Self-Management Support: The Key Ingredients

1. Self-Management Support: The Key Ingredients Connie Sixta, RN, PhD, MBA Robert A. Gabbay, MD, PhD

2. Ancient Greeks described three basic tools of medicine: • The herb • The knife • The word

3. How many of you need to deal with changing patient behavior in your practice?

4. How successful are you in getting patients to change their behavior?

5. The Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInfoSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

6. NCQA PCMH Standard #4 Provide Self-Care Support and Community Resources The practice acts to improve patients’ ability to manage their health by providing a self-care plan, tools, educational resources and ongoing support.

7. What determines positive change in self-care behavior? Clinician counseling style!! Sources: Rost et al, 1991; Glasgow et al., 1999; Anderson & Funnell, 2000; Doherty et al., 2000), and many, many other studies.

8. Our Traditional Style:Directive • Expert Advice Giving • Promotes passive, uninvolved patient. • Lack of fit between clinician agenda and patient agenda. • Look how well it works! • Two components • Information exchange • Persuasion • Can lead to resistance

9. Patient Centered Approach • Goals and agenda are negotiated. • Patient values are examined. • Outcomes are superior! Greenfield et al., 1988; Kaplan et al., 1989; Greenfield et al., 1988; Uhlmann et al., 1988; Roter & Hall, 1989; Golin et al., 1996 and many, many more.

10. To Support Patient Self-Management, the Provider Must: • Give up the agenda. • Let the patient take control of his life. • Help the patient feel success.

11. Remember that the management of a chronic illness is a lifetime proposition. Our job is to guide patients appropriately over time based on patient interest and needs.

12. But How? Ask open-ended questions to: • ASSESS what the patient knows, feels, and believes about diabetes. • Determine what ADVICE the patient is interested in receiving and ready to learn. • Help the patient decide and AGREE on a behavior he/she is interested in changing/improving. • ASSIST the patient with problem solving. • ARRANGE follow-up with the patient to reinforce the change in behavior.

13. The 5 As: Self-Management in the Chronic Care Model ASSESS Knowledge, Beliefs, and Behaviors PERSONAL ACTION PLAN List specific goals in behavioral terms. List barriers and strategies to address barriers. Specify follow-up plan. Share the plan with the patient’s practice team and social support. ARRANGE FOLLOW UP Specify plan for follow up ADVISE Provide information on health risks and benefits of change ASSIST Identify personal barriers and strategies for problem solving AGREE Collaboratively set behavioral goals based on patient interest and confidence Adapted from Glasgow RE, et al. (2002)

14. Assess Patient/Family Knowledge, Beliefs, and Behaviors • Use open-ended questions to assess knowledge and beliefs: • What experiences have either you or your family had with diabetes? • What do you know about diabetes? • Tell me about your friends and family that have diabetes. • Use open-ended questions to assess behaviors: • What do you usually eat each day? Tell me what you had to eat yesterday. • How much activity do you usually get each day? • Tell me about your schedule for taking your medications.

15. Open-Ended Questions • Closed question: Do you always take your insulin? • Open ended question: Tell me a little about how it’s going with taking your insulin? • If you strongly suspect adherence issues: • Many people find it challenging to take their insulin daily. How is it going for you?

16. Good Question or Not? • How do you think it might be helpful if you check your blood sugars more often? • Why don’t you check your blood sugars? • What do you think is the value of taking your medications each day? • How can you put your life at risk by not taking your insulin? • Don’t you know you that by not taking your statin you are going to die of a heart attack?

17. Advise the Patient/Family • Use Open-Ended Questions to determine what information the patient needs right now, is ready to hear, and will address areas of concern. • LISTEN TO WHAT THEY SAID IN ASSESS! • If they said they didn’t know why checking blood sugars was important, explain it to them. • If they said they were worried about an amputation or afraid of starting insulin, explore and give needed information.

18. Rules to giving advice: • Ask the patient what his/her questions are, what he/she wants to know. • Keep the advice as clear and simple as possible. • Start by asking the patient what he/she already knows. • Give advice in small doses to avoid overwhelming the patient with too much information. • Help the patient connect the advice to his/her areas of concern.

19. Agree on a Behavioral Goal • Use open-ended questions to help the patient set a behavioral goal. • What’s the most important thing you can do to control your diabetes? • What part of managing your diabetes is most on your mind? • What would you like to do to better manage your diabetes? • What do you want to work on?

20. Helping Patients SetSelf-Management Goals • Ask what “overall goal” the patient would like to work on. • Such as “get more exercise,” “eat better,” “remember to take my medicines,” “manage stress better.” • Ask “how” the patient would like to move toward achieving that overall goal. • How would you like to go about getting more exercise? • What exercise or activity would you like to do? • What is your usual activity? How much do you usually do? • Help the patient design a goal that is specific and measurable. • The goal statement should answer: what, where, when, and how often?

