Why is Self-Management Important? 3 Jan 2016 Why is Self-Management Important? Improves Outcomes in Chronic Diseases. It’s weaved into NCQA’s PCMH 2017 Standards: TC 09 (Core) - A list of resources for patient education and self- management support. KM 08 (Credit) - self-management resources or other tools to serve the ongoing needs of its population. KM 22 (Credit) - Self-management tools enable patients to collect health information at home that can be discussed with the clinician. KM 27 (Credit) - Meeting the patient’s social needs supports self- management and reduces barriers to care. CM 08 (Credit) - Self-management plans in individual care plans. CC 16 (Core) - Post-Hospital/ED visit Follow-Up to offer self- management support QI 04 (Core) - Conducts a patient survey on self-management support Grace to highlight: 2017 Standards highlight above: Team-Based Care and Practice Organization - (TC) Knowing and Managing Your Patients - (KM) Care Management and Support - (CM) Care Coordination and Care Transitions - (CC) Performance Measurement and Quality Improvement - (QI) (c) CCMI 2014, 2015, 2016

Mike Hindmarsh Hindsight Health Care Strategies and 3 Jan 2016 Mike Hindmarsh Hindsight Health Care Strategies and Centre for Collaboration, Motivation and Innovation Mike is an established healthcare improvement consultant offering strategic planning, project direction, and technical assistance for implementing chronic disease programs in primary, specialty and ancillary care settings. Mike has worked on over 200 improvement efforts in the last 25 years in Canada, the US, Singapore, Kazakhstan, Mexico and the UK. Mike expertise includes quality improvement design, measurement and practice coaching. Mike was formerly the Associate Director, Clinical Improvement under the guidance of Ed Wagner, MD, MPH of the MacColl Institute in Seattle. Along with Dr. Wagner, Mike and his colleagues created the Chronic Care Model - a system redesign strategy to improve the care for chronically ill. Grace to present -> Today’s Content Expert is Mike Hindmarsh is… (c) CCMI 2014, 2015, 2016

Delivering Patient-Centered self-management support in primary care 3 Jan 2016 Mike Hindmarsh In-Partnership with Wyoming Primary Care Association May 1, 2019 Delivering Patient-Centered self-management support in primary care (c) CCMI 2014, 2015, 2016

The Chronic Care Model Improved Outcomes in Chronic Diseases 6 core elements Community Health System 6. Resources and Policies 1. Health Care Organization 5. Clinical Information Systems 2. Self- Management Support 3. Delivery System Design 4. Decision Support Our premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get, and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides. Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec;20(6):64-78. http://www.improvingchroniccare.org/index.php?p=Model_Elements&s=18 Productive Interactions Informed, Activated Patient Prepared, Proactive Practice Team Improved Outcomes in Chronic Diseases

To define Patient and Provider Self- Management support 3 Jan 2016 Today You will learn: To define Patient and Provider Self- Management support The importance of Stepped Care using self- management support techniques About Brief Action Planning: a simple tool for patient-directed goal-setting and action planning How to Integrate Brief Action Planning into primary care: do’s and don’ts (c) CCMI 2014, 2015, 2016

What is self-management? 3 Jan 2016 What is self-management? Self-management are the decisions and actions that I take to protect and improve my health and well-being. Based on Gantz, 1990 Self-Management is Inevitable! Throughout this presentation we will be using several terms, including the first one noted here, self-management. This first definition is a “plain language” definition. Self-management is simply what all of us do every day. We make decisions and we take actions that can protect our health and improve our well-being. (c) CCMI 2014, 2015, 2016

What is chronic illness self-management? Self-management relates to the tasks that an individual must undertake to live well with one or more chronic conditions. These tasks include gaining confidence to deal with Medical Management, Role Management, and Emotional Management. Adams, Greiner, and Corrigan (2004)

1. Medical management [6 clicks] The first task is medical management, a familiar topic to health care professionals. This includes activities such as obtaining and taking medication monitoring symptoms or physiologic measures like blood sugar or blood pressure. It includes attending appointments, changing diet, Such as eating habits or physical activity.

2. Role management [5 clicks] The second task is role management, which means carrying out normal activities and maintaining life roles, such as job, School and play, Home Family and voluntary work.. A newly diagnosed person might be wondering how they will manage working night shift with diabetes or how will they play soccer and keep their asthma in control

3. Emotional management [6 clicks] The final task is to manage the emotional impact. Dealing with anger, Fear or depression, frustration, ambivalence, thoughts about the future. The diagnosis can also change a person’s relationships with others.

