Clinical Tools and Strategies for Supporting Self-Management IBHP Webinar March 18, 2009 Introduction Feel free to change the name, but please give credit to the Institute for Healthcare Communication and the Quality Allies Learning Community, a project directed by the Institute for Healthcare Improvement, funded by the Robert Wood Johnson Foundation with additional support from the California Health Care Foundation. Michael G. Goldstein, MD Chief, Mental Health and Behavioral Sciences Service Providence VA Medical Center Professor, Psychiatry and Human Behavior, Alpert Medical School of Brown University

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 [There are 4 objectives…two here and two the next slide.] [These objectives work for a 6.5-7 hours of training. The Agenda for the full-day training session at CHP is below. Note 4 hours in the afternoon were devoted to the 4th objective – practice with simulated patients (actors). The objectives should be adjusted for a shorter training period.] Wednesday, May 31, SMS Training Day - Livingston Site 8:30 – 9:00am Continental Breakfast 9:00 -- 9:20am Introductions. Orientation to the day (Laurie Francis - 10 minutes) SMS Core Competencies Workshop I(Includes 2 10 min breaks) 9:20- 12:00 pm Introduction and Background 9:40 – 10:10 Exercise: Key relationship skills 10:10 – 10:20 Break 10:20 – 10:40 Assessment, Enhancing Conviction, Information Sharing and Collaborative Goal Setting 10:40 – 11:20 Practice Enhancing Conviction, Information Sharing and Collaborative Goal Setting 11:20 – 11:35 Enhancing confidence, Action Planning & Problem-solving 11:35 – 12:00 Applying skills to videos 12:00 – 1:00pm Lunch 1:00 – 4:30pm SMS Core Competencies Workshop II (Includes 2 10 min breaks) will include didactic presentations, interactive exercises,video case examples, skill practice with actors in small groups and working with each other to develop a personal action plan for change. Featuring: Goal-setting Action planning Problem-solving Addressing barriers 4:30 – 4:40 Break (reconvene in large group) 4:40 – 5:00 Choose two strategies to practice over next month and Evaluation

Outline Self-Management Self-Management Support (SMS) Key Components of SMS Core Clinical Competencies/Tools & Resources Health Care System Redesign Community Linkages Questions and Discussion

Self-Management Tasks To take care of the illness (medical management) To carry out normal activities (role management) To manage emotional changes (emotional management) (Corbin & Strauss, 1998 Bodenheimer et al, 2002; Lorig et al, 2003)

Self-Management Tasks for Diabetes Blood glucose monitoring Managing high/low blood sugars Diet Physical activity/exercise Medication taking Medical monitoring/visits Coping with emotions Foot care Eye care Dental care

What is Self-Management Support? 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)

What Works – Research Evidence? Addressing knowledge is necessary but not sufficient to produce changes in chronic illness care outcomes Key strategies for improving outcomes of educational 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 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 Education Lecturing Inducing fear Finger-wagging “You should” Shaming Waiting for a patient to ask It is useful to contrast the process of self-management support we have described with image of self-management depicted on this slide. What do you think of this clinician’s approach to influencing patients to participate more actively in treatment and self-care? This may be how we were taught to assist and educate patients….through: [Read bullets on slide] [Ask participants about what they understand of believe about the value and effectiveness of these strategies…then share what we know from research] Research tells us that didactic education is necessary but not sufficient to promote patient participation in self-management. Increasing fear through feedback about risks and consequences can sometimes be helpful, but fear can also produce avoidance or unhealthy coping strategies, esp if fear inducing strategies are not accompanied by practical and achievable solutions.

Self-Management Support A Fundamental Shift in the Process of Care Traditional Care Collaborative Care Assumes knowledge + confidence drives change Patient sets agenda Goal is enhanced confidence Decisions made collaboratively Assumes knowledge drives change Clinician sets agenda Goal is compliance Decisions made by caregiver (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)

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)

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 (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 (New Health Partnerships, 2007)

Motivational Interviewing “Definition” “a skillful clinical style for eliciting from patients their own motivation for making changes in the interest of their health.” Which do you like better? Research regarding across a number of different conditions and behavioral targets have found that there are three key components of effective interventions: [Read 3 bullets] (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

The “Spirit of MI” Collaborative Evocative Honoring patient autonomy Partnership, shared decision making Evocative Understand patient goals; evoke arguments for change Honoring patient autonomy Patients ultimately decide what to do Give example of a 1 minute intervention: Gee Mr. Johnson, if you continue smoking, your chance of another heart attack is more than double than if you quit. I strongly recommend that you consider quitting, though the decision is up to you. I know you have been frustrated by previous difficulties quitting, and that you are anxious about how you will manage if you give up cigarettes. However, there are a number of options for quitting that I would like to share with you.. Your previous experience in giving up alcohol will help you to be successful in quitting smoking. (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

