Clinical Tools and Strategies for Supporting Self-Management

1. Clinical Tools and Strategies for Supporting Self-Management IBHP Webinar March 18, 2009 Michael G. Goldstein, MD Chief, Mental Health and Behavioral Sciences Service Providence VA Medical Center Professor, Psychiatry and Human Behavior, Alpert Medical School of Brown University

2. Objectives By the end of the session, participants will be able to: • Describe the key concepts and principles of self-management and self-management support • Identify specific strategies, tools and resources for engaging and activating patients and families in chronic illness care • Describe strategies for redesigning care to enhance the efficient delivery of self-management support

3. Outline • Self-Management • Self-Management Support (SMS) • Key Components of SMS • Core Clinical Competencies/Tools & Resources • Health Care System Redesign • Community Linkages • Questions and Discussion

4. 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)

5. Self-Management Tasks for Diabetes • Blood glucose monitoring • Managing high/low blood sugars • Diet • Physical activity/exercise • Medication taking • Medical monitoring/visits • Coping with emotions • Foot care • Eye care • Dental care

6. What is Self-Management Support? Institute of Medicine Definition: • “The systematic provision of education and supportive interventions • to increase patients’ skills and confidence in managing their health problems, • including regular assessment of progress and problems, goal setting, and problem-solving support.” (IOM, 2003)

7. What Works – 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 are the Desired Outcomes of Self-Management Support? People with chronic conditions (and their families) are more: • Aware and Informed • Engaged • Activated • Empowered • Confident they can self-manage • Partners with health care providers

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

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

11. Assumes knowledge drives change Clinician sets agenda Goal is compliance Decisions made by caregiver Assumes knowledge + confidence drives change Patient sets agenda Goal is enhanced confidence Decisions made collaboratively Self-Management Support A Fundamental Shift in the Process of Care Traditional Care Collaborative Care (Bodenheimer et al, CA Health Care Foundation, 2005)

12. SMS: Key Components • Core Clinical Competencies and Tools and Resources for Teams, Patients & Families • System redesign to efficiently deliver SMS within the context and flow of clinical care • Meaningful links to community resources and community-based programs and campaigns (New Health Partnerships: www.newhealthpartnerships.org)

13. SMS: Key Components • Core Clinical Competencies and Tools and Resources for Teams, Patients & Families • System redesign to efficiently deliver SMS within the context and flow of clinical care • Meaningful links to community resources and community-based programs and campaigns (New Health Partnerships: www.newhealthpartnerships.org)

14. (New Health Partnerships, 2007) SMS: Core Clinical Competencies • Relationship Building • Exploring patients’ needs, expectations and values • Information Sharing • Collaborative Goal Setting • Action Planning • Skill Building & Problem Solving • Follow-up on progress

15. (New Health Partnerships, 2007) SMS: Core Clinical Competencies • Relationship Building • Exploring patients’ needs, expectations and values • Information Sharing • Collaborative Goal Setting • Action Planning • Skill Building & Problem Solving • Follow-up on progress

16. Motivational Interviewing “Definition” “a skillful clinical style for eliciting from patients their own motivation for making changes in the interest of their health.” (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

17. Collaborative • Partnership, shared decision making • Evocative • Understand patient goals; evoke arguments for change • Honoring patient autonomy • Patients ultimately decide what to do The “Spirit of MI” (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

18. Motivational Interviewing “Principles” • Resist the Righting Reflex (Directing) • Understand Patient Motivations • Listen to Your Patient with Empathy • Empower Your Patient (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

19. MI Style A refined form of guiding, rather than directing or following…… helping the patient make his or her own decision about behavior change (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

20. Motivational Interviewing • Asking • Listening • Informing Guiding - balancing skills, flexibly applied (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

21. Explore: Agenda, Needs, Expectations • “What are you hoping to accomplish today?” • “What do you think is most important for us to talk about?” • What concerns do you have about your health? • What reasons do you have to change? • Where would you like to start?

