Gina Tomaszewski SWO Regional Stroke Education Coordinator

1. How can I Assist my Patients with Self-Management?Self-Management ToolkitA Resource for Health Care Providerswww.selfmanagementtoolkit.caStroke Recreation Therapy Workshop October 8, 2009 Gina Tomaszewski SWO Regional Stroke Education Coordinator

2. Objectives • Review key concepts of self-management. • Introduce the Self-Management Toolkit. • Introduce self-management approaches. • Become familiar with some of the self-management tools and concepts. • Reflect on your role with respect to self-management. • Reflect on what approach is right for you and your clients in your environment to assist with clients self management.

3. What is self-management?... 1. The activities that a client takes on to care for themselves or self-care. 2. Really letting the patients manage on their own. 3. None of the Above.

4. What is Self-Management? Self-management refers to the tasks that an individual must undertake to live well with one or more chronic conditions. These tasks include gaining confidence to deal with medical management, role management, and emotional management. McGowan, 2005 Self-management involves “learning and practicing necessary to carry on an active and emotionally satisfying life in the face of a chronic condition”. Lorig,1993

5. Purpose: 1. Expose health care providers to the various self-management approaches, and 2. Provide teams with some of the tools to support the initial implementation of a self-management approach.

6. Chronic Illness • Chronic illness is defined by Wagner, 2004 as: …any condition that requires ongoing activities and response from clients and their personal caregivers, as well as a response from their medical care system.

7. Some stats • Chronic conditions affect nearly one in three Canadians (about 9 million people). Rates are expected to increase due to aging population and rising trends in risk factors (e.g. obesity). (Obtained from Canadians’ Experiences with Chronic Illness Care in 2007, Health Council of Canada, December 2007) • Almost 80% of Ontarians over the age of 45 have a chronic condition, and of those, about 70% suffer from two or more chronic conditions (CCHS 2003). Is our health care system equipped to deal with this challenge?

8. Why is this so important? • We are an aging population. • If left untreated, chronic diseases can worsen, and predispose to other conditions. • Leads to huge costs in terms of quality of life and economic burden. Yet our current system is designed to treat acute illness , not prevent nor manage chronic illness.

9. Limitations of Acute Care Modelfor management of chronic illness… • With acute care: • Success depends on knowledge and skill of HCP • HCP provides treatment, care and follow-up (mostly related to disease) • HCP responsible most of the time. • Patients with chronic disease however manage by themselves (most of the time) • Success depends on new (lifestyle) behaviours • Patient must learn complex, multi-faceted new behaviours (not just disease management) • Patient responsible (most of the time)

11. Acute versus Chronic Disease ACUTE DISEASE CHRONIC DISEASE BEGINNING Rapid Gradual CAUSE Usually one Many DURATION Short Indefinite DIAGNOSIS Commonly accurate Often uncertain, especially early DIAGNOSTIC TESTS Often decisive Often of limited value TREATMENT Cure common Cure rare ROLE OF PROFESSIONAL Select and conduct therapy Teacher and partner ROLE OF PATIENT Follow orders Partner with health professionals, responsible for daily management

12. Obtained from 3 Minute Empowerment (Pfizer/Dr. Jacques Bédard) Power Point Presentation

13. High quality care for chronic illness: • Access to HCPs, and that care is responsive to their needs and preferences. • Integrated across multiple care providers and transition points. • Comprehensiveso that it addresses the gamut of services from health promotion and disease prevention to treatment. • Involves patients in making important care decisions and gives them the knowledge and tools to effectively manage their own condition. (p.2)

14. How often do people with chronic illness (diabetes, asthma, arthritis etc.) seek help from a health care provider?... • Ten Days out of a Year • One Day out of a Year • Twenty Days out of a Year • Thirty Five Days out of a Year

15. (Typical) Chronic Patient Contact with Health Professionals Time managing at home over 1 year • GP visits per annum = 1 hour • Visits to specialists = 1 hour • PT, OT, Dietitian = 10 hours • Total = 12 hours • 364.5 days managing on their own or 8748 hours Barlow, J. Interdisciplinary Research Centre in Health, School of Health & Social Sciences, Coventry University, May 2003.

16. Self-Management Support Assessment of Primary Care Resources and Support (PCRS)is a tool developed for teams participating in the Diabetes Initiative of the Robert Wood Johnson Foundation Integration of self-management into primary care Self-Management Education Patient Input Social Support Continuity of Care Problem-solving skills Organizational Support Patient Support Team Approach Goal-setting Ongoing Quality Improvement Individualized Assessment Continuity of Care System for documentation Emotional health Coordination of referrals Links to Community Resources Brownson et al (2007)

17. Self-Management Skills Successful self-management is based on 5 core skills: • Problem solving: Stroke individual develops a new problem or complication, able to find the most effective way to solve it. • Decision-making: Individuals need to be able to make day to day decisions about their condition based sound knowledge and information about health, symptoms and treatment. e.g: when to seek advice, or treatment, or make a change. • Resource utilization: Knowing what resources are available locally, and making the best use of these resources (e.g Stroke Recovery Groups). • Collaboration: Capability to make informed choices about one’s own treatment in partnership with healthcare providers. 5.Taking action: To change behaviour and master new skills. (Lorig and Holman, 2003)

