Stanford Chronic Disease Self-Management Model

1. Stanford Chronic Disease Self-Management Model Application in a Community Health Worker Program Underwritten partially by a grant from MedTAPP HCA Joan Thoman, PhD, RN, CNS, CDE Pamela Rutar, EdD, RN, CNE Cleveland State University School of Nursing November 17, 2016

2. This session is about: • The Stanford Chronic Disease Self-Management Model • The application to a Community Health Worker Program

3. Impacts of Chronic Disease • Chronic disease will increase 300% by 2049 • Chronic disease results in pain, debilitation, disability, dependence, lost physical function, and less mobility • Chronic diseases include: heart disease, cancer, stroke, arthritis, asthma, lung disease, cancer, diabetes, hypertension, osteoporosis, multiple sclerosis, Parkinson’s disease… Stanford University Patient Education Center, http://patienteducation.stanford.edu/

4. Financial Reality - Rising costs… • Chronic disease costs: 75-95% of health care expenditures! • By 2030: Anticipated increase in healthcare costs tied to chronic disease, 25% to 54% Partnership for Solutions: Better Lives for People with Chronic Conditions, WA State, Health Affairs, 2005, 24 (1) 80-92, National Council on Aging

5. People With Chronic Disease Report… • Significantly reduced productivity • Living with less income • Accomplishing less • Spending more time in bed sick • Having poor mental health LStanford University Patient Education Center http://patienteducation.stanford.edu/ , Lorig, K. 2003, National Council on Aging

6. What is self-management? “The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.” Stanford University Patient Education Center, http://patienteducation.stanford.edu/, Barlow, 2002.

7. Self-Management Benefits Patients… • Builds confidence (self-efficacy) to perform 3 tasks - Disease management - Role Management - Emotional Management • Focuses on improved health status and appropriate health care utilization

8. Self-Management Differs From Patient Education Self-Management - Manage life with disease - Increase skills & self-confidence - Problem solve and make decisions Patient Education - Change behaviors - Increase knowledge - Use specific tools (e.g., Care Plans)

9. Patient ed. vs Self-mgmt. • Information and skills are taught • Usually disease-specific • Assumes that knowledge creates behavior change • Goal is compliance • Health care professionals are the teachers • Skills to solve pt. Identified problems are taught • Skills are generalizable • Assumes that confidence yields better outcomes • Goal is increased self-efficacy • Teachers can be professionals or peers

10. Self-Management Also Encompasses • The patient and health professional working together. • Often involves the family. • An holistic approach to care (i.e., medical and psycho-social components of a condition). • Pro-active and adaptive strategies that aim to empower the individual.

11. Why is self-management so important?What is different? • Clinical outcomes are dependent on patient actions. • Patient self-management is inevitable. • The provider’s role is to be in partnership with the patient • Professionals are experts about diseases, patients are experts about their own lives.

12. Chronic Disease Self-Management Assumptions • Patients with different chronic diseases have similar self-management problems and disease-related tasks. • Patients can learn to take day-to-day responsibility for their diseases. • Confident, knowledgeable patients practicing self-management will experience improved health status and use fewer health resources. Stanford University Patient Education Center, http://patienteducation.stanford.edu/ Lorig and Holeman 2003

13. Self-Management Framework • Patients accept responsibility to manage or co- manage their own disease conditions. • Patients become active participants in a system of coordinated health care, intervention and communication. • Patients are encouraged to solve their own problems with information, but not orders, from professionals. Stanford University Patient Education Center, National Council on Aging

14. Self-Management Skills • Problem-solving • Decision-making • Resource Utilization • Formation of a patient- provider partnership • Action-planning • Self-tailoring Stanford University Patient Education Center, http://patienteducation.stanford.edu/, Lorig and Holeman 2003

15. Chronic Disease Self-Management Means… • Taking care of your illness (using medicines, exercise, diet, technology, physician partnership) • Carrying out normal activities (employment, chores, social life) • Managing emotional changes (anger, uncertainty about the future, changed expectations and goals, and depression) It means having a combination of … SKILLS, SUPPORT, PRACTICE and CONFIDENCE

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

17. ASSESS : Beliefs, Behavior & Knowledge ARRANGE : Specify plan for follow-up (e.g., visits, phone calls, mailed reminders ADVISE : Provide specific Information about health risks and benefits of change 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 ASSIST : Identify personal barriers, strategies, problem-solving techniques and social/environmental support AGREE: Collaboratively set goals based on patient’s interest and confidence in their ability to change the behavior Self-Management in CCM Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87

18. Chronic Disease Self-Management Program (CDSMP) …the Stanford Model • Developed by Stanford University’s patient education program • Structured w/~15 participants in a six-week series of workshops • Participative instruction with peer support • Designed to enhance medical treatment • Outcome-driven: impacts show potential for reduced or avoided costs • Evidence-based: a tested model (intervention) that has demonstrated results