What is self-management support? 3 Jan 2016 What is self-management support? The systematic provision of education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems. Adams, Greiner, and Corrigan (2004) If “self-management” is defined as confidence to deal with medical, role, and emotional management, “self-management support” describes what health care providers can do to facilitate it. This definition is also from Adams and colleagues. They have written that SMS is … (c) CCMI 2014, 2015, 2016

Another view of self-management support “Self-management support is the assistance caregivers give patients with chronic disease in order to encourage daily decisions that improve health-related behaviors and clinical outcomes. Self-management support can be viewed in two ways: as a portfolio of techniques and tools that help patients choose healthy behaviors; and a fundamental transformation of the patient-caregiver relationship into a collaborative partnership.” T Bodenheimer, et al. Helping Patients Manage their Chronic Conditions. Available at http://www.chcf.org Dr Tom Bodenheimer has written about the needs of people with chronic conditions. He made these additional observations about self-management support. read This definition expands the group assisting to any caregiver and it views self-management support as not only tools and techniques but also a transformation of the relationship into a collaborative partnership. In the next slides, we will examine this transformation in more detail. [10 minutes]

Self-management Education 3 Jan 2016 Patient Education Self-management Education Information and skills are taught. Topics determined by health care professionals. Skills are taught to solve patient identified problems Usually disease-specific Skills are generalizable Assumes that knowledge creates behavior change Assumes that confidence yields better outcomes Goal is compliance Goal is increased self-efficacy Teachers are health care professionals Teachers can be professionals or peers One approach to help people with chronic conditions is patient education. This table contrasts patient education with self-management education. Self-management education refers to educational programs or approaches that are tailored to addressing the 3 tasks of self-management support: medical management, role management and emotional management. Both patient education and self-management education are necessary, but they are different. Let’s compare the two. (review table) Many organizations have transitioned their patient education to encompass self-management education so that it helps people put knowledge into action and some workshops, such as those offered by the University of Victoria, are designed around these principles. Bodenheimer et al JAMA 2002;288:2469 (c) CCMI 2014, 2015, 2016

Self-management support tools Action-oriented patient education Patient-centred goal setting and action planning Motivational Interviewing BRIEF ACTION PLANNING

What is Brief Action Planning? 3 Jan 2016 What is Brief Action Planning? a highly structured person-centered stepped-care evidence-informed self-management support technique based on the principles and practice of Motivational Interviewing. Reims et al, Brief Action Planning White Paper, 2014 Gutnick et al, JCOM, 2014. available at www.centreCMI.ca (c) CCMI 2014, 2015, 2016

Spirit of Motivational Interviewing 3 Jan 2016 Spirit of Motivational Interviewing Compassion Acceptance Partnership Evocation Miller W, Rollnick S. Motivational Interviewing: Helping People Change, 3ed, 2012 (c) CCMI 2014, 2015, 2016

3 Jan 2016 “Is there anything you would like to do for your health in the next week or two?” “That’s fine, if it’s okay with you, I’ll check next time.” Have an idea? Not sure? Behavioral Menu Not at this time SMART Behavioral Plan With permission: What? When? Where? How often/long/much? Start date? 1) Ask permission to share ideas. 2) Share 2-3 ideas. The last idea is one of their own. 3) Ask if any of these ideas might work Elicit a Commitment Statement “How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)?” Confidence ≥7 Confidence <7, Problem Solving “Would it be helpful to set up a check on how things are going with your plan?” How? When? With whom? Check on Progress (c) CCMI 2014, 2015, 2016

3 Jan 2016 “Is there anything you would like to do for your health in the next week or two?” (c) CCMI 2014, 2015, 2016

Possible responses to Question 1 3 Jan 2016 Possible responses to Question 1 Have an idea Not sure Need help with an idea Need to know what you mean Not at this time Healthy Not interested (c) CCMI 2014, 2015, 2016

Offer a behavioral menu when needed or requested. 3 Jan 2016 Skill #1 Behavioral Menu Offer a behavioral menu when needed or requested. (c) CCMI 2014, 2015, 2016

ASK: “Do any of these ideas work for you?” 3 Jan 2016 Behavioral Menu ASK: “Would you like me to share some ideas that others have used or that might fit for your situation?” TELL: If yes, share two or three relevant, not too specific, varied ideas ALL AT ONCE. The last idea prompts one of their own. “Some things you might try are ___, ___ or ___ or maybe you have an idea of your own that occurs to you now?” ASK: “Do any of these ideas work for you?” Physical Activity Better Sleep Healthier Eating Adapted from Stott et al, Family Practice 1995; Rollnick et al, 1999, 2010 (c) CCMI 2014, 2015, 2016

