But We Provide Great Healthcare! Why do we have to worry about self-management support?

Kathy Reims, MD, FAAFP

January 20, 2017

Objectives:

1. Define self-management and self-management support

2. Explain the Stepped Care Model and the associated self-management interventions

3. Describe the evidence for self-management support

4. Describe the link between self-management support and improvement initiatives

What comes to mind?

One Definition

“The individual’s ability to manage the

symptoms, treatment, physical and social

consequences and lifestyle changes inherent in

living with a chronic condition.”

1Barlow et al, Patient Educ Couns 2002;48:177

Individuals with Diabetes Mellitus provide about 95% of their own care.

Anderson RM, Funnell MM, Butler PM, et al. Patient empowerment. Results of a randomized controlled trial. Diabetes Care 1995;18(7):943-9

Self-Management Support (SMS): What is it?

“Self-management support” is “the systematic provision of education and supportive interventions by health care staff 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 2002

Medical Professionals often Confuse SMS with Education

Education

Begins with provider

determination of need

Information and technical skills

are taught

Usually disease-specific

Assumes knowledge leads to

behavior change (false)

Goal is compliance

Teachers are always

professionals

SMS

Begins with the patient’s self-

identified problems

Problem-solving skills are

taught

Skills are “generalizable”

Assumes self-efficacy leads

to change (true)

Goal is more self-efficacy

Teachers can be

professionals or peers

Bodenheimer et al JAMA 2002;288:2469

Thinking about SMS is Evolving…

“Self-Management Support is the assistance caregivers give patients and their self-defined circle of support so patients can manage their conditions on a day-to-day basis and develop the confidence to sustain healthy behaviors for a lifetime.”

T Bodenheimer, et al. Helping Patients Manage their Chronic Conditions.

Available at http://www.chcf.org

Who benefits from self-management support?

Perspective of Health vs Health CARE

Framing

When we engage people in their healthcare and health, we are often asking them to make a change or do something differently.

Lose weight

Start a

medication

Get more

exercise

Get health

advice

when you

need it

Eat at least 5

fruits and

vegetables per

day

Get your

mammogram

Follow up in

3 months

Immunize

your baby

What influences health behavior change?

Basic needs met

Competing priorities

Personal resilience and personality traits

Family of choice and community support

Readiness, ability and willingness to change

Advice from a trusted person or professional

Importance of the change

Confidence that you can make the change

Even once you decide to make a change, it is sometimes challenging to follow through.

Self-confidence

People’s beliefs about their capabilities to perform specific behaviors and their ability to exercise influence over events that affect their lives. Self-confidence beliefs determine how people feel, think, motivate themselves and behave.

- Albert Bandura

Mt Frosty, BC by C. Davis

Stepped Care Self-management Support

adapted from Health Council of Canada: Self-management Support for Canadians with Chronic

Conditions, May 2012

Patients vary in

what type and

how much

SMS they need

over time.

Evidence for SMS Programs

Evidence for SMS

Evidence is emerging that self-management support programs improve a variety of outcomes for different chronic conditions 10 - 28

Patient’s sense of engagement and self-efficacy are strong predictors of outcomes.29

Quality improvement interventions that have attempted to improve the outcomes of chronic care without a component that supports patient self-management have not been found to affect patient outcomes.30

Reporting, and pay-for-performance programs encourage the provision of self-management support

Debra DeSilva

“The literature shows that proactive, behaviorally focused self-management support designed to increase self-efficacy can have a positive impact on people’s clinical symptoms, attitudes and behaviors, quality of life and patterns of healthcare resource use.”

Natalie Grazin, p iv

Conclusions

1. Some interventions are more effective than others

If combine studies, dilutes effectiveness

“One off” efforts unlikely to make a difference, so make it part of wider initiatives and system redesign

2. Proactive SMS and focusing on behavior change can impact clinical outcomes and emergency service use.

DeSilva, 2011, “Helping People Help Themselves”

General components that work

Involving people in decision making

Emphasizing problem solving

Developing care plans as a partnership between patient and professional

Setting goals and following up on them

Promoting healthy lifestyles, educating people about their conditions and how to self-manage

DeSilva, 2011, “Helping People Help Themselves”

Components, cont.

Motivating people using targeted approaches and structured information and support

Helping people to monitor their symptoms and know when to take action

Helping people manage social, emotional and physical impacts of their conditions

Proactive follow-up

Providing opportunities to share and learn from others

DeSilva, 2011, “Helping People Help Themselves”

Questions remain…

Best strategies to implement principles

Barriers and facilitators to implementation

How best to build relationships between patients and professionals

Exploring effective strategies for behavior change

Understanding skills clinicians need and barriers that prevent them from offering support

DeSilva, 2011, “Helping People Help Themselves”

Strategies

DeSilva, 2011, “Helping People Help Themselves”

How would things be different?

?

??

?

??

If health care professionals provided excellent self-management

support and patients were excellent self-managers, how would things

be different?