18. Module 2: Foundations for Effective Self-Management • Person-centred care • Interprofessional Collaboration • Behaviour Change • Self-Efficacy • Motivational interviewing • Transtheoretical Model of Change

19. Module 2 -cont’d: Person-Centered Approach “A person centered approach to integrated care is responsive, quality care that acknowledges, understands, and respects client/patient ability, status, and decision-making within their own context. Through balanced partnering integrated care enables seamless response to the evolving needs of individuals to optimize their health across their lifespan”. South West LHIN Framework

20. What is Interprofessional Collaborative Practice(IPCP)? Interprofessional collaborative practice involves a partnership between a team of health professionals and a client in a participatory, collaborative and coordinated approach to shared decision-making around health issues. (Orchard & Curran, 2002)

21. Module 2 -cont’d : Interprofessional Collaboration When team members don’t play together , patients are denied “the benefits of more ears and eyes, the insights of different bodies of knowledge, and a wider range of skills” Wagner (2000)

22. Module 2 -cont’d: Behaviour Change • Helping patient’s self-manage so that they are able to achieve a better quality of life with their chronic illness may entail changing their behaviour e.g., exercising more, eating better, taking medication. • Successful self-management incorporates: • Motivational Interviewing (Miller & Rollick) • Change Readiness Model (Prochaska & DiClemente) • Self-Efficacy Theory (Bandura)

23. Module 2 -cont’d: Motivational Interviewing • A way of being with clients focuses on empathy and trust. • Teaches the HCP to help the client’s understandings and concerns. • Values the client’s beliefs. • Recognizes the client’s choice. • Focuses on exploring the patient’s ambivalence, dealing with resistance, and helping people move through change (Miller and Rollnick, 1991)

24. If after explaining the concept of self-management to your patient s/he does not want to identify a problem, you: A. Suggest some of your issues that you think s/he should address. B. Acknowledge his/her feelings and move on to something else. C. Explain the dangers and consequences of poor self care and ask them to reconsider. D. Respect his/her choice and ask if you can revisit the possibility of working on self care at a future encounter. Question obtained from www.selfmanagementtoolkit.ca

25. Your patient has identified exercise as the behaviour they are struggling with. When you explore importance, you discover that the patient does not see exercise as important at all. S/he chose it simply because it seemed the right thing to do. At this point you: • A. Suggest that this is not the best problem to start with and try working on another that the patient is interested in. • B. Acknowledge his or her feelings and work on elevating the level of importance by pointing out the benefits of exercise. • C Ask him/her to be more focused on their needs and not give socially desirable answers. • D. Take the opportunity to suggest the issues that you think are important and ask him/her to choose one. Question obtained from www.selfmanagementtoolkit.ca

26. Definition • “Goal-setting is….a collaborative process whereby the patient, patient’s family and the rehabilitation team negotiate a shared set of shared goals” Steigert and Taylor, 2004 • Small, measurable discreet step along the path to recovery

27. Collaborative Goal Setting • Goals should be set in partnership with the client/ caregiver and health care provider. • Goals should be: Specific, Measureable, Achievable, Realistic and Time-framed. (What, how much, When, how often?) • All stakeholders need to be aware of the client’s goal. SMART Who’s role on the team is it to set goals with the client?

28. Tools **See handouts

29. Your patient chooses a goal that is not clinically related, and has no apparent benefit in your mind to their self care, you: • A. Point out the error in their thinking and ask them to choose from a menu of options you present. • B. You continue with the goal but try to structure an action plan that is more relevant to their self care needs. • C. You make the sign of an L on your forehead, laugh and say, “Seriously, let’s work on something that will make you feel better”. • D. Proceed to action planning. Question obtained from www.selfmanagementtoolkit.ca

30. You and your patient have set a goal and action plan. Their confidence is high, but they mention a number of possible barriers to enacting the plan. As the patient proposes possible solutions you hear them discounting the solutions as they are generated. You: • A. Reflect back to them their struggle with the solutions and ask if this is an action plan they really want, and ask if they want to try a different plan. • B. Reflect back their struggle and suggest an action plan you think would work better. • C. Ask them to decide what it is they really want to do. • D. Leave the barriers unresolved and hope they work themselves out when the patient tries to enact the plan. Question obtained from www.selfmanagementtoolkit.ca

31. Transtheoretical Model of Change (Prochaska and DiClemente,1986)

32. Snakes and Ladders We provide the ladders and life provides the snakes Cheryl Mayer,2008

33. Module 3: Self-Management Approaches Group Lay Leader ↔ Lay Person Stanford Individual HCP ↔ Client: Flinders 3 Minute Empowerment (Pfizer) 5 A’s

