Chronic Disease Self Management

1. Chronic Disease Self Management Leigh Caplan, RN, MA, CDE, Diabetes Nurse Educator, Sunnybrook Academic Family Health Team Judith Manson, RN, BScN, NCMP, Executive Director, Sunnybrook Academic Family Health Team May 4, 2012

2. Learning Objectives By the end of this presentation, you will have reviewed…. the health care implications of chronic disease the role of self management and be able to … understand options for you and your patients for self management training, processes and programs assist your patients in setting realistic measurable goals Caplan/Manson 2012

3. Outline Review of chronic disease and the implications for patients and the health care system Self management options/programs Application of some self management tools Caplan/Manson 2012

4. Chronic Disease 1 in 3 Canadians suffer from a chronic condition (diabetes, asthma, COPD, CVD, cancer) Chronic disease is considered a major health burden in the world (L. Doeber, 2005) Noncommunicable diseases top world deaths (WHO Global Report Sept 2011) Personal and economic impacts of these diseases are significant (Conference Board of Canada 2004) Caplan/Manson 2012

5. In the past 10 years … Hypertension Rates: 8.7% -16.4% (1.8 million Ontarians) New cases – up 26% Diabetes Rates: 5.4% -8.4% (up 50%) New cases – up 27% OMA Policy on Chronic Disease Management Oct 2009 Caplan/Manson 2012

6. Over 65…(in Ontario) Rheumatism/arthritis – 46.3% Hypertension – 47.3% Diabetes – 17% Number of conditions per person ↑ - 56% with 2 or more chronic conditions Population ↑ from 12.9% - 22.1% by 2031 OMA Policy on Chronic Disease Management Oct 2009 Caplan/Manson 2012

7. Why are chronic diseases on the increase? Aging population Rising rates of obesity Declining rates of physical activity Increasing immigration from high risk populations Caplan/Manson 2012

8. So… we need to manage chronic disease to minimize complications maintain quality of life and manage limited health care resources or we need to prevent chronic disease in the first place Caplan/Manson 2012

9. Drive to “95” Ambulatory Care Sensitive Conditions ER Visits/Admissions/ALC Readmission rates Integration Networks Family Health Teams OTN Rapid Referral Clinics (RADAR) IMPACT Caplan/Manson 2012

10. Ontario’s CDPM Framework INDIVIDUALS AND FAMILIES Healthy Public Policy Personal Skills & Self- Management Support HEALTH CARE ORGANIZATIONS Supportive Environments Delivery System Design Information Systems Provider Decision Support Community Action COMMUNITY Productive interactions and relationships Informed, activated individuals & families Activated communities & prepared, proactive community partners Prepared, proactive practice teams Improved clinical, functional and population health outcomes January 2006 Caplan/Manson 2012

12. Review of self management Self management is a philosophy of health wherein the individual has the knowledge skills judgment and ability and confidence to be an advocate and expert in the management of their own health and wellness Caplan/Manson 2012

13. Self management is not … Didactic patient education Sage on the stage “You should…” Finger wagging Lecturing Waiting for patients to ask for help Caplan/Manson 2012

14. Traditional patient education vs self management education Professional is expert in the disease Professional tells patient what to do and sets goals Professional “solves” the problems Goal is for patient to comply to professional’s plan to achieve benefits Minimal behaviour change occurs Patient is the expert in their lives Patient sets goals with professional Patient identifies problems Patient learns strategies to solve problems Patient internally motivated and uses problem solving goals to achieve benefits that are meaningful Maximal behaviour change occurs Caplan/Manson 2012

15. Is self management education effective? Self management education vs client education produces short term clinical outcomes (Lorig, Ritter & Jacquez, 2005; Skinner et al 2006) improvement in quality of life (Cochran & Conn 2008) will reduce costs (Duncan et al 2009, Robbin et al 2008) Caplan/Manson 2012

16. What is important to include in self management education? Behavioural strategies Self directed goal setting Using more than one strategy increases effectiveness RNAO Clinical Best Practical Guidelines Strategies to Support Self –Management in Chronic Conditions: Collaboration with Clients Sept 2010 Caplan/Manson 2012

17. How well do we support our patient’s in becoming active self managers? Caplan/Manson 2012

18. Individualized assessment of patient's self management educational needs is not done is not standardized and/or does not consistently include most self management components is standardized, fairly comprehensive and documented prior to initial goal setting, takes into account language, literacy and culture, assesses patient’s self management knowledge, behaviors, confidence barriers resources and learning preferences is an integral part of planned care for chronic disease patients; results are documented, systematically reassessed and utilized for planning with patients Caplan/Manson 2012

19. Patient self management education does not occur occurs sporadically or without tailoring to patient skills, culture, educational needs learning styles or resources plan is developed with ( and family if appropriate) based on individualized assessment is documented in patient chart; all team members generally reinforce same key messages is documented in patient charts; is an integral part of the care plan for patients with chronic diseases; involves family and community resources is systematically evaluated for effectiveness Caplan/Manson 2012

