programs work in real world community and clinic settings “Stages of change theory” useful in smoking cessation but not chronic disease management

Evidence For Collaboration Traditional medical practice rarely employs collaboration Collaborative relationship MUST be added to information giving in order to improve outcomes Strongest evidence in support of self- management interventions is collaboration

Evidence on Teaching Self- Management Skills “Information only” programs are important but not sufficient for behavior change Use of goal setting in primary care shows promising results in behavior change Asthma action plans Targeted physical activity and nutrition goals Increased self efficacy Action plans result in better diet, exercise and weight loss

Self-Management Learning Lab Developed for residents 4 years ago with IDPH grant Medical student version three years old Programs in variety of settings UIC Wellness Center-Student and employees Cathedral Shelter-Homeless individuals with alcohol and drug history Rush Hospital Outreach-Older adults with chronic health problems

Goals of the Self-Management Learning Lab (SMLL) Teach medical students to instruct patients in self-management skills Conduct program in a manner that benefits participants

Student Training Blackboard site Readings Assignments Two-hour training pre-workshop Written curriculum guides for each session Brief meetings pre and post sessions

Structure Three 2-hour sessions Session 1: Introduction to Self Management Session 2: Be an Active Member of Your HealthCare Team Session 3: Enhancing Healthy Habits Sample Session Agenda Feedback/Problem-Solving Education Session Break with Healthy Snack Action Planning Wrap-up

Self-Management Skills Taught OARS Open-ended questions Affirmation Reflective listening Summarize

Self-Management Strategies Taught “Ask--Don’t tell” Problem-solving Identification of strengths Interactive health education based on patient needs Phone follow-up Agenda setting with bubble chart Action planning

Agenda Setting (Bubble Chart)

Action Planning Form Calfornia Healthcare Foundation

Demonstration

Strengths Practice with real patients Read short articles and textbook Set own action plan, not just patients Make follow-up phone calls Teach 15-minute interactive education session

Proposed Changes Reduce online blackboard assignments Shorten pre post sessions, still reinforce content Identify reasonable practice opportunities Extend application to broader patient population “These patients were motivated” Explore programming options to reach more students

New Developments Introduction to Self management 4-hour workshop for M3s (two 2-hour sessions ) Performance test for residents using two standardized patient cases

Discussion

References Lorig KR, Ritter P, Steward AL,Sobel DS et al. Chronic Disease Self-Management Program 2-year Health Status and Health Care Utilization Outcomes. Medical Care 39:11 pp , Warsi A, Wang P, La Valley et al. Self-Management Education Programs in Chronic Disease. A systematic Review and Methodological Critique of the Literature. Arch Inter Med 164, Aug 9/23, Fisher E, Brownson CA, O’Toole ML et al. Perspectives on Self-Management From the Diabetes Initiative of the Robert Wood Johnson Foundation. Diabetes Education 33;216s, Bodenheimer T, Lorig K, Holman H, and Grumbach K. Patient Self-Management of Chronic Disease in Primary Care. JAMA 288:19, Nov 20, Handley M, MacGregor K et al. Using Action Plans to Help Primary Care Patients Adopt Healthy Behaviors: A Descriptive Study. JABFM 19:3, May-June Bodenheimer T, MacGregor K, and Sharifi C, Helping Patients Manage their Chronic Conditions, California HealthCare Foundation, 2005.

Useful Resources Bodenheimer T and Grumbach K: Improving Primary Care. New York: Lange Medical Books, McGraw Hill, Lorig K, Holman HR, Sobel D, Laurent D, González V, Minor M: Living a Healthy Life with Chronic Conditions (2nd Edition). Boulder CO: Bull Publishing, Rollnick S, Miller WR, Butler CC: Motivational Interviewing in Health Care, Guilford Press, AMA Resource Guide to Patient Self-Management Support Stanford Patient Education Resource Center

Contact Information: Maureen Gecht-Silver OTR/L, MPH UIC Department of Family Medicine Chris Bobek FNP UIC Department of Family Medicine