Stanford Self Management Programs: Learning to Live Well Mary Hertel, RN EBHP Coordinator/ Trainer, T-Trainer CDSMP, Master Trainer CPSMP Central MN Council on Aging (Area Agency on Aging) Jenny Fransen, RN, Care Coordinator and CDSMP Facilitator at Courage Center Stephanie Foo, MPH, Outcomes and Research Project Specialist at Courage Center Split Rock 2, City Side Tuesday 2:45 pm to 4pm

Information to be presented:  Define Evidence Based programs using the Stanford Self Management program as an example  Discuss Research and demonstrated outcomes  How EBP can fit within the patient engagement model, compare/contrast with patient education  Overview of specific EBP’s including Stanford Self-Management programs  Describe how you or your organization can get more involved

What is Evidence Based health promotion programming? Simply put it is: programs based on research.

What evidence do we need? Evidence that a health issue exists Evidence about design, context and attractiveness of program Evidence that a program is effective

Evidence based:

Why the interest in Evidence Based Programs? Magnitude and serious of health and social problems in our communities Awareness of preventability of many problems Emergence of evidence- based practices and programs Spend limited resources more efficiently

Informed, Empowered Patient and Family Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Patient Centered Timely and Efficient Coordinated Evidence-based and Safe

EBPs have Demonstrated Outcomes

Consider: “people with chronic conditions rarely spend more than 1% of their life at a healthcare facility. It is the other 99% of one’s life - when an individual is at home - that determines whether they return to full health or not.”

Chronically ill patients make many daily health decisions:  Diet, exercise, medication, when to seek medical care  Sometimes make unwise decisions  may not fully understand implications of particular health decision  may lack support to make better choices

Can Clients Be Engaged? 23% adopted new health behaviors (but unsure could maintain if stressed) Remaining 77%: Remain passive recipients (12%) Lack basic facts to follow treatment recommendations (29%) Have facts, but no skills, confidence (36%) Hibbard, J. H., Mahoney, E. R., Stock, R., & Tusler, M. (2007). Do increases in patient activation result in improved self-management behaviors? Health Services Research, 42,

How can Evidence Based Programs help?

Advantages of Evidence Based Programs: First, they can significantly improve the health and well- being of older adults in the community. Second, they can help attract new participants and funders through innovative programming. Third, they can create powerful partnerships with other organizations, including health care providers Evidence-based programming provides value

Evidence Based Programs (using Stanford as example) Stanford University Self Management Programs(in Minnesota): Chronic Disease Self Management (Living Well with Chronic Conditions) Chronic Pain Self Management Diabetic Self Management

Self-Management Differs From Patient Education (but we need both) Self-management - Manage life with disease - Problem solve and make decisions - Improve clients confidence in abilities to make changes - Increase skills & self- confidence Patient Education - Change behaviors - Information, technical skills - Disease–specific knowledge - Use specific tools (e.g., Care Plans, Action Plans)

Self-Management Also Encompasses:  The patient and health professional working together.  Often involves the family.  An holistic approach to care (i.e., medical and psycho-social components of a condition).  Pro-active and adaptive strategies that aim to empower the individual.

What is the Stanford Chronic Disease Self-Management Program (CDSMP) “Living Well with Chronic Conditions” Developed by Stanford University’s patient education program Stanford Programs are licensed Leader Training 4 days lead by 2 MasterTrainers Structured participants in a six-week workshop series done by 2 certified leaders Participative instruction with peer support Designed to enhance medical treatment Evidence-based: a tested model (intervention) that has demonstrated results

CDSMP Techniques Goal setting and action planning Feedback/ problem solving Decision Making Management tools

Curriculum including: Exercise and nutrition Medication usage Stress management and managing fatigue Talking with your doctor or health professional, family and friends Evaluating treatment choices Dealing with emotions, frustration and depression Living Well With Chronic Conditions Workshop Living Well With Chronic Conditions Workshops (CDSMP)

The format addresses specific problems and goals for people with ongoing health problems. It is not a drop-in support group. The workshops are not prescriptive. Participants choose their own goals and track their own progress toward success. Pair of trained peer leaders offer guidance and support, but participants find practical solutions individually and together. Keys to Success Living Well With Chronic Conditions Workshop

Stanford’s CDSMP is Evidence-based Found to benefit targeted populations. Including a decrease in health care costs Demonstrated it does not cause harm. Demonstrated it does not waste resources. CDSMP can facilitate the Triple Aim Goals

Evidence CDSMP participants experienced the following outcomes 6 months after starting the CDSMP program Increased exercise; Better coping strategies and symptom management; Better communication with their physicians; Improvement in their self-rated health, disability, social and role activities, and health distress; More energy and less fatigue; Decreased disability; Fewer physician visits and hospitalizations. Lorig et al., 1999

Chronic Conditions Reported and compiled by MDH Arthritis/other54% Hypertension51% High Chol36% Chronic Pain30% Diabetes24% Heart Disease22% Osteoporosis20% Cancer15% Depression14% Lung disease12% AMD9% Stroke8% Asthma6% Emphysema or COPD3% Parkinson’s Disease3% Kidney disease2% MS2% Other21%

Healthy Living with Courage CDSMP adapted for people with disabilities Offered at Courage Center Rehabilitation and resource center with co-located primary care, psychiatry, and physiatry Facilitated by registered nurse care coordinator and volunteer

The need for a self-management program is great… Persons with disabilities Likely to have multiple secondary conditions More likely to be physically inactive More likely to experience pain Face greater barriers to accessing timely primary care National Center for Health Statistics, 2011.

