Best Practice to Reduce ACH: Patient Self-Management through Planned Care

1. Best Practice to Reduce ACH:Patient Self-Management through Planned Care

2. 2 What is self-management? �Learning and practicing the skills necessary to carry on an active and emotionally satisfying life in the face of a chronic illness.� (Lorig 1993) Based on patient perceived concerns and problems Professor Kate Loring of Stanford University, leading international authority on self-management, recognizes that people with chronic illness deal with common issues and need to develop coping skills on a daily basis. The ability to deal with all that chronic illness entails��symptoms, treatment, social and physical consequences, and lifestyle changes. Professor Kate Loring of Stanford University, leading international authority on self-management, recognizes that people with chronic illness deal with common issues and need to develop coping skills on a daily basis. The ability to deal with all that chronic illness entails��symptoms, treatment, social and physical consequences, and lifestyle changes.

3. 3 Chronic Conditions Chronic Conditions are now the leading cause of illness, disability, and death in the U.S. and affect the majority of elderly home health patients. Affects the quality of life of 100 million Americans Cause of 1.7 million deaths per year (7 out of 10 deaths) 90% of the elderly have at least one chronic illness Approximately 77% have at least two illnesses 25% have 4 or more chronic illnesses The increased longevity we are seeing has brought with it the increased burden to the healthcare system of heart disease, stroke, arthritis, diabetes, asthma, and other conditions. Chronic or long term illness is now the predominant disease pattern rather than acute illness. Physician tells the patient what to do; patient role is passive. The provider/clinician is accustomed to be the expert and the driver of care. Our success has been measured by how compliant/adherent the patient is with the teaching we have given them and the tasks we think they need to do. The increased longevity we are seeing has brought with it the increased burden to the healthcare system of heart disease, stroke, arthritis, diabetes, asthma, and other conditions. Chronic or long term illness is now the predominant disease pattern rather than acute illness. Physician tells the patient what to do; patient role is passive. The provider/clinician is accustomed to be the expert and the driver of care. Our success has been measured by how compliant/adherent the patient is with the teaching we have given them and the tasks we think they need to do.

4. 4 Self-Management Tasks Managing their health condition: diet, exercise, medications, treatments, self-testing, and record keeping Maintaining their functions and roles in life Dealing with the emotional demands of their conditions and their lives

5. 5 �One cannot not manage� Patients are responsible for the day-to-day management of living with chronic illness If one decides not to engage in a healthful behavior or to not be active in managing their illness, this decision reflects a management style It is impossible to not manage one�s health, for better or worse Every day patients make multiple decisions and choices about what to eat, how to spend their time, and what advice to follow. The list of daily or frequent tasks is extensive and ranges from self-triage and self-care of ailments to changing longstanding habits and trying to maintain a balanced, fulfilled life. Whether or not a patient is engaging in a healthy behavior, they have made a decision on how they will manage their illness. Every day patients make multiple decisions and choices about what to eat, how to spend their time, and what advice to follow. The list of daily or frequent tasks is extensive and ranges from self-triage and self-care of ailments to changing longstanding habits and trying to maintain a balanced, fulfilled life. Whether or not a patient is engaging in a healthy behavior, they have made a decision on how they will manage their illness.

6. 6 The Case for Self-Management Support Improved patient outcomes depend on correct diagnosis, correct treatment, and an ongoing series of healthy choices, behaviors and decisions by the patient. To be an informed, activated patient and make healthy decisions, patients need self-management support including: Timely, accurate, understandable information Involvement in collaborative decision making Goal setting and problem solving Help managing psychosocial issues

7. 7 Benefits of Self-Management Support (SMS) Reduced hospitalizations up to 50% Reduced service demand Improved consumer and clinician satisfaction Improved health outcomes Improved medication adherence Reduce hosp: patient can self-triage more successfully, monitor for warning s/sx and act earlier Reduce service demand: informed, activated patients make better decisions, are more independent and can self-care minor aliments more confidently Improved satisfaction: more productive and effective patient-health provider interactions Reduce hosp: patient can self-triage more successfully, monitor for warning s/sx and act earlier Reduce service demand: informed, activated patients make better decisions, are more independent and can self-care minor aliments more confidently Improved satisfaction: more productive and effective patient-health provider interactions