19. Stanford’s CDSMP is Evidence-based • Found to truly benefit targeted populations. • Demonstrated it does not cause harm. • Demonstrated it does not waste resources. National Council on Aging, https://www.ncoa.org/wp-content/uploads/cha_tools_checklists.pdf

20. The Stanford CDSMP Model Why these techniques work… • Peer educators • Constant modeling • Active problem-solving • Formal brainstorming • Goal-setting • Action planning National council on Aging, http://sohealthyoregon.org/wp-content/uploads/2016/02/Chronic-Disease-presentationEugene081.pdf

21. Content/Week 1 2 3 4 5 6 Overview of self-management and chronic health conditions P Making an action plan P P P P P P Relaxation / Cognitive symptom management P P P P P Feedback / Problem solving P P P P P Anger / Fear / Frustration P Fitness / Exercise P P Better breathing P Fatigue P Nutrition P Advance directives P Communication P Medications P Making treatment decisions P Depression P Informing the healthcare team P Working with your healthcare professional P Future plans P CDSMP Content

22. Participant’s Learn How to Manage the Symptom Cycle Disease Fatigue Tense Muscles VICIOUS CYCLE Stress/Anxiety Depression Anger/Frustration/Fear

23. Participant’s Learn and Practice Action Planning • Something YOU want to do • Reasonable • Behavior-specific • Answer the questions: What? How much? When? How often? • Confidence level of 7 or more

24. The Stanford Model: Content… “meets the test of common sense” • Techniques to deal with frustration, fatigue, pain, and isolation. • Exercises/activities for maintaining and improving strength, flexibility, and endurance. • Medication management. • Approaches for improving communication with friends, family and health professionals. • Nutrition information. • Treatment evaluation information.

25. The Stanford Model: Impact All studies looked at behavior, health status and utilization. Findings included: • Improved self-efficacy • Reduced use of doctors, hospital emergency rooms • Improvements in health status - identified by BOTH the participant and the health provider Ahn, S., Basu, R., Smith, M. L., Jiang, L., Lorig, K., Whitelaw, N., & Ory, M. G. (2013). The impact of chronic disease self-management programs: healthcare savings through a community-based intervention. BMC Public Health, 13, 1141. http://doi.org/10.1186/1471-2458-13-1141

26. Impact (continued)… • Improved quality of life • Specific improvements in healthful behaviors • Improvement in overall health status • Decreased hospital stays: .49 days, per patient, over a two year time period • Decreased physician/emergency room use: 2.5 fewer visits to the emergency room and to physicians, per patient, over a two year time period Stanford University Patient Education Center, http://patienteducation.stanford.edu/

27. Specific health-related impacts… • Increased physical activity • Cognitive symptom management • Improved communication with physicians • Better self-reported general health • Improved attitude • Less health distress • Less fatigue • Reduced disability • Fewer social/role limitations Stanford University Patent Education Center; published articles 1997-2003 (Lorig, K)

28. Train the Trainer Model • Group Leaders Facilitate community workshops for people with chronic diseases • Master Trainers In addition to what Leaders do, Master Trainers train Leaders • T-Trainers In addition to what Master Trainers do, T-Trainers train Master Trainers

29. Creating an effective chronic disease self-management system locally -Key Ingredients • Infrastructure • Community networks • Partnerships • Financial support • Sustained marketing • On-going recruitment Challenges and Successes in Implementing the Chronic Disease Self-Management Program, National Council On Aging, http://www.healthyagingprograms.org/resources/CDSMPFinalReport.pdf

30. Community Health Worker Program • Dual certification as a CHW and a Stanford Chronic Disease Self Management Group Leader • In collaboration with Friendly Inn Settlement House, Sisters of Charity Foundation and Fairhill Partners • First Class started January, 2016

31. Stanford Programs • Chronic Disease Self-Management Program (CDSMP)  Tomando Control de suSalud (Tomando)  Chronic Pain Self-Management Program (CPSMP)  Cancer: Thriving and Surviving (CTS)  Diabetes Self-Management Program (DSMP)  Programa de Manejo Personal de la Diabetes (Manejo)  Arthritis Self-Management Program (ASMP)  Positive Self-Management (PSMP) patienteducation.stanford.edu, October, 2015

32. Community Health Worker Role • Educational • Advocacy • Navigational • Referral • Clerical • Community

33. Summary Chronic Disease Self-Management is: • Managing the work of dealing with a chronic disease and/or multiple disease conditions. • Managing the work of dealing with daily activities in light of debilitation and disability. • Managing emotional changes resulting from or exacerbated by the disease conditions.

34. Once a chronic disease is present, one cannot NOT manage, the only question is “how.” Stanford University Patient Education Center, http://patienteducation.stanford.edu/, Lorig, 2003.

35. For further Information Joan Thoman, PhD, RN, CNS, CDE j.thoman@csuohio.edu 216-687-3518 Pam Rutar, EdD, RN, CNE p.rutar@csuohio.edu 216-875-9672 • Additional information & results of studies:Stanford University Patient Education Center, http://patienteducation.stanford.edu/

36. Questions? • ?