Self-Management Support: Some Practical Hints Thomas Bodenheimer MD UCSF Department of Family and Community Medicine

What is self-management? Self-management is what people do every day: decide what to eat, whether to exercise, if and when they will monitor their health or take medications. Everyone self-manages; the question is whether or not people make decisions that improve their health-related behaviors and clinical outcomes. Bodenheimer et al. Helping Patients Manage their Chronic Conditions. California Healthcare Foundation, 2004. www.chcf.org

What is self-management support? Self-management support is what health caregivers do to assist and encourage patients to become good self-managers. 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. Priority Areas for National Action: Transforming Health Care Quality. Washington DC: National Academies Press, 2003, p 52.

Self- Management Support Clinical Information Systems Chronic Care Model Community Health System Resources and Policies Health Care Organization Self- Management Support Delivery System Design Clinical Information Systems Decision Support Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team

The goal of self-management support: the informed, activated patient Requires: Information-giving Collaborative decision-making

Informed, activated patients Informed patient 50% of patients leave the physician office visit without understanding what the physician said. [Roter and Hall. Ann Rev Public Health 1989;10:163] However, studies in diabetes, hypertension, asthma, arthritis, and medication adherence show that providing information to patients is not sufficient to improve health-related behaviors and clinical outcomes. Something additional is needed. Norris et al. Diabetes Care 2001;24:561. Fahey et al. Cochrane Review 2005;(1):CD005182. Gibson et al. Cochrane Review 2002;(1):CD001005. Riemsma et al. Cochrane Review 2003;(2):CD003688. Haynes et al. Cochrane Review 2002;(2):CD000011.

Informed, activated patients The additional factor needed is collaborative decision making, including goal-setting and teaching problem-solving skills. Patients engaged in collaborative decision-making and thereby becoming active participants in their care have better health-related behaviors and clinical outcomes compared with those who remain passive recipients of care. [Heisler et al. J Gen Intern Med 2002;17:243. Bodenheimer T, Lorig K, et al. JAMA 2002;288:2469]

The goal of self-management support: the informed, activated patient What tools can we use to assist patients with chronic illness to become informed and activated? Informed: Closing the loop Activated: Collaborative agenda setting Shared decision-making Goal-setting, problem-solving with regular, sustained follow-up

Providing information: closing the loop Study of patients with diabetes: in only 12% of patient visits, the clinician checked to see if the patient understood what the clinician had told the patient Asking patients if they understood what was said is called “closing the loop” In 47% of cases of closing the loop, the patient had not understood what the physician said When closing the loop took place, HbA1c levels were lower than when it did not take place Closing the loop should be an integral part of advising patients Schillinger et al. Arch Intern Med 2003;163:83.

Encouraging patients to be activated: agenda setting A study of 1000 physician visits found that the patient did not participate in decisions 91% of the time. [Braddock et al. JAMA 1999;282;2313] In a study of 264 visits with family physicians, patients making an initial statement of their problem were interrupted after an average of 23 seconds. In 25% of visits the physician never asked the patient for his/her concerns at all. [Marvel et al. JAMA 1999;281:283] Collaboratively setting the visit agenda is the first step in activating the patient

Encouraging patients to be activated: shared decision making The combination of good patient-clinician communication and shared decision making Increases patient satisfaction Higher self-reported health status More adherence to treatment plans Improved health outcomes (especially diabetes) Heisler et al. JGIM 2002;17:243

Chronic care improvement project #1 One chronic care improvement project would be to have training sessions for the entire clinic staff on closing the loop, collaborative agenda setting and shared decision making Then have patients complete simple anonymous questionnaires about whether they noticed these changes taking place

Encouraging patients to be activated: Goal-setting and action plans An important part of activating patients is goal-setting: assisting patients to set goals and make realistic and specific action plans Patient chooses goal: to lose weight Unrealistic action plan: “I will lose 20 pounds in the next month.” “I will walk 5 miles a day.” Realistic and specific action plan: “I will eat one candy bar each day rather than the 5 per day I eat now.” “I will walk for 15 minutes each day after lunch.” Success in achieving an action plan increases self-efficacy (confidence that one can improve one’s life)

Setting a goal Kate Lorig’s question: “Is there anything you would like to do this week to improve your health?” Other things? Physical activity Taking medications Reducing stress? This is called a “bubble diagram” and it can be used early in a visit to set the agenda or to work to setting a goal later in the visit. Source: Rollnick, Health Behavior Change Healthy diet Checking sugars

Self management support If people don’t want to do something, they won’t do it Kate Lorig RN, Dr. PH Stanford Medical School

Goal-setting Goal-setting theory from studies in industry: A specific goal leads to higher performance than does no goal or a vague goal such as “do your best” Self-efficacy theory Success increases self-efficacy (confidence in one’s ability to achieve a goal), which in turn breeds more success and the setting of higher goals. Failure reduces self-efficacy leading to goal abandonment Self-efficacy in health care: A number of studies related to health behavior change demonstrate that increased self-efficacy – which can be measured using validated questionnaires – is associated with improved health-related behaviors and better clinical outcomes Bandura A. Self-efficacy: The Exercise of Control. New York, NY: WH Freeman Co; 1997; Strecher et al. Health Educ Q. 1995;22:190; Marks et al. Health Promotion Practice 2005;6:37,148.

