Practical Strategies for Supporting Perceptual Motor Difficulties
Clinical Tools and Strategies for Supporting Self-Management
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Transcript of Clinical Tools and Strategies for Supporting Self-Management
Clinical Tools and Strategies for Supporting Self-Management
Michael G. Goldstein, MDChief, Mental Health and Behavioral Sciences Service
Providence VA Medical CenterProfessor, Psychiatry and Human Behavior, Alpert Medical School of Brown University
IBHP WebinarMarch 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 SMS Key Components of SMS
• Core Clinical Competencies/Tools & Core Clinical Competencies/Tools & Resources 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 To take care of the illness (medical management)(medical management)
• To carry out normal activities To carry out normal activities (role management)(role management)
• To manage emotional changes To manage emotional changes (emotional management)(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: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 Addressing knowledge is necessary but not sufficient to produce changes in chronic illness care outcomesto produce changes in chronic illness care outcomes
• Key strategies for improving outcomes of Key strategies for improving outcomes of educational and behavior change interventionseducational 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 Assumes knowledge drives changechange
Clinician sets agenda Clinician sets agenda
Goal is complianceGoal is compliance
Decisions made by caregiverDecisions made by caregiver
Assumes knowledge + Assumes knowledge + confidence drives changeconfidence drives change
Patient sets agendaPatient sets agenda
Goal is enhanced confidenceGoal is enhanced confidence
Decisions made Decisions made collaborativelycollaboratively
Self-Management SupportA Fundamental Shift in the Process of Care
Traditional CareTraditional Care Collaborative CareCollaborative Care
(Bodenheimer et al, CA Health Care Foundation, 2005)(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: www.newhealthpartnerships.org)
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: www.newhealthpartnerships.org)
(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”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”
• Resist the Righting Reflex (Directing)
• Understand Patient Motivations
• Listen to Your Patient with Empathy
• Empower Your Patient
(Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)
A refined form of A refined form of guidingguiding, rather than directing or following……, rather than directing or following……helping the patient make his or her own decision about behavior changehelping 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 careTaking 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
Totallyconvinced0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10
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 InformationShare Information
AskAsk Permission Permission
AskAsk Understanding Understanding
TellTell (Personalize)(Personalize)
AskAsk Understanding 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 Plan1. Goals: Something you WANT to do1. Goals: Something you WANT to do2. 2. Describe Describe
HowHow WhereWhereWhatWhat FrequencyFrequencyWhenWhen
3. Barriers -3. Barriers -4. Plans to overcome barriers -4. Plans to overcome barriers -
5. Conviction and Confidence ratings (0-10) -5. Conviction and Confidence ratings (0-10) -6. Follow-Up:6. Follow-Up:
Action Plan1. Goals: Something you WANT to do 1. Goals: Something you WANT to do Begin ExerciseBegin Exercise2. 2. Describe Describe
HowHow WalkingWalking Where Where NeighborhoodNeighborhoodWhatWhat 20 min20 min Frequency Frequency 3x/week3x/weekWhen When After dinnerAfter dinner
3. Barriers - 3. Barriers - Dishes, safety (no sidewalks)Dishes, safety (no sidewalks)4. Plans to overcome barriers - 4. Plans to overcome barriers - get kids to clean up, ask get kids to clean up, ask
neighbor or husband to join me, wear reflective neighbor or husband to join me, wear reflective vestvest
5. Conviction and Confidence ratings (0-10) - 5. Conviction and Confidence ratings (0-10) - 9/89/86. Follow-Up: 6. Follow-Up: Will keep log and bring to next visit in 1 Will keep log and bring to next visit in 1
monthmonth
• Review past experience - Review past experience - especially successes especially successes
• Define small steps that Define small steps that are likely to lead to are likely to lead to successsuccess
Action Planning
“How confident are you that you can meet your goal of exercising 5 days a week?
Not at all confident
Totallyconfident0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10
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, Provide tools, strategies, resources, skillsresources, skills
• Address barriersAddress barriers• Attend to progress and to Attend to progress and to
perceive slips as occasions perceive slips as occasions for problem solving for problem solving rather than as failurerather 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 Plan1. List specific goals
in behavioral terms2. List barriers and strategies
to address barriers3. Specify follow-up plan4. Share plan with practice
team and patient’s socialsupport
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: www.newhealthpartnerships.org)
Prepared,Proactive
Practice Team
Informed,Informed,ActivatedActivated
PatientPatient
Productive Interactions
Functional and Clinical Outcomes*E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound
Health SystemOrganization of Health Care
Self-Management
Support
DecisionSupport
DeliverySystemDesign
ClinicalInformation
Systems
CommunityCommunityResources and PoliciesResources and Policies
A Model for Planned Care*
Delivery System Redesign• Determine process and define roles for delivering Determine process and define roles for delivering
SMS among members of the care teamSMS 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 Provide support and coordination according to
level of needlevel of need
Opportunities for SMS:Opportunities for SMS:When, Where and By WhomWhen, 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 Developed and studied by Kate Lorig and colleagues at Stanford 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 Focus on collaborative goal-setting, personalized
problem solving, skill acquisitionproblem solving, skill acquisition• Outcomes: improved health behaviors and health Outcomes: improved health behaviors and health
status, fewer hospitalizationsstatus, fewer hospitalizations• Limitations: limited population Limitations: limited population
(Lorig et al, Med Care 1999, 37:5-14; Lorig, et al., Med Care, 2001, 39: 1217-1223)
Clinical Information Systems
• Provide access to educational materials Provide access to educational materials and toolsand tools
• Create capacity to identify and contact Create capacity to identify and contact relevant subpopulations for proactive carerelevant subpopulations for proactive care
• Monitor and share SMS performance Monitor and share SMS performance data.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 Raise community awareness: community
campaignscampaigns
Implementing Health System Changes to Support Self-Management
• Quality Improvement CollaborativesQuality Improvement Collaboratives: : with focus on SMS (e.g., New Health with focus on SMS (e.g., New Health Partnerships) and Patient Activation (MN)Partnerships) and Patient Activation (MN)
• Educational Outreach Educational Outreach – QIOs, DOQ-IT, – QIOs, DOQ-IT, Voluntary AgenciesVoluntary Agencies
• Provider education and trainingProvider education and training - Core - Core Competencies, Motivational InterviewingCompetencies, Motivational Interviewing
• Incentives, rewards Incentives, rewards for provider delivery of for provider delivery of SMS, system changeSMS, 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: www.newhealthpartnerships.org)
(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