Clinical Tools and Strategies for Supporting Self-Management 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 IBHP Webinar March 18, 2009

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

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

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

Blood glucose monitoringBlood glucose monitoring Managing high/low blood sugarsManaging high/low blood sugars DietDiet Physical activity/exercisePhysical activity/exercise Medication takingMedication taking Medical monitoring/visitsMedical monitoring/visits Coping with emotionsCoping with emotions Foot careFoot care Eye careEye care Dental careDental care Self-Management Tasks for Diabetes

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)

Addressing knowledge is necessary but not sufficient to produce changes in chronic illness care outcomesAddressing knowledge is necessary but not sufficient to produce changes in chronic illness care outcomes Key strategies for improving outcomes of educational and behavior change interventionsKey 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 Works – Research Evidence?

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 EducationDidactic Patient Education LecturingLecturing Inducing fearInducing fear Finger-waggingFinger-wagging “You should”“You should” ShamingShaming Waiting for a patient to askWaiting for a patient to ask

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

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:

(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) 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

“a skillful clinical style for eliciting from patients their own motivation for making changes in the interest of their health.” Motivational Interviewing (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008) “Definition”

The “Spirit of MI” (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008) Collaborative Partnership, shared decision making Evocative Understand patient goals; evoke arguments for change Honoring patient autonomy Patients ultimately decide what to do

Motivational Interviewing “Principles” R esist the Righting Reflex (Directing) U nderstand Patient Motivations L isten to Your Patient with Empathy E mpower Your Patient (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

A refined form of guiding, rather than directing or following…… helping the patient make his or her own decision about behavior change MI Style (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

Motivational Interviewing Asking Listening Informing Guiding - balancing skills, flexibly applied (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?

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

“How convinced are you that it is important to monitor your blood sugars?” Not at all convinced Totally convinced Explore Conviction/Importance “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)

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

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

(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

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

Action Plan 1. Goals: Something you WANT to do 2. Describe HowWhere WhatFrequency 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

Review past experience - especially successesReview past experience - especially successes Define small steps that are likely to lead to successDefine small steps that are likely to lead to success Action Planning

“How confident are you that you can meet your goal of exercising 5 days a week? Not at all confident Totally confident Action Planning: Assess and Enhance Confidence “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)

Provide tools, strategies, resources, skillsProvide tools, strategies, resources, skills Address barriersAddress barriers Attend to progress and to perceive slips as occasions for problem solving rather than as failureAttend to progress and to perceive slips as occasions for problem solving rather than as failure Enhancing Confidence

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

Self-Management Support Cycle Adapted from: Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87 EXPLORE : Needs, Expectations, Values, Behavior, Progress SHARE : Provide specific Information about health risks, benefits of change, and strategies to self- manage 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 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

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:

Prepared, Proactive Practice Team Informed,ActivatedPatient Productive Interactions Functional and Clinical Outcomes *E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound Health System Organization of Health Care Self- Management Support Decision Support Delivery System Design Clinical Information Systems Community Resources and Policies A Model for Planned Care*

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

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

Chronic Disease Self- Management Program Developed and studied by Kate Lorig and colleagues at StanfordDeveloped and studied by Kate Lorig and colleagues at Stanford Lay-leaders, 6 sessions, 2 1/2 hours eachLay-leaders, 6 sessions, 2 1/2 hours each Single or multiple conditionsSingle or multiple conditions Focus on collaborative goal-setting, personalized problem solving, skill acquisitionFocus on collaborative goal-setting, personalized problem solving, skill acquisition Outcomes: improved health behaviors and health status, fewer hospitalizationsOutcomes: improved health behaviors and health status, fewer hospitalizations Limitations: limited population Limitations: limited population (Lorig et al, Med Care 1999, 37:5-14; Lorig, et al., Med Care, 2001, 39: )

Clinical Information Systems Provide access to educational materials and toolsProvide access to educational materials and tools Create capacity to identify and contact relevant subpopulations for proactive careCreate capacity to identify and contact relevant subpopulations for proactive care Monitor and share SMS performance data.Monitor and share SMS performance data.

Community Linkages Identity community programs and resourcesIdentity community programs and resources Partner with community organizationsPartner with community organizations Partner with employersPartner with employers Raise community awareness: community campaignsRaise 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)Quality Improvement Collaboratives : with focus on SMS (e.g., New Health Partnerships) and Patient Activation (MN) Educational Outreach – QIOs, DOQ-IT, Voluntary AgenciesEducational Outreach – QIOs, DOQ-IT, Voluntary Agencies Provider education and training - Core Competencies, Motivational InterviewingProvider education and training - Core Competencies, Motivational Interviewing Incentives, rewards for provider delivery of SMS, system changeIncentives, 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:

(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