1. Self-Management in pcmh
Promoting empowerment in chronic illness

2. Patient self-management Definitions
Definition #1 – Self-management is how patient manages aspects of their chronic disease (s). Definition # 2 – Learning and practicing the skills necessary to carry on an active and emotionally satisfying life in the face of chronic illness.

3. Self-management tasks
Managing the elements of their chronic disease: medication adherence, diet, exercise, treatments, self-testing and record keeping.
Maintaining their roles and functions in life.
Dealing with the emotional demands of their lives.

4. The case for self-management support
The role of the PCMH team is to provide motivating support and education needed by chronically ill patient needs . This includes
Timely, accurate, understandable information
Involvement in collaborative decision making
Goal setting and problem solving
Help managing psychosocial needs

5. NCQA 2011 Certification Guidelines for PCMH
PCMH 4A: Support Self-Care Process- MUST PASS
Requires practice to develop and document self-management plans/goals (CRITICAL FACTOR) in at least 50% of patients/families.
Documents self-management abilities for at least 50% of patients/families.
Provides self-management tools to record self-care results for at least 50% percent of patients/families.
Counsels at least 50% of patients/families to adopt healthy behaviors.
Provides educational resources or refers at least 50 % of patients/families to assist in self-management.
Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients/families.

6. Patient teaching vs. Self-management support
Patient Education Self-Management Support Information and skills are taught Skills to solve patient-identified problems are taught Usually disease specific Assumes that confidence yields better outcomes Goal is compliance Goal is increased self confidence Healthcare professionals are the teacher Teachers can be professionals or peers
Gives information
Provides tools
Gets patient involved in day-to-day decisions

7. Stages of change model Precontemplation (not ready to change)
Development of self-management skills means change to the patient’s life.
Recognizing where patient is on the continuum of change is critical to effective support
The stages of changes as 1st proposed by Prochaska and DiClemente in 1983:
Precontemplation (not ready to change)
Contemplation (thinking of changing)
Preparation (ready to change)
Action (Making the change)
Maintenance (Staying on track)
**Added to the theory since then, is # 6 Relapse (falling of the wagon!)

8. Other Skills and tools needed
Open-ended and exploratory questioning- frame your communication so a simple “yes, no or I don’t know” are not possible answers.
Reflective listening – encourages patient communication. Patient can’t/won’t talk if staff member is “telling” them what to do.
Depression Assessment – soon to be done practice wide.
Health literacy assessment – Don’t assume people understand what they are told by the PCP or yourself. Use the Teach-Back technique.
Engaging family members, caregivers and other signifigant social supports – should be with patient’s agreement. Be careful of self-appointed family members who want to become the “diabetic police”!
Goal setting, prioritizing and planning of care- use of motivational interviewing technique's and work toward the patient’s strengths and health belief system.
Effective team membership and participation- required by NCQA. Be proactive.
Document all of the above in the EHR

9. self- Management and goal setting
Step 1 - Problem identification
Impact of illness
Identify specific symptoms and signs of illness
Identify factors leading to preservation and promotion of a healthy lifestyle
Step 2 – Identifying barriers to self-management
Motivation
Knowledge of condition
Knowledge of symptom management
Comorbidities
Health beliefs
Self efficacy
Social context

10. Self Management and goal setting
Step 3 – Planning (setting of goals) – SMART
Specific
Measurable
Achievable
Realistic
Timely
Goals should focus on medication adherence, smoking cessation, self-monitoring
(i.e. glucose logs), diet, exercise, foot care, managing comorbidities and continuing
to live a participative lifestyle. Once goals are set , patient should get copy and they
should be shared with team via EHR.

11. Brief Negotiation Roadmap
Developed in 2002 by Kaiser Permanente and two psychologists, Miller and Rollnick
Needed a tool for practitioners to use in day-to-day patient interactions to promote healthy behavior changes.
Systematic way to efficiently and effectively discuss these changes with the patient/family.
Basic tenet of brief negotiations is that everyone has the potential for positive change.
Structure is a brief collaborative interaction to discuss health care changes.

12. Further Learning ONline