Patient-Centered Care: Supporting Self-Management to Improve Outcomes

1. Patient-Centered Care: Supporting Self-Managementto Improve Outcomes Michael Goldstein, MD Associate Director, Institute for Healthcare Communication MaineHealth Learning Community: Improving Care Across Conditions (PRISM-1) January 18, 2007

2. Objectives By the end of the session, participants will be able to: • List the 7 core competencies for supporting self-management • Experience the value of using self-management support core competencies • Identify opportunities for enhancing self-management support in the practice setting

3. Patient-Centered Care • IOM Report: Crossing the Quality Chasm –Quality = care that is safe, effective, timely, efficient, equitable and patient-centered • Patient-centered care = providing care that is respectful of and responsive to individual patient preferences, needs, and values …..patient values guide all clinical decisions (Committee on Quality of Health Care in America, 2000)

4. Community Resources and Policies Health System Organization of Health Care Self- Management Support Decision Support Delivery System Design Clinical Information Systems A Model for Planned Care* Informed, Activated Patient & Family Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes *E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound

5. Self-Management Tasks • To take care of the illness (medical management) • To carry out normal activities (role management) • To manage emotional changes (emotional management) (Corbin & Strauss, 1998Bodenheimer et al, 2002; Lorig et al, 2003)

6. Self-Management Support is NOT • Didactic Patient Education • Lecturing • Inducing fear • Finger-wagging • “You should” • Shaming • Waiting for a patient to ask

7. Research Evidence • Addressing knowledge is necessary but not sufficient to produce changes in chronic illness care outcomes • Key strategies for improving outcomes of educational 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)

8. What is Self-Management Support? A process to help people to: • Understand • Decide among treatments • Identify and set goals • Adopt and change behaviors • Cope and overcome barriers • Follow-through

9. SMS: Core Competencies • Relationship Building • Exploring patients’ needs, expectations and values • Information Sharing • Collaborative Goal Setting • Action Planning • Problem Solving • Follow-up on progress

10. 5As of SMS • Assess (knowledge, behavior, beliefs) • Advise and inform • Agree (on goals and methods) • Assist (overcome barriers) • Arrange follow-up Whitlock et al, 2002 Am J Prev Med 22:267-84

11. Assess Advise Agree Assist Arrange Core Competencies & 5As • Relationship Building • Exploring patients’ needs, expectations and values • Information Sharing • Collaborative Goal Setting • Action Planning • Problem Solving • Follow-up on progress

12. Self-Management Support: Core Competencies Relationship Building Skills • Open-ended inquiry • Reflective listening • Empathy

13. Skill: Open-ended inquiry • Goal • Obtain a story not an answer • Search is for meaning not facts • Tasks • Simple request - “Tell me….” • “What” and “How” questions are effective • “Why” questions aren’t as effective; provoke defenses • If a person can answer in one word (yes, no, a number) the question was not open-ended

14. Skill: Reflective Listening Goal • Listen, express interest and understandthe meaning of what the speaker is saying

15. 2 The words the speaker says The words the listener hears 3 1 What the listener thinks the speaker means 4 Reflective Listening Bridges the Gaps What the speaker means (Thomas Gordon, 1970)

16. Skill: Reflective Listening Tasks • To be a mirror reflecting meaning: • repeat the words you have heard • short summaries • reflect meaning • wait for a response • Non-verbal: • attentive • open • non-judgmental

17. Responding reflectively Stems: • So, you are saying …. • It sounds like ….. • You are wondering if.... • I hear you saying…. • You are…

18. Skill: Reflective Listening (continued) • Every reflection opens a possibility: speaker may correct, verify, add, refine • As mirrors, we all have flaws -- we learn about our distortions or misinterpretations as we attempt to accurately reflect

19. Skill: Empathy Goals • Strive to understand the “other” at a deeper level: emotions, thoughts, values • The person experiences being seen, heard and understood

20. Skill: Empathy Tasks • Attend to and reflect the other’s expressed thoughts, emotions, values • Express understanding • Normalize, legitimize, affirm • Self-disclose, when appropriate • Non-verbal: • Open, non-judgmental body posture and gestures

21. Empathy - examples “You seem pretty frustrated.” “So, you feel more relaxed when you are able to find time for exercise.” “Many people have difficulty remembering to take their medications regularly .” “I’m impressed with what you have been able to accomplish, despite the barriers you mentioned.” “I have struggled with similar issues with my parents.”

22. Exercise: Exploring Motivation Interviewer: Practice using open-ended inquiry, reflective listening and empathy skills Interviewee: Share and explore your own motivation to engage in a specific self-management behavior and reflect on your response to the interviewer’s use of skills

24. SMS: Core Competencies • Relationship Building • Exploring patients’ needs, expectations and values • Information Sharing • Collaborative Goal Setting • Action Planning • Problem Solving • Follow-up on progress

25. Explore: Agenda, Needs, Expectations • “What are you hoping to accomplish today?” • “What do you think is most important for us to talk about?” • Which of these self-care behaviors would you like to work on? • What concerns do you have?

26. 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 Skin care Taking insulin Diet Depression  Losing weight Daily foot care Smoking (RI Dept of Health Chronic Care Collaborative)

27. Explore Conviction/Importance “How convinced are you that it is important to monitor your blood sugars?” Totally convinced Not at all convinced 0 1 2 3 4 5 6 7 8 9 10 “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)

28. Strategies for Enhancing Conviction • Use the Conviction/Importance ruler • Explore ambivalence • Elicit and respond to change talk • Share information (with permission)

29. Collaboratively Set Goals • Consider patient’s agenda, priorities, conviction & confidence • Consider clinician priorities • Negotiate goals • Support patient autonomy and choice

30. SMS: Core Competencies • Relationship Building • Exploring patients’ needs, expectations and values • Information Sharing • Collaborative Goal Setting • Action Planning • Problem Solving • Follow-up on progress

31. Action Planning – Starts with SMART Goals • Specific and behavioral • Measurable • Attractive • Realistic • Timely

32. Action Planning: Explore and Enhance Confidence “How confident are you that you can meet your goal of exercising 5 days a week? Totally confident Not at all confident 0 1 2 3 4 5 6 7 8 9 10 “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)

33. Enhancing Confidence • Review past experience - especially successes • Define small steps that are likely to lead to success

34. Enhancing Confidence • Provide tools, strategies, resources, skills • Address barriers • Attend to progress and to perceive slips as occasions for problem solving rather than as failure

35. Action Plan 1. Goals: Something you WANT to do 2. Describe How Where What Frequency When 3. Barriers 4. Plans to overcome barriers 5. Conviction and Confidence ratings (0-10) 6. Follow-Up:

36. SMS: Core Competencies • Relationship Building • Exploring patients’ needs, expectations and values • Information Sharing • Collaborative Goal Setting • Action Planning • Problem Solving • Follow-up on progress

37. Opportunities for SMS:When, Where and By Whom • Before the Encounter • During the Encounter • After the Encounter

38. Clinician-Centered Directive Passive Patients/Family Clinician Teaches, Solves Information Given Patient/Family-Centered Collaborative Active Patients/Family Patients Empowered to Learn, Solve Information Shared Key Drivers of Change Patient and Family Centeredness

39. One Size Fits All Clinic-Based Reactive Institution Driven Hierarchical Tailored Home/Community Based Proactive Community Partnerships All Teach…All Learn Key Drivers of Change Patient and Family Centeredness

40. A Model for Planned Care* Community Resources and Policies Health System Organization of Health Care Self- Management Support Decision Support Delivery System Design Clinical Information Systems Informed, Activated Patient & Family Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes *E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound