Patient Engagement and Self-Management

1. Patient Engagement and Self-Management Jeanie Knox Houtsinger University of Pittsburgh School of Medicine Department of Psychiatry Robert Wood Johnson Foundation Depression in Primary Care National Program

2. Presentation Overview • Key concepts related to patient engagement and self-management • Why is self-management and patient education so critical to good chronic illness care? • Strategies for engaging patients, developing wellness toolkits and working through symptom relapse

3. PCASG Recognition Awards • PCASG quality program is based on NCQA PPC – PCMH system • Creates baseline (floor) quality requirements • Creates pay for performance requirements • Allows organizational selection of participation / priorities • National Committee on Quality Assurance(NCQA) Physician Practice Connections® Patient-Centered Medical Home Survey

4. PPC-PCMH Content and Scoring

5. National Committee on QualityAssurancePhysician Practice Connections® Patient-Centered Medical Home Survey Tool PPC9C Electronic Care Management Support: For patients with the three clinically important conditions, the practice care management team uses electronic communication for the following: Factor Description PPC9C_fct1 To communicate with disease or case managers about patient needs PPC9C_fct2 Web-based educational modules for patient self-management.

6. NCQA PPC/PCMH Home Survey Tool PPC4: Patient Self-Management Support - Practice works to improve patients' ability to self-manage health by providing educational resources and ongoing assistance and encouragement. Intent: The practice collaborates with patients and families to pursue their goals for optimal achievable health. Description: The practice assesses patient/family-specific barriers to communication using a systematic process to: Factor Description PPC4A_fct1 Identify and display in the record the language preference of the patient and family. PPC4A_fct2 Assess both hearing and vision barriers to communication.

7. NCQA PPC-PCMH Home Survey Tool PPC4B: Self-Management Support Description: The practice conducts the following activities to support patient/family self-management, for the three important conditions: • Assesses patient/family preferences, readiness to change and self-management abilities • Provides educational resources language or medium that the patient and family understands • Provides self-monitoring tools or personal health record, or works with patients' self-monitoring tools or health record, for patients/families to record results home setting where applicable • Provides or connects patients/families to self-management support programs • Provides or connects patients/families to classes taught by qualified instructors • Provides or connects patients/families to other self-management resources where needed • Provides written care plan to the patient/family.

8. NCQA PPC-PCMH Home Survey Tool PPC4B: Self-Management Support Description: The practice conducts the following activities to support patient/family self-management, for the three important conditions: Factor Answers (based on patients see in the past 3 months) PPC4B_fct1 10% or less have at least 3 activities documented; 11%-24% have at least 3 activities documented 25%-49% have at least 3 activities documented 50%-74% have at least 3 activities documented 75%-100% have at least 3 activities documented

9. NCQA PPC-PCMH Home Survey Tool PPC8B: Patient Experience Data Description: The practice collects data on patient experience with care in the following areas:   Factor Description   PPC8B_fct1 Patient access to care   PPC8B_fct2 Quality of physician communication  PPC8B_fct3 Patient/family confidence in self care   PPC8B_fct4 Patient/family satisfaction with care

10. Engagement – Strategies that providers can use to help educate and motivate patients to access and use services and tools to manage their illness. Self Management – Strategies that patientscan use to look at their health behaviors and then make choices to improve their health based on their knowledge, skills and attitudes.  Definitions

11. Strategies for Addressing Barriers to Patient Engagement Systems Barriers • Cultural - Reform curriculum for health care providers so that it incorporates determining patient expectations of care and education/management strategies. • Infrastructure - Modify systems so that personal health information includes goal-setting and achievement/compliance with self-management plans • Financial – Incentivize use of patient education and self-management techniques by rewarding providers/practices that actively incorporate them into day-to-day practice.

12. Strategies for Addressing Barriers to Patient Engagement Patient Barriers • Language – Determine language preference early • Literacy – Determine what reading level and technical abilities they are to determine which tools are the most appropriate • Support system – Find out who will be their partner in helping them to better manage their illness • Financial challenges – Be prepared to offer suggestions for low cost/no cost activities the patient can use when developing self-management plans.