22. 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)

23. 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)

24. Share Information Ask Permission Ask Understanding Tell(Personalize) Ask Understanding Benefits of Physical Activity

25. Collaboratively Set Goals • Share clinician priorities • Offer options • Agree on something to work on • Negotiate a specific action plan

26. (New Health Partnerships, 2007) SMS: Core Clinical Competencies • Relationship Building • Exploring patients’ needs, expectations and values • Information Sharing • Collaborative Goal Setting • Action Planning • Skill Building & Problem Solving • Follow-up on progress

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

28. 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:

29. Action Plan 1. Goals: Something you WANT to do Begin Exercise 2. Describe How Walking Where Neighborhood What 20 min Frequency 3x/week When After dinner 3. Barriers - Dishes, safety (no sidewalks) 4. Plans to overcome barriers - get kids to clean up, ask neighbor or husband to join me, wear reflective vest 5. Conviction and Confidence ratings (0-10) - 9/8 6. Follow-Up: Will keep log and bring to next visit in 1 month

30. Action Planning • Review past experience - especially successes • Define small steps that are likely to lead to success

31. Action Planning: Assess 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)

32. 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

33. Enhancing Confidence: Identifying Barriers & Problem-Solving • What will get in the way? • Anything else? • What might help you to overcome that barrier? • Anything help in the past? • Here is what others have done... • Ok, now what is your plan? • Reassess confidence

34. Self-ManagementSupport Cycle EXPLORE: Needs, Expectations, Values, Behavior, Progress SHARE: Provide specific Information about health risks, benefits of change, and strategies to self-manage ARRANGE: Specify plan for follow-up (e.g., visits, phone calls, mailed reminders Personal Action Plan 1. List specific goals in behavioral terms 2. List barriers and strategies to address barriers 3. Specify follow-up plan 4. Share plan with practice team and patient’s social support SET GOALS: Collaboratively set goals based on patient’s conviction and confidence in their ability to change BUILD SKILLS : Identify personal barriers, strategies, problem-solving techniques and social/environmental support Adapted from: Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87

35. SMS: Key Components • Core Clinical Competencies and Tools and Resources for Teams, Patients & Families • System redesign to efficiently deliver SMS within the context and flow of clinical care • Meaningful links to community resources and community-based programs and campaigns (New Health Partnerships: www.newhealthpartnerships.org)

36. 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 Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes *E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound

37. Delivery System Redesign • Determine process and define roles for delivering SMS among members of the care team • Planned Care visits • Medical Group visits • Chronic Disease Self-Management groups • Planned peer interactions • Provide support and coordination according to level of need

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

39. Chronic Disease Self-Management Program • Developed and studied by Kate Lorigand colleagues at Stanford • Lay-leaders, 6 sessions, 2 1/2 hours each • Single or multiple conditions • Focus on collaborative goal-setting, personalized problem solving, skill acquisition • Outcomes: improved health behaviors and health status, fewer hospitalizations • Limitations: limited population (Lorig et al, Med Care 1999, 37:5-14; Lorig, et al., Med Care, 2001, 39: 1217-1223)

40. Clinical Information Systems • Provide access to educational materials and tools • Create capacity to identify and contact relevant subpopulations for proactive care • Monitor and share SMS performance data.

41. Community Linkages • Identity community programs and resources • Partner with community organizations • Partner with employers • Raise community awareness: community campaigns

42. Implementing Health System Changes to Support Self-Management • Quality Improvement Collaboratives: with focus on SMS (e.g., New Health Partnerships) and Patient Activation (MN) • Educational Outreach – QIOs, DOQ-IT, Voluntary Agencies • Provider education and training - Core Competencies, Motivational Interviewing • Incentives, rewards for provider delivery of SMS, system change

43. SMS: Key Components • Core Clinical Competencies and Tools and Resources for Teams, Patients & Families • System redesign to efficiently deliver SMS within the context and flow of clinical care • Meaningful links to community resources and community-based programs and campaigns (New Health Partnerships: www.newhealthpartnerships.org)

44. (New Health Partnerships, 2007) SMS: Core Clinical Competencies • Relationship Building • Exploring patients’ needs, expectations and values • Information Sharing • Collaborative Goal Setting • Action Planning • Skill Building & Problem Solving • Follow-up on progress