8. 8 Patient Education v. Self Management Support Patient Education: Information & skills are taught Usually disease specific Assumes that knowledge creates behavior change Goal is compliance Healthcare professionals are the teachers Gives information Provide Tools Self-Management Support: Skills to solve patient identified problems are taught Assumes that confidence (self-efficacy) yields better outcomes Goal is increased self-efficacy Teachers can be professionals or peers Gets patient involved in making day to day decisions Traditional focuses on giving disease specific information and imparting technical skills, but is relatively ineffective in changing behavior. The goal of traditional patient education is �compliance.� Self-management education teaches practical skills such as problem-solving, action planning, and decision-making which are more effective at supporting behavior change. The goal in self-management education is increased self-efficacy and improved health outcomes Our role to inspire, inform, support, and facilitate! 30-60% of the medical information given in an encounter is forgotten 50% of treatment plans are not followed to the fullest extent. Traditional focuses on giving disease specific information and imparting technical skills, but is relatively ineffective in changing behavior. The goal of traditional patient education is �compliance.� Self-management education teaches practical skills such as problem-solving, action planning, and decision-making which are more effective at supporting behavior change. The goal in self-management education is increased self-efficacy and improved health outcomes Our role to inspire, inform, support, and facilitate! 30-60% of the medical information given in an encounter is forgotten 50% of treatment plans are not followed to the fullest extent.

9. 9 Key Principles To know and understand one�s condition; To monitor and manage signs and symptoms of one�s condition; To actively share in decision-making with health professionals; To adopt lifestyles that promote health; To manage the impact of the condition on one�s physical, emotional, and social life; To follow a treatment plan agreed with one�s health care providers. Self management involves patients working in partnership with health professionals so they can: 1. Know their condition & various treatment options 2. Negotiate a plan of care 3. Engage in activities that promote health 4. Monitor and manage the signs & symptoms of the condition 5. Manage the impact of the condition on physical functioning, emotions, and interpersonal relationships. Self management involves patients working in partnership with health professionals so they can: 1. Know their condition & various treatment options 2. Negotiate a plan of care 3. Engage in activities that promote health 4. Monitor and manage the signs & symptoms of the condition 5. Manage the impact of the condition on physical functioning, emotions, and interpersonal relationships.

10. 10 The Clinician�s Role: Support Emphasize the patient's central role in managing their illness. Assess patient self-management knowledge, behaviors, confidence, and barriers. Provide effective behavior change interventions and ongoing support with peers or professionals. Help patients understand their health behaviors and develop strategies to live as fully and productively as they can. Our role as healthcare providers is to assist our patient to move forward toward a state of action that leads to improved health outcomes. Understanding life context of our patients increases the probability that treatment plans will fit their needs The role of the clinician is to help patients: understand decide choose adopt and change behavior cope overcome barriers follow-through Our role as healthcare providers is to assist our patient to move forward toward a state of action that leads to improved health outcomes. Understanding life context of our patients increases the probability that treatment plans will fit their needs The role of the clinician is to help patients: understand decide choose adopt and change behavior cope overcome barriers follow-through

11. 11 Elements of a Successful SMS Program Collaborative problem identification Patients & providers contribute their perspective and priorities in defining issues to be addressed by the clinical and educational interventions. Targeting, Goal Setting, and Planning Target the issues of greatest importance, set realistic goals, and develop a personalized improvement plan. SMS programs aim to empower patients through providing information and teaching skills and techniques to improve self care and doctor � patient interaction, with the ultimate goal of improving quality of life. SMS programs aim to empower patients through providing information and teaching skills and techniques to improve self care and doctor � patient interaction, with the ultimate goal of improving quality of life.

12. 12 Elements of a Successful SMS Program Continuum of self-management training & support services Includes instructions in disease management, behavioral change support, exercise options, and interventions that target the psychosocial impact of chronic illness. 4. Active and sustained follow up

13. 13 Behavior Change Principles Attitudes, Beliefs & Moods Matter: They matter in deciding to change a behavior, being successful in changing, & can directly impact health outcomes. Perversity Principle: If you are told what to do, it is likely that you will do the opposite. Self-Talk Principle: Your beliefs are more influenced by what you hear yourself say than by what others say to you.

14. 14 Behavior Change Principles (cont�d) Change Talk: Self-motivating statements made by patients Recognition of an issue Personal reasons for making a change Potential consequences of current behavior Hope of confidence about making a change

15. 15 Communication Good communication skills and interview techniques, together with a clear understanding of the change being undertaken, are required by the clinician in order to begin the process of encouraging a patient to change their behavior. Starts with the clinician and patient developing rapport to bring confidence and trust, build empathy, understanding, and respect�then follows a clear plan to develop the patient�s sense of involvement and partnership with the clinician. The patient needs to convince the clinician that they have a problem and need to change, not the clinician attempting to convince the patient they need to change. Starts with the clinician and patient developing rapport to bring confidence and trust, build empathy, understanding, and respect�then follows a clear plan to develop the patient�s sense of involvement and partnership with the clinician. The patient needs to convince the clinician that they have a problem and need to change, not the clinician attempting to convince the patient they need to change.

16. 16 Questions Can Be More Powerful than Answers What worries you most about your problem? What do you think might be causing your symptoms? What have you already tried to treat your problem? There are several alternatives, which do you prefer? Do you anticipate any problems with this treatment plan? So that I am sure I explained things clearly, can you tell me what you are going to do next?

