Programs for Improving Health & Wellbeing A Case for Chronic Disease Self-Management Education Sue Vaeth Health and Aging Liaison, DHMH

Purpose  Learn what the Chronic Disease Self-Management Program (CDSMP) is and how it is being implemented in Maryland  Learn how CDSMP interfaces with Patient Centered Medical Homes  Learn how “Living Well” can help meet the Triple Aim of improving care management, clinical outcomes, and lower health care costs  Learn how CDSMP has evolved on the Eastern Shore, and how it has benefitted health care partners and the community

 Self-management programs empower people to take an active role in managing their chronic illnesses.  These programs help participants make lifestyle choices and changes, adhere to prescribed medical treatments, and become educated, responsible and informed patients.  Based on its wide availability, proven results, and fulfillment of several of the NCQA’s Physician Practice  Connections® – Patient Centered Medical Home (PCC- PCMH-CMS™) guidelines, the CDSMP is a key resource for providers in meeting the requirements to become a medical home. What is Self-Management and Why is it Important?

Why Self-Management Workshops? The CDSMP program is built on three underlying assumptions:  1. Regardless of the chronic condition, people have similar challenges with self management.  2. People can learn the skills needed to better manage their diseases day to day.  3. People who understand and take control of their condition will be healthier and happier.

Role of Self-Management Programs in PCMH Recognition  NCQA Recognition Standards reinforce the critical role of patient self-management and practice self- management support  Referring patients to CDSMP workshops offered in your community will help qualify medical practices  to meet the following activities: Provides or connects patients/families to self- management support programs Provides or connects patients/families to classes taught by qualified instructors Provides or connects patients/families to other self- management resources where needed

Benefits of Self-Management Programs in Health Care  Connects external resource to medical practices to enhance medical treatment, e.g., improve clinical outcomes and decrease utilization  Empowers patients to increase control of their health  Promotes collaboration and continuity of care among providers, community/organizations, individuals, caregivers  Ensures quality by maintaining fidelity to the program  Reinforces communication “feedback loop”  Documents disease education/self-management in PCMH terms

 Historically an Aging Network program  Prevention and Health Promotion Admin (PHPA):  Prison Project - Allegany AAA  CDC grant - 5 year grant providing funding for Living Well, with focus on diabetes  Quit Line Referrals  IRB Approval  Branching out to include many types of health care and community partnerships DHMH and Department of Aging Support

Aging Network – An Infrastructure that Supports 11 Million Older Adults and Caregivers AoA 56 State Units on Aging 629 Area Agencies 246 Tribal organization 242 million meals 20,000 Service Providers & 500,000 Volunteers 28 million rides 29 million hours of personal care 69,000 caregivers trained 855,000 assisted 4 million hours of case management 0ver 22,000 individuals transitioned 81,759 individuals completing CDSMP Provides Services & Supports to 1 in 5 Seniors

Area Agency on Aging (AAA Services)  MARYLAND ACCESS POINT (Information, Assistance, and Options Counseling)  Advocacy and Assistance Programs (LTC Ombudsman, Public Guardianship, Elder Abuse Prevention)  Caregiver Support  In-Home Services  Insurance Assistance (SHIP)  Health Promotion and Disease Prevention  Nutrition (Meals on Wheels and Congregate Meals)  Medicaid Home and Community Based Services  Senior Centers  Volunteer Services  Assisted Living Program Subsidies  MAC, Inc.  Day Care Center for the memory impaired  Wellness Center  Evidence-based program training, implementation and quality assurance  50+ Network for Creative Engagement  Assisted Transportation  Community Outreach

 Most Maryland counties and Baltimore City  Western Maryland  Southern Maryland  Eastern Shore Maryland’s Living Well

CDSMP workshop types include…  Living Well - All chronic conditions (CDSMP)  Chronic Pain Self Management Program – (CPSMP)  Living Well with Diabetes (DSMP)  New Cancer CDSMP just beginning on the Eastern Shore  Others developed but not currently being provided in Maryland:  Arthritis and HIV  On-line CDSMP  Other languages (52 countries in 20+ languages)  Maryland - Korean, Chinese

Living Well Reach

What People Are Saying…  “The…class has been a remarkable resource for anyone dealing with chronic health problem. Living healthy life.”  “During the many years I've had diabetes, I never really knew what to eat and that is one of the most important elements in managing diabetes. Thank you to our instructors!”  “I have a better understanding of how to manage my chronic pain. Very helpful class!”

So just what goes on in Living Well?  6-week workshop, 2.5 hours per session  Interactive peer-led groups of people  Facilitated by 2 trained peer leaders, most of whom are non- health professionals with chronic diseases or are caregivers  Standardized participant materials and standardized training for leaders  Highly scripted to maintain fidelity to original program  Free or low cost to participants  Learn skills that complement clinical care  Participants become active in managing their care  DOES NOT replace existing programs or treatments

Living well workshop topics  Action Planning and Goal Setting  Problem Solving  Decision Making  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 15

CDSME includes 16 Living Well with Diabetes (DSMP)  Glucose monitoring, Complications specific to diabetes, Information about medication specific to diabetes, Prevention of low blood sugar, Skin and foot care, Exercise and maintaining a balance of blood sugar Chronic Pain Self-Management (CPSMP)  Includes a movement component where people actively exercise in the workshops Thriving and Surviving (Cancer)  Geared to cancer survivors and caregivers  Activities are specific to cancer and include dealing with the unknown, integrative cancer care, telling your family