3 Jan 2016 “Is there anything you would like to do for your health in the next week or two?” “That’s fine, if it’s okay with you, I’ll check next time.” Have an idea? Not sure? Behavioral Menu Not at this time SMART Behavioral Plan With permission: What? When? Where? How often/long/much? Start date? 1) Ask permission to share ideas. 2) Share 2-3 ideas. The last idea is one of their own. 3) Ask if any of these ideas might work Elicit a Commitment Statement “How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)?” Confidence ≥7 Confidence <7, Problem Solving “Would it be helpful to set up a check on how things are going with your plan?” How? When? With whom? Check on Progress (c) CCMI 2014, 2015, 2016

3 Jan 2016 Skill #2 SMART Behavioral Plan Action Planning is “SMART”: Specific, Measurable, Achievable, Relevant and Timed. With permission: What? When? Where? How often/long/much? Start date? Based on the work of Locke (1968) and Locke & Latham (1990, 2002); Bodenheimer, 2009 (c) CCMI 2014, 2015, 2016

Elicit a Commitment Statement 3 Jan 2016 Skill #3 Elicit a Commitment Statement After the plan has been formulated, the helper/coach elicits a final “commitment statement.” Strength of the commitment statement predicts success on action plan. Aharonovich, 2008; Amrhein, 2003 (c) CCMI 2014, 2015, 2016

3 Jan 2016 “Is there anything you would like to do for your health in the next week or two?” “That’s fine, if it’s okay with you, I’ll check next time.” Have an idea? Not sure? Behavioral Menu Not at this time SMART Behavioral Plan With permission: What? When? Where? How often/long/much? Start date? 1) Ask permission to share ideas. 2) Share 2-3 ideas. The last idea is one of their own. 3) Ask if any of these ideas might work Elicit a Commitment Statement “How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)?” Confidence ≥7 Confidence <7, Problem Solving “Would it be helpful to set up a check on how things are going with your plan?” How? When? With whom? Check on Progress (c) CCMI 2014, 2015, 2016

3 Jan 2016 “How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)?” (c) CCMI 2014, 2015, 2016

Problem-solving is used for confidence levels less than 7. 3 Jan 2016 Skill #4 Problem Solving Problem-solving is used for confidence levels less than 7. Bandura, 1983; Lorig et al, Med Care 2001; Bodenheimer review, CHCF 2005; Bodenheimer, Pt Ed Couns 2009. (c) CCMI 2014, 2015, 2016

Problem solving Yes No Behavioral Menu Confidence <7 3 Jan 2016 Problem solving Confidence <7 “A __ is higher than a zero, that’s good! We know people are more likely to complete a plan if it’s a 7 or higher” Problem Solving: “Any ideas about what might raise your confidence?” Yes No Behavioral Menu Assure improved confidence. Restate plan and rating as needed. (c) CCMI 2014, 2015, 2016

3 Jan 2016 “Is there anything you would like to do for your health in the next week or two?” “That’s fine, if it’s okay with you, I’ll check next time.” Have an idea? Not sure? Behavioral Menu Not at this time SMART Behavioral Plan With permission: What? When? Where? How often/long/much? Start date? 1) Ask permission to share ideas. 2) Share 2-3 ideas. The last idea is one of their own. 3) Ask if any of these ideas might work Elicit a Commitment Statement “How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)?” Confidence ≥7 Confidence <7, Problem Solving “Would it be helpful to set up a check on how things are going with your plan?” How? When? With whom? Check on Progress (c) CCMI 2014, 2015, 2016

3 Jan 2016 “Would it be helpful to set up a check on how things are going with your plan?” How? When? With whom? (c) CCMI 2014, 2015, 2016

Checking on the plan builds confidence. 3 Jan 2016 Skill #5 Check on progress Checking on the plan builds confidence. Check often with new action plans and decrease frequency as behaviour is more secure. Regular contact over time is better than 1x intervention. Follow-up builds a trusting relationship. Resnicow, 2002; Artinian et al, Circulation, 2010 (c) CCMI 2014, 2015, 2016

Checking On Plan with helper 3 Jan 2016 Checking On Plan with helper “How did it go with your plan?” Completion Partial completion Did not carry out plan Recognize success Recognize partial completion Reassure that this is common occurrence “What would you like to do next?” (c) CCMI 2014, 2015, 2016

3 Jan 2016 “Is there anything you would like to do for your health in the next week or two?” “That’s fine, if it’s okay with you, I’ll check next time.” Have an idea? Not sure? Behavioral Menu Not at this time SMART Behavioral Plan With permission: What? When? Where? How often/long/much? Start date? 1) Ask permission to share ideas. 2) Share 2-3 ideas. The last idea is one of their own. 3) Ask if any of these ideas might work Elicit a Commitment Statement “How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)?” Confidence ≥7 Confidence <7, Problem Solving “Would it be helpful to set up a check on how things are going with your plan?” How? When? With whom? Check on Progress (c) CCMI 2014, 2015, 2016