Motivational Interviewing “Principles” Resist the Righting Reflex (Directing) Understand Patient Motivations Listen to Your Patient with Empathy Empower Your Patient Which one do you like better (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

MI Style A refined form of guiding, rather than directing or following…… helping the patient make his or her own decision about behavior change Give example of a 1 minute intervention: Gee Mr. Johnson, if you continue smoking, your chance of another heart attack is more than double than if you quit. I strongly recommend that you consider quitting, though the decision is up to you. I know you have been frustrated by previous difficulties quitting, and that you are anxious about how you will manage if you give up cigarettes. However, there are a number of options for quitting that I would like to share with you.. Your previous experience in giving up alcohol will help you to be successful in quitting smoking. (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

Motivational Interviewing Asking Listening Informing Guiding - balancing skills, flexibly applied Motivational Interviewing (Miller & Rollnick) Positive impact on: alcohol use in problem drinkers, outpatient and inpatient settings other substance abuse diabetes management cardiovascular rehabilitation ? smoking cessation (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

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? An efficient way to conduct an assessment of conviction is to ask about it directly using open-ended questions. Here are two ways to assess the patients’ conviction: [READ FROM SLIDE] [Note to presenter: can substitute a target of diabetes management for the word “change”. For example: “How important is it for you to monitor your blood sugars regularly?” or “How important is lowering your blood sugars to you?” or “How important is losing weight to helping you achieve your goals for managing your diabetes” or “How committed are you to increasing your levels of physical activity?”]

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 Skin care Taking insulin Diet Depression  Losing weight Daily foot care Smoking (RI Dept of Health Chronic Care Collaborative)

Explore Conviction/Importance “How convinced are you that it is important to monitor your blood sugars?” Not at all convinced Totally convinced 0 1 2 3 4 5 6 7 8 9 10 “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)

Benefits of Physical Activity Share Information Ask Permission Ask Understanding Tell (Personalize) Benefits of Physical Activity

Collaboratively Set Goals Share clinician priorities Offer options Agree on something to work on Negotiate a specific action plan

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 (New Health Partnerships, 2007)

Action Planning – Starts with SMART Goals Specific and behavioral Measurable Attractive Realistic Timely

Action Plan 1. Goals: Something you WANT to do 2. Describe How Where What Frequency When 3. Barriers - 4. Plans to overcome barriers - 5. Conviction and Confidence ratings (0-10) - 6. Follow-Up:

Action Plan 1. Goals: Something you WANT to do Begin Exercise 2. Describe How Walking Where Neighborhood What 20 min Frequency 3x/week When After dinner 3. Barriers - Dishes, safety (no sidewalks) 4. Plans to overcome barriers - get kids to clean up, ask neighbor or husband to join me, wear reflective vest 5. Conviction and Confidence ratings (0-10) - 9/8 6. Follow-Up: Will keep log and bring to next visit in 1 month

Action Planning Review past experience - especially successes Define small steps that are likely to lead to success To enhance confidence, it’s helpful to start with the patient’s own experience with change. Ask the patient to recall times when they have been successful with change in the past. Most patients have had some success, but they tend to minimize or discount the impact of the strategies they have previously used. Even if success was short-lived, you can ask, “What strategies did you use that helped you to get through those first few days?”. Moreover, strategies use to change behavior successfully in one area, may help in another. For example, patients who have successfully managed to address problem drinking, may be able to use the same strategies to alter their diet or to stop smoking. Many patients think of change in an “either-or” way and become discouraged when can’t reach the final goal right away. Helping patients to identify small or intermediate steps that are more achievable and realistic will help the patient to experience success. This will boost confidence for further change. Assisting patients to make a conscious deliberate choice can also boost confidence. Setting a specific target date for beginning a new diet or physical activity program helps individuals to plan and focus their effort. As we noted earlier, providing options and supporting the patient’s decision also boosts autonomy and conviction and subsequently, adherence. Finally, helping patients to see slips or relapses as a “normal” part of the change process and as a potential learning experience, rather than failure also can keep patients from losing too much confidence when they slip.

