1. This material was prepared by TMF Health Quality Institute under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Any statements expressed by the individual and resources cited in this publication are not an opinion of, nor endorsement by, TMF or CMS. Self-Management Support for Providers Elisha Jewett, MPH Pratheep Arora, MD David Ehrenberger, MD

2. Advanced Strategy: Self-Management Support ColoradoNationally # Selected SMS32272 % Selected SMS44%56%

3. DR. DAVID EHRENBERGER Avista Adventist Hospital and Integrated Physician Network

4. This material was prepared by TMF Health Quality Institute under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Any statements expressed by the individual and resources cited in this publication are not an opinion of, nor endorsement by, TMF or CMS. Meeting Patients Where They Are… The Art and Science of Self-Management Support David Ehrenberger, MD April 27, 2016

5. An Unlearning Session: Making room for three take-home messages Self-management as an ideal The noncompliant patient Power of the traditional office visit

7. Ruben’s Message

8. Self-Management Registry Outreach Pre-Visit Huddles Group Visits Medical Home

9. Poll

10. Self-Management Support Agenda 1.Why Bother? 2.It Works! 3.What Works? 4.Prove It… 5.Play It... 6.Tools for the Road

11. Why Bother? S___ happens! Always. Who are the experts? Disease versus lives. Education alone doesn’t cut it. If advanced teamwork were a wheel… “Understanding that the experience of giving care is different that of receiving care."

12. It Works! The noncompliant provider Ideal SMS programs Summit Medical Clinic (Colorado Springs) – Barriers and successes from the trenches

13. DR. PRATHEEP ARORA Summit Medical Clinic

14. This material was prepared by TMF Health Quality Institute under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Any statements expressed by the individual and resources cited in this publication are not an opinion of, nor endorsement by, TMF or CMS. SMS “Sustainable Menu of Success” Pratheep Arora, MD Summit Medical Clinic Colorado Springs, Colorado

15. DM/CKD/CHF: 1 st Step Lunch and Learn What did we find? – No show. – Not much interaction from patient. – Not customized or individually focused, probably decline in follow-through outside office visit. – Classroom environment fallen out of favor. -DNR. – Concept: Great. Goal: Probably achievable and sustainable with long- lasting impact. Question is how do we sell this idea.

16. workflow We went back to the Consumer: ESRD on HD from Diabetic Nephropathy. “What would you have done differently if you were able to turn the clock back three years?” The Birth of Day-to-Day Self-Management Support questionnaire use in our day-to-day work. HR Diabetic Visit Meet with CM Diabetic Quiz Go Over Number Copy to Pt and EHR Phone f/u CM CM Revisit Next Office Visit

19. What Works? Concepts: – ‘Taps’ for the traditional office visit – Motivational interviewing – Meta Teamwork – Negotiating goals—confidence scale – Meeting patients where they are… – Powering Self-Management: Group Visits, Home Visits, non-visit care

20. What Works? (cont.) The Core Competencies of SMS – Describe and promote SMS for your patients – Engage family members, as appropriate – Work on patient/family relationship (duh) – Explore/understand patient’s values, preferences – Share information, effectively – Collaboratively set goals, build Action Plans – Build teams/teamwork – Follow up…or give up!

21. Effective SMS Program in 5 Steps

22. 1. Negotiate Agenda Ask what is important for the patient first…otherwise they will not hear what you have to say (won’t “engage”). Engagement and activation lead to self-efficacy.

23. 2. Information Giving List the important disease-specific info patient needs to know. Close the Loop: – “Please tell me what you understand about what we just talked about?”

24. 3. Motivational Interviewing Ask-Tell-Ask: Ask patients what they want to know about, tell them, ask them if they have more Q’s. Engage patients around what behavior change interests them. Define Goal and do Readiness Assessment: importance and confidence (>=7). Good Goals. Document the final goal with specifics—the Action Plan; both patient and MD sign the agreement.

25. Make it formal!

26. The EMR as your friend…

28. 4. Follow-up Set follow-up plan—next OV, commitment of team to follow up by phone or patient portal. Key is non-OV follow-up—preferably by phone, must be by team-member.

29. 5. Create and Train Team/Teamwork Providers do not have the time. Train key members in SMS techniques (Ask-Tell- Ask, Close the Loop, Readiness Assessment, collaborative goal setting) and disease-specific information.

30. Prove it The science of SMS…behind the obvious* – More effective than patient education – Improved self-efficacy and health behaviors – Reduced hospitalizations/days of hospitalization – Improves outcomes, reduces cost *See handout: “Self-Management Support Reference List”

31. Play it! Your turn to explore the challenges of SMS…table exercises 1.The engaged and ready patient 2.The ambivalent patient 3.The “not my problem” patient 1.Too good to be true 2.Psychosocial priorities (Maslow strikes again)

32. Tools to Take Home IHI Self-Management Tool Kit Action Plan Template Self-Management Support Reference List Chronic Disease Self-Management in Primary Care (Bodenheimer)

33. An Unlearning Session— Three take-home messages: 1.Self-management as an ideal 2.The noncompliant patient 3.Power of the traditional office visit

34. An Unlearning Session— Three take-home messages: 1.Self-management as an ideal inevitable 2.The noncompliant patient not yet engaged/activated 3.Power of the traditional office visit meeting patients where they are!

35. Finis