The theory and evidence behind self management Natalie Grazin Assistant Director The Health Foundation

Why support self-management? Life with a long term condition: the person’s perspective Interactions with the service: planned or unplanned Problem solving: Time limited consultation/s providing motivational support Care planning: A system of regular scheduled appointments, providing proactive structured support SLIDE 2: Why support self-management   The greatest challenge for the NHS is no longer curing infectious diseases or treating acute conditions. The greatest challenge now is enabling the nearly1 in 3 people who have a long-term condition – whether coronary heart disease or diabetes; asthma or COPD; chronic pain or rheumatoid arthritis; Parkinson’s disease or as a survivor of cancer treatment – to live healthier and longer lives without bankrupting the NHS. If that is the challenge, what is the reality? The reality is that People who live with a long-term condition spend very few hours in contact with health service. Some of those hours are for routine tests and appointments; many are for crisis interventions. Treating their long-term condition demands a different sort of health service, one in which the primary function is to support people to self-manage. This picture in this slide was drawn by people living with a long-term condition supported by some clinicians. It really does capture that reality nicely. There is a growing appreciation in health services of this reality and of the central importance both to improving outcomes and to improving quality of people with a long-term condition being actively engaged in their care. Care pathways: providing specific interventions NB : People may also be accessing a wide variety of other support e.g. from within their communities

What is self-management support? “Self management support can be viewed in two ways: as a portfolio of techniques and tools that help patients choose healthy behaviours; and a fundamental transformation of the patient-caregiver relationship into a collaborative partnership.” Bodenheimer T, MacGregor K, Shafiri C (2005). Helping Patients Manage Their Chronic Conditions. California: California Healthcare Foundation. SLIDE 3: What Is Supported Self-Management?   Supporting self-management is very different from telling patients what to do. Being a good ‘self-manager’ is very different to following the doctor’s orders. To be effective at managing their own health, a patient must have a central role in determining their care, one that fosters a sense of responsibility for their own health. A health services that supports people to manage their condition ensures that they have the confidence and the skills to do so. Supporting self management involves providing encouragement and information to help people understand their condition, monitor symptoms and take appropriate action. This may include: involving people in decision making promoting healthily lifestyles providing education about conditions and self care motivating people to look after themselves setting goals and checking whether these are achieved over time proactively following up goals providing opportunities to share and learn from other people There are all sorts of things that nudge our behaviour. Will power may help. But for most of us most of the time, it really isn’t enough. A little bit of audience participation: raise your hand if you have you ever determined to go to a gym regularly or to shed a few pounds? Now keep your hand raised if you were still using the gym regularly six months later That’s why gyms charge you an annual fee. They know that those new year’s resolutions will soon wane, so they want your money up front. Weightwatchers understands it too. That’s why their model is built around peer support. And it works in the digital age too: [Natalie can you insert the name of the web site you use – and which I failed to use!] not only provide you with information and tools to help you understand what you can do and to measure your progress, but have also adopted a facebook approach, allowing you to share your progress with an online community that can support and encourage you.

The Chronic Care Model The problems: Lack of care coordination Lack of active follow-up Patients inadequately trained to manage their illnesses ‘Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible.’   Co-Creating Health is located in the Chronic Care Model developed by Dr Ed Wagner and his team at the MacColl Institute for Health Care Innovation in the USA, a model that has been rigorously evaluated.    Their work highlights and addresses the three problems facing managing long-term conditions: a lack of care co-ordination a lack of active follow-up and patients inadequately trained to manage their illness. In the words of Improving Chronic Illness Care, overcoming these problems: ‘will require nothing less than a transformation of health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible.’

The Chronic Care Model ‘Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible.’ Co-Creating Health approaches these problems at their pivot point: creating productive interactions by changing the relationship between the practitioner and the patient. Understanding have role; confident and capable in role Supporting people on their journey of activation Developed by the MacColl Institute ACP-ASIM Journals and Books