21. Example Goal I am going to walk three blocks (what) around the neighborhood (where) in the early morning before I go to work(when) three days/week on Monday, Wednesday, and Friday(how often).

23. Ask How Important the Goal Is • Patients are more likely to be successful with a change they think is important. • Ask the patient to rate how important the goal is to him/her on a scale of 1 to 10. • If the patient rates the goal at 6 or below, ask him/her to agree on another goal that is more important. 1 2 3 4 5 6 7 8 9 10 Not Unsure Somewhat Very Important Important Important

24. Ask How Confident in Success • Patients are more likely to be successful with a change they think they can accomplish. • Ask the patient to rate how confident he/she is in being able to accomplish the goal on a scale of 1 to 10. • If the patient rates his/her confidence at 6 or below, explore barriers or ask him/her to agree on another goal he/she is more confident in achieving. 1 2 3 4 5 6 7 8 9 10 Not Unsure Somewhat Very Confident Confident Confident

25. REMEMBER TO START SMALL

26. Overall behavioral objective A small, specific, measurable goal that moves the patient toward the overall objective. Weight: Lose 25 lbs. I will lose 1 lb. by the end of this week by limiting the number of cans of soda I drink to one per day after dinner. Exercise: Run 3 miles daily I will walk 2 miles every other day in the morning before I go to work, starting tomorrow. Diet: Decrease daily calories to 1500/day I will have dessert only 2 times this week on Saturday and Sunday after I eat dinner. Stress management: I will walk home from work every day to refocus my mind and release my tension. I will walk home from work three times this week on Tuesday, Wednesday, and Thursday. My wife will take me to work on those mornings.

27. Assist the Patient/Family in Problem Solving • Use open-ended questions to help the patient identify barriers during goal setting. • What is in the way of you achieving that goal? • What could you do to succeed with that goal? • Use open-ended questions to help the patient problem solve when goals are not met. • What kept you from achieving your goal? • What could you do to help with that situation? • What could you do to handle that differently?

28. Arrange Follow-up • Can be as simple as: • A phone call from your staff 2 weeks after the visit to see how things are going and to help problem-solve any barriers [CAN BE SCRIPTED IF NEEDED]. • Remembering to ask the patient about progress toward the goal at the next visit.

29. Why is Follow-Up Important? • Shows the patient that the behavior change is important. • Tells the patient you are concerned about their health and interested in helping them change their behaviors. • Helps the patient build skills that will help them with behavior change and problem- solving in the future.

30. Let’s Practice Scenario: Mrs. Gonzales is a 55-year-old Hispanic female who has had type 2 diabetes for the past 20 years. She watches her two very active grandchildren (both under age five) every day during the week. Lately she has been having trouble keeping up with them when they walk to the park. She has decided that if she lost some weight she could keep up with them more easily. Mrs. Gonzales sets a goal to lose 10 lbs. this week. • Is this an appropriate goal for her? Why? • What questions could you ask that would help her develop a more appropriate goal? • How could the goal be rewritten?

31. Let’s Try Another Case Scenario: Mr. Singh is a 48-year-old Indian male who has type 2 diabetes and travels frequently for his job as a salesman. He noticed on one of his last trips that his suit pants and suit coat are getting very tight. He has decided that he wants to resume his running to lose weight. Mr. Singh sets a goal to run Monday, Wednesday, and Friday before work. • Is this an appropriate goal for him? Why? • What questions could you ask that would help him develop a more appropriate goal? • How could the goal be rewritten?

32. Let’s Practice It Tonight!

33. One of you is the patient, and one is the provider.

34. Patient’s Topic • Something about yourself that you: • want to change • need to change • should change • have been thinking about changing but you haven’t changed yet (i.e. – something you’re ambivalent about) • Something you’re comfortable discussing (no dark secrets)

35. Provider • Listen carefully with a goal of understanding the dilemma. • Give no advice. • Just listen.

36. ProviderAsk open-ended questions to: • ASSESS knowledge, feelings, and beliefs about the topic. • Determine what ADVICE the patient wants and is ready to learn. • Help the patient AGREE on a small, specific, measurable goal and rate his/her importance and confidence levels. • ASSIST with problem solving. • ARRANGE for follow-up.

37. A Change of Role Is Needed • You don’t have to make change happen. You can’t. • You don’t have to come up with all the answers. You probably don’t have the best ones. • You’re not wrestling… You’re dancing. X

38. Conclusions • Patient education is necessary, but not sufficient. • People don’t change just because we tell them to. • We need to work with patients to help them with behavior change. • The counseling style is key. • Ask open-ended questions to help patients set their own goals.

39. Questions?