Assess and Enhance Confidence Action Planning: Assess and Enhance Confidence “How confident are you that you can meet your goal of exercising 5 days a week? Not at all confident Totally confident 0 1 2 3 4 5 6 7 8 9 10 “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)

Enhancing Confidence Provide tools, strategies, resources, skills Address barriers Attend to progress and to perceive slips as occasions for problem solving rather than as failure To enhance confidence, it’s helpful to start with the patient’s own experience with change. Ask the patient to recall times when they have been successful with change in the past. Most patients have had some success, but they tend to minimize or discount the impact of the strategies they have previously used. Even if success was short-lived, you can ask, “What strategies did you use that helped you to get through those first few days?”. Moreover, strategies use to change behavior successfully in one area, may help in another. For example, patients who have successfully managed to address problem drinking, may be able to use the same strategies to alter their diet or to stop smoking. Many patients think of change in an “either-or” way and become discouraged when can’t reach the final goal right away. Helping patients to identify small or intermediate steps that are more achievable and realistic will help the patient to experience success. This will boost confidence for further change. Assisting patients to make a conscious deliberate choice can also boost confidence. Setting a specific target date for beginning a new diet or physical activity program helps individuals to plan and focus their effort. As we noted earlier, providing options and supporting the patient’s decision also boosts autonomy and conviction and subsequently, adherence. Finally, helping patients to see slips or relapses as a “normal” part of the change process and as a potential learning experience, rather than failure also can keep patients from losing too much confidence when they slip.

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 Here are some simple ways to ask about and explore ways to address barriers: [Read slide] Note that the first few examples are open-ended questions. Asking what else encourages reflection and disclosure of what may be key barriers. Notice also that this strategy encourages patients to come up with their own solutions, based on their own experience and values. Asking “what else” is also useful when identifying possible solutions. The solutions that patients identify themselves are likely to be relevant and meaningful. When folks come up with their own solutions, they often feel more empowered, which increases confidence over the long-term. Brainstorming has been used to describe the process of identifying multiple possible solutions. Once the patient’s ideas have been gathered, the clinician may share what they have learned from their own and their patient’s experience. They are learning how to problem-solve…a core skill for addressing barriers.

Self-Management Support Cycle EXPLORE : Needs, Expectations, Values, Behavior, Progress SHARE : Provide specific Information about health risks, benefits of change, and strategies to self-manage ARRANGE : Specify plan for follow-up (e.g., visits, phone calls, mailed reminders Personal Action Plan 1. List specific goals in behavioral terms 2. List barriers and strategies to address barriers 3. Specify follow-up plan 4. Share plan with practice team and patient’s social support 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 Adapted from: Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87

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)

A Model for Planned Care* Health System Organization of Health Care Self- Management Support Decision Delivery System Design Clinical Information Systems Community Resources and Policies Briefly review Planned Care Model, emphasizing that research has determined that good functional and clinical outcomes occur as a result of productive interactions between a prepared, proactive practice team and an informed activated patient and family member. [For groups exposed to the model…no need to specify each of the elements below…just concentrate on SMS] How can we promote productive interactions? Research in the quality improvement arena has found that several elements within the health care system will support and promote productive interactions and improve health outcomes. These elements include: Self-management support….the focus of todays training. I will provide a definition and some examples of self-management support shortly Decision support, or guidelines…knowing the right thing to do for the right person at the right time. Delivery system design….how to organize care so that it is proactive and efficient. This might include group visits for patients with diabetes or planned follow-up calls to determine how folks are doing with their treatment plans. Clinical Information systems – like registries to track and remind clinicians and patients about key components of care Health system organization – this includes leadership and support And finally links to Community Resources Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes *E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound

Delivery System Redesign Determine process and define roles for delivering SMS among members of the care team Planned Care visits Medical Group visits Chronic Disease Self-Management groups Planned peer interactions Provide support and coordination according to level of need

Opportunities for SMS: When, Where and By Whom Before the Encounter During the Encounter After the Encounter

Chronic Disease Self-Management Program Developed and studied by Kate Lorig and colleagues at Stanford Lay-leaders, 6 sessions, 2 1/2 hours each Single or multiple conditions Focus on collaborative goal-setting, personalized problem solving, skill acquisition Outcomes: improved health behaviors and health status, fewer hospitalizations 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 and tools Create capacity to identify and contact relevant subpopulations for proactive care Monitor and share SMS performance data.

Community Linkages Identity community programs and resources Partner with community organizations Partner with employers Raise community awareness: community campaigns

Implementing Health System Changes to Support Self-Management Quality Improvement Collaboratives: with focus on SMS (e.g., New Health Partnerships) and Patient Activation (MN) Educational Outreach – QIOs, DOQ-IT, Voluntary Agencies Provider education and training - Core Competencies, Motivational Interviewing Incentives, rewards for provider delivery of SMS, system change

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)

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 (New Health Partnerships, 2007)