1. Self-management support and patient education for chronic conditions at Group Health
Small steps to big changes
Background
Self-management support
Patient education resources for supporting self-management support
Lessons learned
Future directions
May 10, 2012 | Kim Wicklund, MPH

2. Randy’s story
Whether you think you can do a thing or you can’t do a thing, you’re right.
– Henry Ford

3. Chronic Conditions in U.S.
Among the American adult population:
50% have at least one chronic condition
25% have multiple chronic conditions
75% of people age ≥65 have multiple chronic conditions
½ of those with hypertension, and over 60% of those with diabetes and hyperlipidemia do not have conditions well controlled
Vogeli, Shields, Lee 2007 JGIM
Medical Panel Expenditure Survey 2006
Schneider et al. 2009
Bodenheimer, Wagner, Grumbach 2002 JAMA

4. Chronic Care Model

5. Rationale for self-management support
Through SMS people gain knowledge, skills, and self-confidence
Majority of care for chronic conditions is complex and challenging self care
SMS improves patient outcomes and controls costs
Various SMS approaches: care managers, one-on- one, group, telephonic coaching, online, peer
Need effective models that are affordable and have population level impact

6. Chronic Disease Self-Management Program
Developed at Stanford Patient Health Education Research Center
6-week workshop (2.5 hrs/wk) based on self-efficacy theory
Designed for people with one or more chronic conditions
Leaders have personal experience with chronic conditions
Premise– people with chronic conditions share similar challenges and need to master a generic set of self- management skills
Contributes to improvements in psychological health status, self-efficacy and select health behaviors. Modest effects can have significance across large population. (CDC 5/2011)

7. CDSMP at Group Health Started in 1998 18 medical centers
65 volunteer leaders
Average age: 65
Most common conditions: diabetes, arthritis, asthma/COPD, heart disease, depression
Reach : 1,615 Group Health patients
Recruitment: letters, care team, ghc.org, flyers, word of mouth

8. Challenges of scaling CDSMP
Limited access for network members in eastern and central Washington
Capacity determined by volunteer leader and room availability
Schedule is sporadic
Chronic condition flare-ups can impact attendance
Difficult to commit to weekly 2 ½ hour sessions
Discomfort discussing sensitive topics face to face

9. Online CDSMP

10. Online CDSMP pilot Funded by GHF Partners: NCOA, Stanford, GHRI
Target: 500 participants
Timeline: June, 2009-June, 2011
Eligibility:
Adult Group Health member
Any chronic condition
Enhanced access to MGH

11. Intervention 6-week highly interactive online workshop
Follows structure of in-person program
6-week highly interactive online workshop
25 participants per workshop
Two peer moderators
New lessons posted each week
Participants log on at their convenience 2-3 times/week
Time commitment of 2-3 hours/week

12. Home page

13. Evaluation questions
Will the online program expand CDSMP’s reach to Group Health members who are not reached by the in-person workshops?
Will participants in the online program at Group Health experience similar benefits to those reported in Stanford’s evaluation?
What resources and expertise are needed to administer the online program at Group Health?
Is the online format a viable strategy for bringing the CDSMP intervention to scale at Group Health?

14. Participant flow Stage in process Total Signed up as interested 1043
Enrolled
473 (45%)
Attended ≥1 session
91%
Completed ≥4 sessions
66%
Data for baseline and 6 months
50%

15. Evaluation Health Status Self-mgt behaviors Healthcare Utilization
Self-efficacy
Social/role activity limitations
Depression
Pain severity
Shortness of breath
Self-rated general health
Health distress
Exercise
Communica- tion w/MD
Cognitive symptom management
Medication management
Smoking status
Visits to physician
Visits to ED
Hospital stays
Nights in hospital
6 item self- efficacy scale

16. Demographics

17. Conclusions Online program expanded CDSMP’s reach
Benefits were similar to but not consistent with Stanford’s
Resources and expertise needed to administer the online program are reasonable
Mixed staffing model– GH Administrator; NCOA mentor and facilitators
Costs– per workshop: $4350; per participant: $174; per completer: $255
Online format is a viable strategy for helping to bring the CDSMP to scale at Group Health

18. Other strategies

19. Employer pilots Testing 3 approaches:
Worksite-based workshops (King County)
4 workshops- 56 employees
Gold status for documented attendance of ≥4 sessions
Formal reporting of participation (SHWT)
GH/SHWT reporting process for incentivizing employees attending ≥4 sessions online or in person
Employee self report on participation (Group Health)
≥4 sessions in person or online for 400 wellness points
317 reported met goal

20. Disease-specific pilot
Living Well with Diabetes (DSMP)
GHF Partnership for Innovation grant to pilot workshops
To date offered 8 workshops to 128 people (14 scheduled)
Evaluating impact on self-management behaviors, blood sugar knowledge, medication management
“Today I received my latest blood and kidney test results, and for the first time in my adult life they all were within normal ranges. My A1c was 5.7….”

21. Integrating referrals into care
Point of care prompts in EMR
CMEs and nursing education
Clinical Pearls
Standard tools
Health Profile
After Visit Summaries
Brochures
MyGroupHealth

22. Reach

23. Patient education resources

24. Myths about patient education
If patients have more information, they’ll have better outcomes.
If I don’t share everything I know with my patients, they won’t fully understand their condition and what they need to do.
If my patients hear medical jargon, that’s ok. They’ll be able to understand it from the context.
My patient is well educated, so s/he will understand complex words and ideas.
My patient didn’t ask any questions so s/he must have understood my instructions.

25. The reality for many patients
Most patients forget up to 80% of what their clinician tells them as soon as they leave the office
Nearly 50% of what patients do remember they remember incorrectly 
Implications:
– Non-adherence and disengagement
– Patient safety concerns
– Medication errors
– Missed surgeries and other appointments

26. Strategies for providing information
Break the information into understandable chunks
Use plain language
Limit key points to 3 or fewer
Focus on action-oriented messages
Repeat key messages
Use analogies to help explain concepts
Use images and graphics
Tailor the message to the patient
Give consistent messages

27. Modular approach

28. Graphics clarify key concepts

29. Action planning

30. Action plan for diabetes management

31. Patient instructions provided in AVS

32. Lessons Learned 32

33. Lessons learned We have an ethical obligation to provide effective SMS
Patients want and need different options for engaging in SMS
People cycle through readiness and need to hear about SMS from different sources at different times
Clinical teams need ongoing reminders about the program
Employers are an underutilized resource for promoting SMS
Incorporating SMS concepts into patient education supports awareness of care team and patients about SMS 33

34. Future directions

35. Next steps
Continue exploring how to integrate referrals into standard work
Continue to identify alternative ways to reach network members
Update functionality and design of online program
Further analyze evaluation data
Explore more partnerships with employers (SU, Puyallup Tribe)
Partner with community programs to address gap areas
Create online community of LWCC alumni to provide ongoing support
Considering SMS program for youth or young adults

36. Discussion