34. Stanford Self Management Program • 6-week lay-led workshop to develop pts’ skills in managing their condition. • Topics covered in six-week program: • techniques to deal frustration, fatigue, pain and isolation • exercise for maintaining and improving strength, flexibility, and endurance • appropriate use of medications • communicating effectively with family, friends, and health professionals • nutrition • how to evaluate new treatments • Structured program, tools and resources listed on website. Variety of self management programs available. • Cost involved to implement and requires infrastructure. • Program evaluation- significant improvement in exercise, cognitive symptom management, communication with physician, and spent fewer days in hospital. Obtained from Stanford website:http//patienteducation.stanford.edu/programs/cdsmp Training also at OPSMN website: www.ontpsm.net

35. Stanford Master Trainer Lay Leader Trainers To ensure quality of programming there are levels of certified trainers T Trainer Lay- led Groups

36. Other programs…. Check out: • Living with Stroke • Stepping Out: www.steppingoutuk.org.uk

37. Flinders • Developed by the Flinders Human Behaviour & Health Research Unit (FHBHRU) associated with the School of Medicine at Flinders University, Australia. Aim of the Model: • Improve the partnership between the client and health care provider(s) • Together with the client identifies problems and interventions. • Utilizes 3 Assessment Tools: • Partners in Health Scale (12 part questionnaire based on the 6 principles of self-management; completed by client) • Cue and Response Interview (uses a series of open-ended questions or cues to further examine the client’s responses to the PIH scale. It allows for exploration of barriers to self-management. • Problems and Goals Assessment (assessment tool that helps to define the problem from the client’s perspective, and identifies goal(s) that the client can work towards. Obtained from: The `Flinders Model’ of Chronic Condition of Self-Management –Information Paper, 2006)

38. Flinders: Partners in Health Scale (Sample Questions )(0 Very well ...8 not very little) 1. Overall what do you know about your health condition 2. Overall what do you know about the treatment for your health condition: I take medication prescribed by my doctor. 3. I share in decisions made about my health condition with my doctor or health care provider. a. I arrange appts as asked by my doctor or my health care worker. b. I attend these appts. 4. I understand why I need to check for early warning signs and symptoms associated with my health condition e.g., blood sugar levels, weight, SOB, pain, sleep problems.

40. Cue and Response Interview(Obtained from Flinders DVD in Self-Management Toolkit, Malcolm Battersby, Flinders University, PowerPoint Presentation in Calgary 2008).

41. Three Minute Empowerment • Uses the Conviction/Confidence Model (Keller &White). • Originally developed by the Institute for Healthcare Communication for Choices and Changes: Clinician Influence and Patient Action workshop. • Assess the stage of change, and where the patient falls within the 4 quadrants (i.e. Frustrated, Cynical, Skeptical, Empowered) 3 Questions: • What do you think of (behaviour)…. • If you decided to change (behaviour), how would that benefit you? • If you really decided to (change behaviour), how would you do it?

42. EMPOWERED Conviction – Confidence Model SUCCESS 10 PREPARATION CONVINCED FRUSTRATION C O N V I C T I O N (Benefits) CONTEMPLATION LACK OF KNOWLEDGE CYNICISM SKEPTICISM AMBIVALENT PRE-CONTEMPLATION 0 10 POWERLESS (Barriers) UNWAVERING C O N F I D E N C E Keller V et al. Journal of Clinical Outcomes Management 1997. Miller WR et al. Guilford Press, 1991.

43. Your patient has set an action plan to start running a mile 3 times a week. During your conversation you learn they have never run before. Despite that the patient assesses confidence as 8 out of 10. • A. Proceed with the patient’s action plan. • B. Double check confidence and/or assess possible barriers before proceeding. • C. You proceed with the action plan but warn the patient of the high likelihood they will not succeed given their lack of running experience. • D. Proceed with the action plan and remind them of the 911 number. Question obtained from www.selfmanagementtoolkit.ca

44. Module 4: Getting Ready Key steps to implementation of a self-management approach. • Define the patient population. • Decide an approach that is best for your practice and patient population. • Arrange staff training. • Develop a flowchart of how the team currently interacts with the patient. • What and how will it be evaluated? • Set a launch date.

45. What about Self Management and Stroke?? • Literature is sparse in the area of stroke and self-management. (Jones, 2006) • Complex due to multiple co-morbidities. • If individual’s cognition is affected it can be more challenging.

46. To summarize…. Effective self-management involves: • Assessment of patient self-management skills and behaviours and identifies “gaps” (e.g., Flinders: Partners in Health scale). • Development of a “care plan” with patient that identifies personal and community resources. • Refer to self-management program and lifestyle programs (nutrition, exercise, stress management). • Support self-management behaviours; monitor care plan.

47. Evaluates changes in lifestyle behaviours; give feedback. • Provide referrals to appropriate specialists and community-based support. • Provides opportunities for follow-up with client on achieving goals.

48. Which is the best self-management approach? • Flinders • Stanford • An approach that builds on the strengths of the client, so they are to deal with the sequelae of their chronic illness. • An approach as described in #3 and encompasses self-management supports as described in the PCRS framework.

49. Group work The year is 2016, and we are now immersed in a chronic care paradigm. If you were to be working in your current setting in the year 2016: #1. How might your work and practice be different? #2. What would you be doing differently with clients. #3. What tools might you be using with clients? #4. Which approach might you consider using with your clients? Spend 10 minutes discussing this at your table with your group.