Class Materials 17

Where are programs held? A Senior Centers Libraries Faith-Based Private Industry Assisted Living Facilities Housing Facilities Hospitals & Other Health Care 55+ Communities Disease Specific Groups

1. Something YOU want or decide to do (not what someone else thinks you should do, or that you think you should do) 2. Achievable (something you can expect to be able to do this week) 3. Action-specific (for example, losing weight is not an action or behavior, but replacing snacks with fruit between meals is; losing weight is the RESULT of actions) 4. Answer the questions:  What? (specific action) (for example, walking or replacing junk food snacks with fruit)  How much? (time, distance, amount) (for example, 30 minutes, or 4 blocks, or 1portion.)  When? (time of day or which days of the week) (for example, after dinner or Monday, Wednesday, Friday)  How often? (number of days in the week) (for example, 3 times; avoid “every day”, if something comes up, it’s better to have succeeded when you say you’ll do something 3 times rather than to feel you’ve failed if you’ve done it 6 times; you feel even better if you do it 7 times when you’ve said you’ll do it 3 or 5 times!) 5. Confidence level of 7 or more (Ask yourself, “On a scale of 0=not at all sure to 10=totally sure, how sure am I that I will complete the ENTIRE action plan?” If you rate your confidence below a 7, you might want to look at the barriers and consider reworking your action plan so that it’s something you are confident that you can accomplish. It’s important that you succeed! Action Planning

1. Something YOU want or decide to do 2. Achievable 3. Action-specific 4. Answer the questions:  What? (specific action)  How much? (time, distance, amount)  When? (time of day or which days of the week)  How often? (number of days in the week) 5. Confidence level of 7 or more Action Plan

Leader Training  Peer Leaders receive 4 days of training; are trained by Master Trainers  Master Trainers receive 4.5 days of training from T-trainers trained at Stanford  Maryland has a cadre of Peer Leaders and Master Trainers  Master Trainers also ensure fidelity to the program 21

CDSMP Facilitates the Triple Aim Goals  Better Care: Improving the experience of care  Better Health: improving population health  Lower Cost: reducing per capita health care costs

Triple Aim Triple Aim Goal Outcome Measure Base- line Mean 12- Month Mean % Change Better Care Communication with MD IMPROVED % Medication Compliance IMPROVED % Health Literacy IMPROVED % Better Outcomes Self-assessed Health IMPROVED % PHQ Depression REDUCED % Quality of Life IMPROVED % Unhealthy Physical Days REDUCED % Unhealthy Mental Days REDUCED % Lower Health Care Costs % w/ ED Visits in the Past 6 Months REDUCED 18%13% ratio.68 Whitelaw, N., Lorig, K., Smith, M. L., & Ory, M. G. (March 19, 2013)

Financial Effects HOSPITALIZATIONSREDUCTION AT 6 MONTHS EMERGENCY ROOM VISITSODDS REDUCED BY 32% NET COST SAVINGS PER PERSON (after program cost of $350) $390 PER PERSON

 Examined the pattern of health care utilization use  Identified mean costs from national data (age- adjusted)  Estimated costs saved from reduced utilization  Estimated program costs in CDSMP Study  Deducted program costs for net savings  Extrapolated to national savings  Considered study limitations (e.g., self-reported data, generalizing from aggregated national data instead of exact expenses, only included people with chronic conditions) Calculating Potential Cost Savings

 Preliminary Results:  ~$740 per person savings in ER and hospital utilization  ~$390 per person net savings after considering program costs at $350 per participant  Reaching even 10% of Americans with one or more chronic conditions would save ~$4.2 billion! Estimated Cost Savings Related to Reduced ER Visits & Hospitalization

 Increase New Partnerships  Provide space, purchase workshop materials, recruit participants  Have your staff or volunteers trained as Peer Leaders to provide Living Well workshops for your patients  Have your staff or volunteers trained as Master Trainers, to train Peer Leaders and monitor fidelity  Designate a CDSMP Manager with several hours per week dedicated to coordinating CDSMP activities  Refer patients to CDSMP and DSMP workshops  CDC Claims Study for Evidence Based Programs  Medicare Reimbursement  Center of Excellence Future of Living Well

Living Well Center of Excellence at MAC, Inc.

 Coordinating body for all CDSMP activity beginning January 2015  Grant pending to further develop the concept and create hubs in Western, and Central/Southern Maryland  Center will hold the statewide license and work with regional partners as sublicensees  Will become the training hub for all of Maryland, i.e., coordinating trainings for Peer Leaders and Master Trainers  Community Health Workers are an integral part of the Center of Excellence plan to address MCC Center of Excellence

Center of Excellence Vision  The goal of the Maryland Living Well Center of Excellence (MLWCE) "Project Living Well" is to develop a coordinated, cost saving, replicable model to empower people to manage multiple chronic conditions (MCC) using Community Health Workers (CHWs) to conduct evidence-based self- management and falls prevention programs. The CHWs will also serve as a formal interface between medical providers and community resources, to reduce risk factors and reduce needs for ER care and re-hospitalizations

Visit the Living Well website at dhmh.maryland.gov/livingwell/ (or search dhmh maryland living well) Learn more

Questions

Contact Sue Vaeth DHMH Pam Toomey Maryland Department of Aging Shirley Guinn Maryland Department of Aging Leigh Ann Eagle MAC, Inc

References  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  National Council on Aging, Chronic Disease Self Management & PCMH Fact Sheet, pager%20Final.pdf