20. Goal setting/Action Planning is not done occurs but goals are established primarily by health care team rather than developed collaboratively with patients is done collaboratively with all patients/families and members of their health care team goals are specific, documented and available to any team member goals are reviewed and modified periodically is an integral part of care for patients with chronic diseases goals are systematically reassessed and discussed with patients progress is documented in patient charts Caplan/Manson 2012

21. Problem Solving Skills are not taught or practices with patients are taught and practice sporadically or used by only a few team members are routinely taught and practiced using evidence-based approaches and reinforced by members of the health care team is an integral part of care for people with chronic diseases takes into account family, community and environmental factors results are documented and routinely used for planning with patients Caplan/Manson 2012

22. Emotional Health is not assessed is not routinely assessed; screening and treatment protocols are not standardized or are nonexistent assessment is integrated into practice and pathways established for treatment and referral patients are actively involved in goal setting and treatment choices team members reinforce consistent goals systems are in place to assess, intervene, follow up and monitor patients’ progress and coordinate among providers standardized screening and treatment protocols are used Caplan/Manson 2012

23. How do we as healthcare providers become more supportive? Caplan/Manson 2012

24. Stages of Change Caplan/Manson 2012

25. The 5 A’s Assess Advise Agree Assist Arrange Goldstein et al, AJPM 2004 Caplan/Manson 2012

26. Twelve principles for implementing self management support in primary care Assessment Information alone is insufficient Non judgmental approach Collaborative priority and goal setting Collaborative problem solving Diverse providers Diverse formats Patient self efficacy Active follow up Guideline –based case management Linkage to evidence based community programs Multifaceted interventions Battersby, M et al, The Joint Commission Journal on Quality and Patient Safety Dec.2010 Caplan/Manson 2012

27. Motivational Interviewing “A client centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” Miller and Rollnick, 2002 Caplan/Manson 2012

28. Motivational Interviewing Four General Principles Express Empathy Reflective Listening Develop Recognition of Discrepancy Clarify ambivalence Roll with resistance Avoid arguing Support Self Efficacy Individual’s belief in his or her ability to accomplish a task or behaviour Caplan/Manson 2012

29. No “Why” Caplan/Manson 2012

30. How to use scaling Caplan/Manson 2012

31. Change in Human Behaviour How important is it for you to help your patient to make changes ? Conviction “How important” How confident are you that you can help your patient to change? Confidence (Barriers)

33. Learning Options for Clinicians Health Coaching Choices and Change Motivational Interviewing 3 Minute Empowerment Stanford Self-Management Program Caplan/Manson 2012

34. Choices and Changes: clinician influence and patient action is: 1 day or half day sessions Small groups: 6 to 30 participants Efficient and effective tools to enhance patient health behavior change and adherence to treatment plan Clinicians explore their own beliefs vs research Specific, brief and efficient communication strategies Offered through the Diabetes Regional Coordination Centres (free!) Caplan/Manson 2012

35. 3 Minute Empowerment Two step tool: Evaluation: Intervention goal: Stage of change (Prochaska) Intervention target: conviction and confidence (Miller and Rollnick) Intervention Technique: Motivational Interviewing Offered through Pfizer Canada Caplan/Manson 2012

36. Health Coaching New approach Designed to assist people to make and maintain behavioural changes which lead to positive health outcomes Not a lot of evidence to support success with this method Caplan/ Manson 2012

37. How do patients become more active self managers? Caplan/Manson 2012

38. Key aspects of patient self management programs… should teach and help develop these essential skills: Problem solving Decision making Resource utilization Developing an effective patient/provider relationship How to take action Caplan/Manson 2012

39. Self Management Tasks To take care of their illness To carry out their normal activities To manage their emotional changes Lorig,K et al, Living a Healthy Life with Chronic Conditions 2006 Caplan/Manson 2012

40. Stanford Chronic Disease Self Management Program Six weekly sessions Interactive May be peer led Text – “ Living a Healthy Life with Chronic Conditions” Caplan/Manson 2012

41. Stanford Model Overview of self management and chronic health conditions Action Plans Using your mind to manage symptoms Feedback/problem solving Difficult emotions Fitness/exercise Better breathing/relaxation Pain Fatigue and sleep Nutrition Future plans for health care Communication Medication Making treatment decisions Depression Working with your health care professional Working with the health care system - resources Future plans Caplan/Manson 2012

42. Leader Training Standardized 4 Days (24 hours) Leader Manual Reference Book Leader characteristics and requirements Caplan/Manson 2012

43. Your turn … Caplan/Manson 2012

44. Activities Brainstorming Action Plans Caplan/Manson 2012

45. Guidelines for Brainstorming Activity Anyone who has an idea can share it No one will comment either positively or negatively on any of the ideas during the brainstorm No one will ask questions or discuss any of the ideas until after the brainstorm When all the ideas are out, we’ll go over anything that needs clarification Caplan/Manson 2012

46. What are some ways to deal with difficult emotions? Anger Fear Worry Frustration Caplan/Manson 2012

47. Action Plan Something you WANT to do Achievable Action specific Describe what? how much? when? how often? Confidence level Caplan/Manson 2012

48. Action Plan Something you WANT to do Achievable Action specific Describe what? how much? when? how often? Confidence level I want to be more active I will walk 20 minutes after dinner Monday, Wednesday and Friday 8 Caplan/Manson 2012