17. 17 Motivational Interviewing (MI) Introduced by William Miller and Stephan Rollnick in 1990s Patient-centered counseling style for eliciting behavior change which helps patients explore and resolve ambivalence Acknowledges that patients both want and do not want to change Patients can perceive the advantages and disadvantages of changing or continuing with current behavior Patients are more likely to to decide to change their behavior and to sustain the new behavior if they have made decisions for themselves instead of in response to external pressures. Useful for patients who are reluctant to change and are ambivalent about changing. Basic Principles of MI Express empathy Develop discrepancy Roll with resistance Build confidence/support self-efficacy Patients are more likely to to decide to change their behavior and to sustain the new behavior if they have made decisions for themselves instead of in response to external pressures. Useful for patients who are reluctant to change and are ambivalent about changing. Basic Principles of MI Express empathy Develop discrepancy Roll with resistance Build confidence/support self-efficacy

18. 18 Communication Styles Standard Approach Focused on fixing the problem Paternalistic relationship Assumes the patient is motivated Advise, warn, persuade Ambivalence means the patient is in denial Goals are prescribed Resistance is met with argumentation & correction Motivational Interviewing Focused on patient�s concerns and perspectives Collaborative partnership Interventions are matched to patient goals and readiness to change Emphasizes personal choice Ambivalence viewed as a normal part of the change process Goals are collaboratively set Resistance seen as an interpersonal pattern influenced by the clinician�s behavior

19. 19 Express Empathy Show interest and caring in understanding the patient�s experiences Seek to understand the patient�s frame of reference Use reflective listening: Use open-ended questions to draw out the patient�s feelings Avoid �why� questions, as they imply judgment Empathy is the most powerful skill to promote behavior change Acceptance and understanding will facilitate change Each patient has a unique �story��unique ideas, experiences, expectations and preferences that have developed within their social and environmental context. Asking about and listening to a patient�s story is a first step towards meeting a patient�s educational, treatment, and self-management needs. Empathy is the most powerful skill to promote behavior change Acceptance and understanding will facilitate change Each patient has a unique �story��unique ideas, experiences, expectations and preferences that have developed within their social and environmental context. Asking about and listening to a patient�s story is a first step towards meeting a patient�s educational, treatment, and self-management needs.

20. 20 Develop Discrepancy Help the patient see that some behaviors do not jive with their ultimate goals that are important to them Engage in discussion about present behavior and valued goals Define what their most important goals are What is he/she doing now that is contrary to those goals? Change will not occur without discrepancy If patients can talk themselves out of changing, they can talk themselves into it. Change will not occur without discrepancy If patients can talk themselves out of changing, they can talk themselves into it.

21. 21 Roll with Resistance Explore both the positive and negative consequences of change or continuing the current behavior Acknowledge and respect the patient�s concerns Invite new perspectives Reduce resistance by: Using reflective statements Focus on building the relationship rather than the change Exploring concerns Accepting change without a full consideration of the pros and cons of the change can lead to �buyer�s remorse� and early relapse. Patients may argue with you, ignore you, or �yes you to death.� Resistance often stems from fear of change. It is important to respond to resistance in a way that defuses it rather than fuels it. In MI, resistance is viewed as a problem of communication between the patient and the clinician, rather than one that lies with the patient alone. Accepting change without a full consideration of the pros and cons of the change can lead to �buyer�s remorse� and early relapse. Patients may argue with you, ignore you, or �yes you to death.� Resistance often stems from fear of change. It is important to respond to resistance in a way that defuses it rather than fuels it. In MI, resistance is viewed as a problem of communication between the patient and the clinician, rather than one that lies with the patient alone.

22. 22 Build Confidence Promote self-esteem. Promote belief in the patient�s ability to do the skill needed, take the action needed�and stick with it! Focus on the patient�s skills that show they can do the behavior. Believe in your patient! Hope is motivating!Believe in your patient! Hope is motivating!

23. What is a planned visit? A planned visit is an encounter with the patient initiated by the clinician to focus on aspects of care that are important to the patient. The clinician�s objective is to deliver evidence-based clinical management and patient self-management support at regularly scheduled intervals. Organized approach: Emphasis on the patients role Effective, meaningful interventions Care planning and problem solving Promoting self-efficacyOrganized approach: Emphasis on the patients role Effective, meaningful interventions Care planning and problem solving Promoting self-efficacy