How important is it for you to develop or expand the SMS you provide in your practice?

0 1 2 43 65 7 8 9 10

Not at all

important

Very

important

Starting or Expanding SMS as an Improvement Project

Set an aim

Select measures and calculate your baseline

Choose changes that will help you achieve your aim. These might include changes to roles and responsibilities, workflows, documentation norms, et al.

Setting an Aim

What SMS do you want to offer?

To whom?

By when?

Be specific about what success looks like

“By January 31, 2018 we will have offered 90% of our patients with diabetes the opportunity to set patient-directed self-management goals”

Who Should we Target for SMSUnderstanding our Patients

DemographicsCulturesEducational levelHealth behavior insights (how savvy is the population

about their health)Chronic disease burdenHealth outcomesTop 10 diagnosesTop 5 referral specialtiesCAHPS scores around respect, understood, listened to…. What else?

Clinical Status and Confidence Matrix

Wasson – How’s Your Health www.howsyourhealth.org

• Front desk

• iPad kiosk check in

• MA

• Nurse

• Physician or provider

• Community Health worker

• Health coach

Evaluation Metrics

Maintenance costs – structure, facility, training

Process development – education, coaching, reach

Patient self-efficacy and knowledge

Patient behavior change

Biometrics – disease parameters

Health outcomes – health status, quality of life

Utilization markers – hospitalizations, ER visits

Cost – overall costs, shared savings

Patient satisfaction and experience

CAHPS Supplemental Survey Sets

https://cahps.ahrq.gov/Surveys-Guidance/index.html

What changes do we need to make?

Consider internal capacity as well as community resources

Think about and ask staff about what requests pop up frequently

Ask patients what would be most helpful

Look to available change packages

Staff Skills for Interventions that work: Step 1

Involving people in decision making

Promoting healthy lifestyles, educating people about their conditions and how to self-manage

Helping people to monitor their symptoms and know when to take action

de Silva, 2011, “Helping People Help Themselves”

Staff skills for Interventions that work: Step 2

Setting goals and following up on them

Developing plans as a partnership between patient and professional

Emphasizing problem solving

de Silva, 2011, “Helping People Help Themselves”

Staff skills For Interventions That work: Step 3

Helping people manage social, emotional and physical impacts of their conditions

Proactive follow-up

Providing opportunities to share and learn from others

de Silva, 2011, “Helping People Help Themselves”

What can our existing staff do ?

Differentiate self-management support tasks

Look for people with different skills for different tasks (may cross roles)

Remote versus face-to face

At versus between visits

What can our community offer?

MOUs and partnerships

Ensure philosophically aligned

Coordinate approach and language

How might you expand further?

New roles – Community Health Workers, Health Coaches

Modified roles – MA role takes on action planning

Engage behavioral health or addiction specialists to provide services at your facility

Summary

Described SM, SMS and why it is an important and integral part of the care we provide

Reviewed the evidence for SMS

Discussed different ways to assess your practices’ SMS needs

Provided guidance on how to improve SMS in your practice

Online Resources

http://www.centrecmi.ca/

Stepped Care brochure

Brief Action Planning algorithm and Guide

BRAIN tool

Contact me:

kreims@spreadinnovation.com

References

19 Norris SL, Engelgau MM, Venkat Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 2001;24(3):561-87.

20 Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports. Br Med J 2002;325(7370):925.

21 Norris SL, Lau J, Smith SJ, et al. Self-management education for adults with type 2 diabetes: A meta-analysis of the effect on glycemic control. Diabetes Care 2002;25(7):1159-71.

22 Warsi A, Wang PS, LaValley MP, et al. Self-management education programs in chronic disease: a systematic review and methodological critique of the literature. Arch Intern Med 2004;164(15):1641-9.

References

23 Chodosh J, Morton SC, Mojica W, et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med 2005;143(6):427-38.

24 Guevara JP, Wolf FM, Grum CM, et al. Effects of educational interventions for self-management of asthma in children and adolescents: systematic review and meta-analysis. Br Med J 2003;326(7402):1308-9.

25 McAlister FA, Stewart S, Ferrua S, et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am CollCardiol 2004;44(4):810-9.

References

26 Gibson PG, Powell H, Coughlan J, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2002;3:CD001117.

27 Gibson PG, Ram FS, Powell H. Asthma education. Respir Med 2003;97(9):1036-44. 41

28 Bravata DM, Sundaram V, Lewis R, et al. Asthma care. Vol 5 of: Shojania KG, McDonald KM, Wachter RM, et al., editors. Closing the quality gap: a critical analysis of quality improvement strategies. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville (MD): Agency for Healthcare Research and Quality; 2007. AHRQ Publication No. 04(07)-0051-5.

References

29 Bandura A. Promotion from the perspective of social cognitive theory. Psych Health 1998;13:623-49.

30 Renders CM, Valk GD, Franse LV, et al. Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice. Diabetes Care 2001;24(8):1365-70.