Get Up, Stand Up! Self-Management Support for Chronic Conditions Alex J. Reed, PsyD, MPH Director of Behavioral Health Education

Learning Objectives Discuss the benefits of self-management support for primary care patients with chronic diseases. Explore techniques to eliciting and developing brief action plans. Describe techniques for implementing self- management support strategies for primary care settings.

Was this who Marley was referring to in that song?

What is Self-Management? Self management is one’s ability to develop and use skills to manage chronic disease while continuing one’s life. Barlow defined it as the individuals ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition. Self-management support is the care and encouragement provided to people with chronic conditions and their families to help them understand their central role in managing their illness, make informed decisions about care, and engage in healthy behaviors.

What works for self- management? Involve people in decision making Emphasize problem solving Develop care plans as a partnership between patients and providers/professionals Promoting and negotiating healthy lifestyles and educating people about how to self-manage Motivating people to self manage using targeted approaches and structured information and support DeSilva, 2011, “Helping People Help Themselves”

What types of support work? Written motivational leaflets can help people feel more confident to raise their concerns and discuss their symptoms, although there is sparse evidence that such methods improve self-management behaviors or clinical outcomes.

What types of support work? Providing structured education programs by video may be as effective as in person education groups. For instance, a randomized trial with older people with long term conditions compared to group education, a home study programs with videotapes and booklets and a control group. Both educational interventions compared to controls were associated with reduced pain, sleep difficulties and the symptoms of depression and anxiety. Videos were lovers cost and may be more accessible. Another novel approach is using text messages as reminders and support mechanisms.322–323 One trial found that, when combined with other strategies, sending text messages to young people with diabetes helped to improve self-management behaviours.324 One randomised trial assessed sending standardised health promotion email messages to people weekly for 12 weeks. People who received emails had better self-management behaviours and reported favourable changes in healthy eating and physical activity.325 Other studies suggest that email interventions can be targeted to the person’s ‘stage of change’, thus providing more tailored and meaningful support.326

What types of support work? Individual education – United Health Center in NYC, a free-standing pc clinic, trained health coaches four hours per month in common chronic conditions, including diabetes, htn, hyperlipidemia, asthma, obesity and tobacco use, MI, self management support, working in teams and using a chronic disease registry. Coaches huddle, meet with pts before or after visit and make pre-visit calls. 500 pts showed a statistically significant deacrease in hbA!c, blood pressures below 130/80 and LDL less than 100. Pts with all three values at goal increased from 13 to 36%. At Caresouth Carolina, it is the job of every person in the center to sure that every patient receives SMS for asthma, CAD, depression, diabetes and HTN. MA’s initiate goal setting in the pre-visit. Can discuss with PCP if pt prefers. If pt agreed on an action plan, MA checks to see if pt is fulfilling plan and may suggest modifying it. Pts with major barriers are referred to care managers who have more time. 90% of pts with the 5 targetd conditions have engaged in goal setting discussions. Group education- Research generally suggests that group education can improve people’s self confidence, clinical outcomes and even health service use. Telephone coaching- IDEALL project (Improving Diabetes Efforts Across Language and Literacy) is an automated telephone SMS service for pts with diabetes. Contact pts at preferred times in preferred languages. Automated health education messages and some nurse care manager follow up. Pts responded to 50-60% of calls. No HbA1C differences found, but increased self efficacy found. Tobacco quitlines Work based support- initiatives can help increase self-management behavior. Examples include fitness and nutrition classes, health assessments, online supports or health fairs. Self monitoring – Many studies on self monitoring. It appears to have value for those with diabetes, asthma, and high blood pressure

What Types of Support Work: Defining the Problem

What Types of Support Work: Making Decisions Pros of Behavior How does this behavior help me? Cons of Behavior What do I dislike about this behavior? Pro Importance (1-10) Con   Open ended – What brings you in today? Affirmations – Your lab numbers look good. You are doing a great job in lowering your cholesterol. Reflections: You have been under a lot of stress lately Summary: Let me take a moment to recap what you have talked about…

What Types of Support Work: Action Planning What, how much, when, how often. Must be action specific, not general (lose weight)

A Word About Self-Efficacy How people think and feel about their condition can have a big impact on their health behaviours and outcomes.53–57 Self-efficacy refers to an individual’s belief in their capacity to successfully learn and perform a specific behaviour. A strong sense of self-efficacy leads to a feeling of control, and willingness to take on and persist with new and difficult tasks. When applied to health, this theory suggests that patients are empowered and motivated to manage their health problems when they feel confident in their ability to achieve this goal.58 There is evidence that improved self-efficacy is correlated with improved health behaviours and clinical outcomes so it is valid to examine the impact of self-management support on self-efficacy as representative of other outcomes.59–71

Kai (good) Zen (change)

How To Proceed in Your Practice

Create Your Own Action Plan What is the problem? List ideas to solve the problem? List what are you going to do? How much will you do? When will you do this? How often will you do the activity?

References Desilva, R. (2011). Evidence: Helping people help themselves. London: The Health Foundation. Bodenheimer, T., Abramowitz, S. (2010). Helping patients help themselves: How to implement self-management support. California Healthcare Foundation. Lorig, K., Holman, H., Sobel, D., Laurent, D., Gonzalez, V., Minor, M. (2012). Living a healthy life with chronic conditions. Boulder: Bull Publishing Co.