24. What does a planned visit look like? The clinician conducts a visit (30-40 minutes) to systematically review care priorities Visits occur at regular intervals as determined by the case manager and patient Each team member has clear roles and tasks Patient self-management support is the key aspect of care Encounters may be in person or via the telephone Collaborative: What does the patient want? What are his/her goals? What supports and resources will be needed to sustain self-management after discharge from the agency? Stabilize the patient and ensure safety Medication reconciliation and simplification Review patient�s medication regimen Identify and eliminate unnecessary drugs Problem-solve adherence issues with patient Create a patient action plan Collaboratively set patient goals Schedule follow-up Collaborative: What does the patient want? What are his/her goals? What supports and resources will be needed to sustain self-management after discharge from the agency? Stabilize the patient and ensure safety Medication reconciliation and simplification Review patient�s medication regimen Identify and eliminate unnecessary drugs Problem-solve adherence issues with patient Create a patient action plan Collaboratively set patient goals Schedule follow-up

25. 25 Format of the Visit: The 5 As Sequential series of steps to facilitate patient self-management and behavior changes (WHO, 2004). 1. Assess knowledge, behavior, readiness 2. Advise and inform 3. Agree on goals and methods 4. Assist to overcome barriers 5. Arrange for follow up How to guidelines that have been proven to work if used consistently First used for smoking cessation programs Employ all 5 at each visitHow to guidelines that have been proven to work if used consistently First used for smoking cessation programs Employ all 5 at each visit

26. 26 ASSESS Evaluate the patient�s beliefs, behaviors, and knowledge: Ask the patient what they know about their illness(es) Use open ended questions Evaluate behavior changes and how the patient feels about this Ask what the patient most wants to discuss today Review the goals the patient has or that have been set previously What do you know about checking your blood sugar? What do you need to manage your�..?What do you know about checking your blood sugar? What do you need to manage your�..?

27. 27 ADVISE Provide personally relevant information about health risks and the benefits of change: Communicate that what the patient does is as important as medication Short statements with specific recommendations Ask what patient thinks about the recommendations Ask Permission Ask Understanding Tell (personalize) Ask Understanding

28. 28 AGREE Collaboratively set goals with the patient based on their confidence in their ability to change their behaviors: Ask the patient what he/she most wants to work on Ask what he/she thinks would be a reasonable goal Assess confidence level using a scale of 1-10 Start when the patient has a confidence level of 7 or higher Use questions and comments to help patient focus & specify� NOT to set goal you think they should Goals should be concrete & behaviorally specific. The goal: �I will take my medicine,� is not very helpful for motivating self-action. Behavior-specific goal: �I will take my medication every evening before I go to bed. My confidence level is 8 that I will meet this goal.� Use questions and comments to help patient focus & specify� NOT to set goal you think they should Goals should be concrete & behaviorally specific. The goal: �I will take my medicine,� is not very helpful for motivating self-action. Behavior-specific goal: �I will take my medication every evening before I go to bed. My confidence level is 8 that I will meet this goal.�

29. 29 Goal Setting & Action Planning

30. 30 ASSIST Problem solving with the patient by identifying personal barriers, strategies, and social/environmental supports: Ask patient what he/she sees as the greatest challenges to achieving the goal Ask what he/she has done in the past to overcome obstacles Teach problem-solving skills Include supports and resources to help with the goal and enhance confidence Start with patient�s own experience with change�.ask the patient to recall times when they had been. Many patients become discouraged when they can�t reach the final goal right away. Helping patients to identify small or intermediate steps that are more achievable and realistic will help the patient experience success. Identify the problem 2. List all possible solutions 3. Pick one 4. Try it for 2 weeks 5. If it doesn�t work, try another 6. If that doesn�t work, find a resource for ideas 7. If that doesn�t work, accept that the problem may not be solvable now Start with patient�s own experience with change�.ask the patient to recall times when they had been. Many patients become discouraged when they can�t reach the final goal right away. Helping patients to identify small or intermediate steps that are more achievable and realistic will help the patient experience success. Identify the problem 2. List all possible solutions 3. Pick one 4. Try it for 2 weeks 5. If it doesn�t work, try another 6. If that doesn�t work, find a resource for ideas 7. If that doesn�t work, accept that the problem may not be solvable now

31. 31 ARRANGE Collaboratively develop specific follow up plans to check on progress: Set specific date and time for the next encounter Negotiate an agenda for the next encounter Begin next contact/visit with review of progress on goal(s) Follow up on patient experiences with any referrals to community resources Sustaining change can be difficult. Plan for follow up with the patient. Knowing that someone cares and is �on their team� supporting them helps patients continue with healthy change over the long term. Sustaining change can be difficult. Plan for follow up with the patient. Knowing that someone cares and is �on their team� supporting them helps patients continue with healthy change over the long term.

32. 32 Self-Management Transition Self-management helps move people from being passive recipients of health services to becoming engaged and informed partners.

33. 33 Resources New Health Partnerships http://www.newhealthpartnerships.org/ Planned Care Workbook http://www.masspro.org/HH/index.php

34. 34 Best Practice Intervention Package For more information related to Self-Care Management reference the Best Practice Intervention Package: Patient Self-Management Located at www.homehealthquality.org