Goal-setting Goal-setting theorists Locke and Latham support the action plan concept with their empirical observation that proximal goals (short-term and specific) are more effective than distal (long-term and general) goals. Action plans are proximal goals. Locke and Latham, American Psychologist 2002;57:705.

Goal-setting Ammerman et al. reviewed 92 studies involving behavioral interventions to improve diet. Goal setting was associated with a greater likelihood of obtaining a significant intervention effect for all 3 outcomes (less total fat, less saturated fat, and more fruits/vegetables). Ammerman et al. Preventive Medicine 2002;35:25.

Goal-setting Cullen reviewed 13 studies utilizing goal-setting in adult nutrition education. Persons engaged in goal setting to improve diet did better in terms of self-reported dietary change, weight loss and improved serum cholesterol than control groups. Goal setting was most successful if it included follow-up, problem-solving, and adjusting activities if goals were not being achieved. Cullen et al. J Am Diet Assoc 2001;101:562.

There is no improvement, Henry There is no improvement, Henry. Are you sure you’ve given up everything you enjoy?

Goal-setting Shilts reviewed 28 studies of goal-setting for dietary and physical activity behavior change. 32% of the studies were evaluated as fully supporting the use of goal-setting. The review concluded that goal-setting has shown some promise in promoting dietary and physical activity behavior change among adults and that The literature for adolescents and children is limited. Shilts et al. Am J Health Promotion 2004;19:81.

Goal-setting A review of the evidence on improving diet, published by the Agency for Healthcare Research and Quality, included goal-setting in a list of a few intervention components shown to be associated with improved behavioral outcomes. [Systematic Evidence Review Number 18. Counseling to Promote a Healthy Diet. AHRQ April 2002] Pignone et al. reviewed dietary counseling for the USPSTF. Goal-setting was one activity thought to be associated with healthier behaviors [Am J Prev Med 2003;24:75]

Goal-setting In a study of action planning in 4 private practices and 4 safety net clinics, the majority of patients reported a behavior change based on making an action plan, and low-income patients had equal success as higher-income patients Handley et al. JABFM 2006 (in press)

Goal-setting in groups Kate Lorig created the Chronic Disease Self-Management Program. People with a variety of chronic illnesses come together for 7 weekly classes learning coping and problem-solving skills, goal-setting and action plans. The classes are led by a peer leader, usually a person with a chronic condition, who is trained through Kate Lorig’s “train the trainer” program. Patients buddy-up to check on each others’ action plans 2 years after the classes were completed, there were still improvements in quality of life scores and reduced physician and ED visits [Lorig et al. Medical Care 2001;39:1217] Lorig, Holman, et al. Living a Healthy Life with Chronic Conditions. Palo Alto, CA: Bull Publishing, 2006. http://patienteducation.stanford.edu

Goal setting Regular and sustained follow-up is crucial for the success of goal-setting and action-planning Follow-up includes problem-solving of barriers to goal achievement Follow-up can be done in person, by phone, by medical assistants, promotoras, or other patients

Chronic care improvement project #2 Train everyone in the clinic to do goal setting and action-planning Choose a few people (medical assistants, health educators, promotoras) to engage patients in goal-setting and action-planning, including regular follow-up Action plans need to be entered into registries or charts and need regular and sustained telephone follow-up with problem-solving

2 Chronic care improvement projects Training sessions for the entire clinic staff on closing the loop, collaborative agenda setting and shared decision making 2. Train everyone in the clinic to do goal setting and action-planning. Choose a few people (medical assistants, health educators, promotoras) to engage patients in goal-setting and action-planning, including regular follow-up Not possible in many primary care settings

Self-management support and primary care To do self-management support Closing the loop, Collaborative agenda setting Shared decision making Goal-setting and action-planning Regular follow-up Requires planned visits

Planned chronic care visits Planned visits are visits in which the only agenda topic is the patient’s chronic condition(s) Planned visits are essential to assist people to adopt healthy behaviors Planned visit is antidote to “tyranny of the urgent” -- acute issues crowding out chronic care management Visits can be with nurses, pharmacists, health educators, nutritionists, promotoras, or trained patients Group or individual visits

Planned visits There is a large body of evidence that planned visits improve outcomes for patients with chronic conditions Sadur et al. Diabetes Care 1999;22:2011. Wagner EH et al. Diabetes Care 2001;25:695. Peters, Davidson. Diab Care 1998;21:1037. Anderson, Funnell et al. Diab Care 1995;18:943. Renders et al. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Review. In Cochrane Library Issue 3, 2001.

Summary Two chronic care improvement projects Training sessions for the entire clinic staff on closing the loop, collaborative agenda setting and shared decision making Train everyone in the clinic to do goal setting and action-planning. Choose a few people (medical assistants, health educators, promotoras) to engage patients in goal-setting and action-planning, including regular follow-up Needs a team (clinicians, medical assistants, health educators, promotaras, trained patients) Needs planned visits by one or more team members

Self-management support: “including patients in their own care.”