The evidence Evidence for supporting self management grows every year. Research is up to date Internationally, studies are consistently positive Research has used a range of methodologies. Studies are from small to large scale. It shows that supporting self-management can improve: SLIDE 6: The evidence   There is strong evidence from over 600 studies and across a range of conditions – from arthritis to diabetes, COPD to hypertension; coronary heart disease to rheumatoid arthritis. The research is up to date. Most studies have been published in the past 15 years. Internationally, studies are consistently positive: from the UK, North America, Europe, Australasia and Asia are available. The findings are similarly positive across all countries. The research has used a range of methodologies, including systematic reviews, randomised trials and observational and comparative studies. Studies sizes have ranged from tens of people to several thousand. The evidence shows that when people are supported to look after themselves, they feel better, enjoy life more and have fewer visits to GPs, fewer admissions to hospital and, when they are admitted, shorter lengths of stay, costing health services less: Studies have shown a wide range of improvements: people living with arthritis reported a 12% reduction in pain; their disability decreased by 7% people living with diabetes had a significantly reduction [0.9%] in HbA1c, improvements in their quality of life as well as their diet and exercise people with hypertension saw a 20% reduction in systolic blood pressure the confidence of people with asthma to manage symptoms improved, they had a more appropriate use medication and reduced hospital admission reduced hospital admission COPD, asthma, CHD – the number of sick days for people with rheumatoid and osteo-arthritis was cut in half self confidence / self efficacy self management behaviours quality of life clinical outcomes patterns of healthcare use

Active support works best Research shows that more active support focused on self-efficacy (confidence) and behaviour works best to improve outcomes. Information and knowledge alone are not enough.   How do we support people to manage their condition more effectively? Again, the evidence is clear. We know what does not work: Providing information is helpful, but it is not sufficient: without the confidence and skills to use information, the information will not lead to better health outcomes. Telling a person that they need to lose weight, why they need to lose weight and that they can achieve it through exercise and eating less fat and more fruit rarely changes their behaviour Self management courses alone are of limited effectiveness if isolated from mainstream services. The gains in confidence are insufficient when faced with the medical model of care and the infrastructure that supports it. We also know what does work: methods that improve people’s activation and self-efficacy are the most effective ways of improving self-management, healthy behaviours and outcomes for people living with a long-term condition. collaborative interactions have the greatest impact on changing people’s behaviour and supporting them to take on responsibility for their healthcare shared agenda setting, collaborative goal setting and health service follow-up on goals lead to better quality of life, more appropriate patterns health service utilisation and better clinical outcomes.

Active support works best Approaches that focus on whether people are ready to change work well. SLIDE 7: Active support works best   How do we support people to manage their condition more effectively? Again, the evidence is clear. We know what does not work: Providing information is helpful, but it is not sufficient: without the confidence and skills to use information, the information will not lead to better health outcomes. Telling a person that they need to lose weight, why they need to lose weight and that they can achieve it through exercise and eating less fat and more fruit rarely changes their behaviour Self management courses alone are of limited effectiveness if isolated from mainstream services. The gains in confidence are insufficient when faced with the medical model of care and the infrastructure that supports it. We also know what does work: [Click mouse/pointer/return key to move slide to first builD] methods that improve people’s activation and self-efficacy are the most effective ways of improving self-management, healthy behaviours and outcomes for people living with a long-term condition. collaborative interactions have the greatest impact on changing people’s behaviour and supporting them to take on responsibility for their healthcare shared agenda setting, collaborative goal setting and health service follow-up on goals lead to better quality of life, more appropriate patterns health service utilisation and better clinical outcomes. [Click mouse/pointer/return key to move slide to second build.] Supporting people to become activated self-managers enables them: to begin the journey of taking a role in their health to build their knowledge and their confidence to take action and to maintain their changed behavirours Source: Prof Judy Hibbard, University of Oregon

Examples of improvement Self monitoring and agenda setting reduce hospitalisations, A&E visits, unscheduled visits to the doctor and days off work or school for people with asthma (Gibson et al 2004). Goal setting for older women with heart conditions reduces days in hospital and overall healthcare costs (Wheeler et al 2003). Telephone support may improve self care behaviour, glycaemic control, and symptoms among vulnerable people with diabetes (Piette et al 2000). Motivational interviewing improve self efficacy, patient activation, lifestyle change and perceived health status (Linden et al 2010). Individual education and group sessions improve symptoms for people with high blood pressure (Boulware et al 2001). SLIDE 8: Examples of improvement following active support   So, the evidence shows that methods that improve people’s self-efficacy are most effective. There are many examples from the evidence. Here are a few: A Cochrane review of 36 trials found that self monitoring and agenda setting reduced hospitalisations, A&E visits, unscheduled visits to the doctor and days off work or school for people with asthma A US trial found that personalised goal setting for older women with heart conditions reduced days in hospital and overall healthcare costs A trial found that telephone support may improve self care behaviour, glycaemic control, and symptoms among vulnerable people with diabetes US researchers found that motivational interviewing helped improve self efficacy, patient activation, lifestyle change and perceived health statu A large meta analysis found that individual education and group sessions improved symptoms for people with high blood pressure

More information Visit our self management support resource centre on the Health Foundation’s website: www.health.org.uk/sms