Healthy Living with Courage Participants Two six-week sessions since January 2013 Nine participants in total, five completed the program 78% male, 67% white 44% were 51 years of age and over 67% had public insurance

Healthy Living with Courage Participants

Adapting CDSMP Modifications are necessary to make CDSMP disability sensitive Some additions were made to the lessons and classroom setup Exercise issues: “Do what you can do.” Sensitivity to hearing, vision, and cognitive impairments Larger room, smaller group Avoid snacks, serve bottled water instead

Addressing Barriers Persons with disabilities face unique barriers that make attending the program more difficult Barriers to attendance must be addressed Transportation Organization Financial barriers Need for additional personal assistance

Outcomes Tracked pre-program and post-program scores for three measures Center for Disease Control’s Healthy Days measure Patient Activation Measure PROMIS Depression Measure (Short Form 8a) Post-program survey on self-reported improvements and satisfaction with program

Measures CDC’s Healthy Days Assesses perceived sense of well-being over past 30 days PROMIS Depression Measures symptoms of depression over past week Patient Activation Measure (PAM) Gauges patient’s knowledge, skills, and confidence in managing own health

Outcomes MeasuresBefore Program After Program Change Avg. HD Score Avg. Depression Score Avg. PAM Score Higher Healthy Days and PAM scores indicate improved outcomes. Lower PROMIS depression scores indicate improved outcomes.

Patient Activation Measure A change of one point is associated with 1.7% decline in hospitalizations 3.4% gain in A1c testing or LDL testing 1.8% gain in A1c control

Reported Improvements

Program Satisfaction

In summary… Improvements in Healthy Days, PROMIS depression, and PAM scores were detected but were not statistically significant Small sample size Measurement period Post-program survey indicates that participants believe the program helped them better manage their stress and health conditions Realistic expectations Self-acceptance Tools for self-care (action plans, relaxation exercises)

Facilitator Feedback Facilitating the program can be demanding Time commitment Consciousness and support of clients’ disability needs But also very rewarding “Participants have a sense of pride in their accomplishments and want to continue to succeed in making positive changes in their health. I’ve been seeing patients that attended the program more frequently in our clinic since the class ended.” Facilitators also benefit from the program

Chronic Pain Self-Management CPSMP is a 6 week, 2.5 hours per week workshop developed for people who have a primary or secondary diagnosis of chronic pain. Pain is defined as being chronic or long term when it lasts for longer than 3 to 6 months, or beyond the normal healing time of an injury. During this workshop a variety of topics important to those with chronic pain are covered including: goal setting, relaxation, nutrition, medication management, exercise, communication and problem solving Requires 2 Certified trained Leaders Training is either 4 days or 2 days if CDSMP trained

Diabetic Self-Management Program DSMP is a 6 week, 2.5 hours per week. This workshop is for people with type 2 diabetes. It teaches the skills needed in the day-to-day management of diabetes and to maintain and/or increase life’s activities. Requires 2 Certified trained Leaders Training is either 4 days or 2 days if CDSMP trained

Implementation of CDSMP in Minnesota Current license holders include: Central MN Council on Aging(Area Agency on Aging) 5 Area Agencies on Aging covering all of Minnesota Minnesota Department of Health Native American Community Clinic: “Living in Balance” Sanford Health: “Better Choices, Better Health” Veterans’ Administration Health System

Options for Involvement Offer the program(s) at your clinic/organization with your staff, and/or volunteer peer leaders. Training is available through the Area Agencies on Aging (please see handout) Offer the program at your clinic/organization in partnership with a community provider Refer your patients to programs that your organization offers or to community partners; visit for a listing of workshops or call Senior Linkage Line

MN Healthy Aging website

Resources Minnesota Board on Aging: National Council on Aging (NCOA): NCOA: Center for Healthy Aging Online Training Modules: modules/ modules/ Highest Tier Evidence-Based Health Promotion/Disease Prevention Programs IIID-Highest-Tier-Evidence-FINAL.pdf IIID-Highest-Tier-Evidence-FINAL.pdf Stanford Patient Education Research Center: SAMHSA National registry of Evidence Based Programs and Practices:

Questions ? “Those things that we do for ourselves, day-to-day that improve or maintain our health and make us feel better”

Contact information: Mary Hertel: RN, T-Trainer CDSMP, Master Trainer CPSMP, DSMP Central MN Council on Aging (Area Agency on Aging) Direct: Agency: Jenny Fransen, RN, Care Coordinator and CDSMP Facilitator at Courage Center Stephanie Foo, MPH, Outcomes and Research Project Specialist at Courage Center