Tips for using Brief Action Planning 3 Jan 2016 Tips for using Brief Action Planning APRIL KEY POINTS Brief action planning is simple, but that doesn’t make it easy. There are some things we all tend to do, so let’s look at some tips for using BAP before we practice it. (c) CCMI 2014, 2015, 2016

Avoid the expert trap 3 Jan 2016 (c) CCMI 2014, 2015, 2016 KEY POINT The expert trap is when you give people advice based solely on your expertise and it doesn’t fit their circumstances, so it can be easily dismissed. Remember the Spirit of MI, especially acceptance of autonomy, partnership and evocation/encouraging to explore When we push people to do things, they tend to push back by resisting us. We aren’t experts on other people’s lives. Telling people what to do rarely works. (c) CCMI 2014, 2015, 2016

The Person does most of the talking in brief action Planning (BAP) 12/20/2014 The Person does most of the talking in brief action Planning (BAP) KEY POINT If you are doing all the talking, it isn’t BAP. Remember the Spirit of MI, evocation. (c) CCMI 2014

Avoid the assessment trap 3 Jan 2016 Avoid the assessment trap (c) CCMI 2014, 2015, 2016

Learning “how to” do brief action Planning is like 3 Jan 2016 Practice Feedback Practice Feedback Until. . . You develop self-awareness of skills and become unconsciously competent (c) CCMI 2014, 2015, 2016

How brief action Planning is being advanced 3 Jan 2016 How brief action Planning is being advanced Through 2018: CCMI has trained over 2000 people Nurses in all fields of practice Physicians Allied health professionals Staff of women’s transition houses Shelter workers Addictions and mental health workers Peer counselors for seniors and pregnant women at risk (c) CCMI 2014, 2015, 2016

brief action Planning in Practice: 2015 Study led by Dr Amy CHristison 3 Jan 2016 brief action Planning in Practice: 2015 Study led by Dr Amy CHristison Examined the impact on goal setting when BAP was combined with the Family Nutrition Physical Activity (FNPA) screening during Well Child visits Controlled trial with 36 providers having support to use the FNPA but only 19 supported to use BAP (c) CCMI 2014, 2015, 2016

3 Jan 2016 Results Visits using BAP saw 72% result in an action plan as opposed to 3.6% without BAP 56% of the lifestyle goals set were met Providers were more likely to discuss and record issues like weight when combined with BAP Provider satisfaction with the tool was high (3.8 and 3.9 of a 5 point rating) When BAP was used patients were more likely to feel the visit was patient-centered Both groups found the intervention easy (c) CCMI 2014, 2015, 2016

Delivering BAP fulfills Core Competency B 3 Jan 2016 BAP and PCMH Delivering BAP fulfills Core Competency B in the Care Management Section of the Patient Medical Home Standards But is BAP for everyone? PCMH Standards and Guidelines (2017 Edition, Version 4) Pages 64-65 (c) CCMI 2014, 2015, 2016

Stepped Care Self-management Support 18 Mar 2015 Stepped Care Self-management Support Adapted from Health Council of Canada: Self-management Support for Canadians with Chronic Conditions, May 2012 (c) CCMI 2014, 2015

Sub-populations for care Good Clinical Control Poor Clinical Control High Self-Confidence Low Self-Confidence One way to consider how to designate subpopulations for self-management support. Proportions will vary by community, physician panel and clinical diagnosis. Patients with good clinical control and high self-confidence are ideal candidates for peer mentoring programs. Patients with Good control and low self-confidence are likely to benefit from group interventions. Patients with poor clinical control and high self-confidence are likely to benefit from further investigation. There may be a disconnect between knowledge and skills for management of the clinical condition. Those with poor control and low self-confidence are more likely to need 1:1 interactions in addition to group.

Confidence scale How confident are you that you can manage your health in the next month? 0 1 2 3 4 5 6 7 8 9 10 Not Confident At all Completely Wasson et al: How’s Your Health Survey.

Support them differently Good Clinical Control Poor Clinical Control High Self-Confidence Low Self-Confidence Usual Care Clinical Care, Action Planning how to adjust our SMS for different kinds of people Action Planning Partnership Interview +

SUMMARY Self-Management Support is a Core Competency for PCMH designation. Brief Action Planning is a patient-centered tool to assist patients with behavior change. The Self-Management Support techniques should be tailored to the patient’s clinical control and willingness to change.

18 Mar 2015 APRIL Thank you very much for attending this webinar and thank you to Dr. Bruce Hobson for sharing this presentation with me. (c) CCMI 2014, 2015