13. Engagement Interventions • Focus on 2 phases of treatment • Initial attendance • Ongoing retention • Can be implemented in all areas of Chronic Care Model

14. Engagement Interventions and the Chronic Care Model • Delivery system • Redesign system to assure effective and efficient clinical care and promote self-management • Create culture, organization and mechanisms that promote effective interaction, workflow improvement, and self-management. • Clinical information systems • Use patient registry to track assessment scores, appointment attendance, patient action plan. • Decision support • Promote self-management strategies consistent with scientific evidence and patient preferences • Telephone engagement and use of patient action plan • Self-management • Use evidence-based guidelines to help patient address barriers to achieving self-management goals • Community services • Information and linkages with community services (e.g. childcare, transportation, activities) to reduce no-shows and help patients achieve self-management goals

15. Empowering the Patient

16. Effective Self-Management Tools: • Don’t require an “expert” • Rely on “natural supports” (friends, family, neighbors, etc.) rather than “programs” • Can be applied across a range of conditions (not just a single disorder) • Meet people “where they are” through the course of their illness and recovery • Can fit on a refrigerator door

17. Self–Management Supports:What to Avoid • Gender bias • Cultural bias • Literacy assumptions – including “computer literacy” • Excessive focus on medication management • Overuse of the word ”Compliance”

18. Examples of Self-Management Action Plans

19. Wellness Action Recovery Plan (WRAP)www.mentalhealthrecovery.com • Wellness Toolbox: Used to develop WRAP Plan • List of activities that patients have done in the past - or could do in the future - to help them stay well • List of activities that patients can do to help them feel better when they are not doing well • Elements of written WRAP plan • Daily Maintenance List • Triggers • Early Warning Signs • Things are Breaking Down • Crisis Planning Developed by Mary Ellen Copeland, MA

20. Wellness Toolbox:Examples of Wellness Tools • Talk to a friend • Talk to a health care professional • Peer counseling or exchange listening • Focusing exercises • Relaxation and stress reduction exercises • Guided imagery • Journaling (writing in a notebook) • Creative affirming activities • Exercise • Diet considerations

21. Elements of WRAP Plan • Daily Maintenance List • Describe how you feel when you are feeling well. • List the things you need to do for yourself every day to stay well. • List reminders that you might need to do based on how you are feeling. • Triggers • List those things that, if they happen, might cause an increase in your symptoms or things that may have triggered your symptoms in the past. • Write an action plan that you can use if triggers come up.

22. Elements of WRAP Plan • When Things Are Breaking Down • List early warning signs that you have noticed in the past when your condition worsened. • Write an action plan to use if early warning signs come up. • Crisis Planning • Develop crisis plan slowly when you are feeling well. • Use crisis plan to instruct others about how to help you when you are not feeling well and need help. • Crisis plan keeps you in control even when it seems like things are out of control. • Insures your needs are met because others will know what to do • Saves time and frustration

24. Depression Self-Care Action PlanDEPRESSION IS TREATABLE! • STAY PHYSICALLY ACTIVE. • Make sure you make time to address your basic physical needs, for example, walking for a certain amount of time each day. • Every day during the next week, I will spend at least _________ minutes (make it easy and reasonable) doing ____________________________. • MAKE TIME FOR PLEASURABLE ACTIVITIES. • Even though you may not feel as motivated, or get the same amount of pleasure as you used to, commit to schedule some fun activity each day, for example, doing a hobby, listening to music or watching a video. • Every day during the next week, I will spend at least _________ minutes (make it easy and reasonable) doing ____________________________.

25. Depression Self-Care Action PlanDEPRESSION IS TREATABLE! • SPEND TIME WITH PEOPLE WHO CAN SUPPORT YOU. • It’s easy to avoid contact with people when you’re depressed, but you need the support of friends and loved ones. Explain to them how you fell, if you can. If you can’t talk about it, that’s okay – just ask them to be with you, maybe accompanying you on one of your activities. • During the next week, I will make contact for at least ________ minutes • (make it easy and reasonable) with: • ____________ (name) doing/talking about _______________________. • ____________ (name) doing/talking about _______________________. • ____________ (name) doing/talking about _______________________.

26. Depression Self-Care Action PlanDEPRESSION IS TREATABLE! • PRACTICE RELAXING. • For many people, the change that comes with depression – no longer keeping up with our usual activities and responsibilities, feeling increasingly sad and hopeless – leads to anxiety. Since physical relaxation can lead to mental relaxation, practicing relaxing is another way to help yourself. Try deep breathing, or a warm bath, or just a quiet, comfortable, peaceful place and saying comforting things to yourself (like “It’s okay.”) • Every day during the next week, I will practice physical relaxation at least ________ times, for at least __________ minutes each time (make it easy and reasonable).

27. Depression Self-Care Action PlanDEPRESSION IS TREATABLE! • SIMPLE GOALS AND SMALL STEPS. • It’s easy to feel overwhelmed when you’re depressed. Some problems and decisions can be delayed, but others cannot. It can be hard to deal with them when you’re feeling sad, have little energy, and not thinking clearly. Try breaking things down into small steps. Give yourself credit for each step that you accomplish. • The problem is _________________________________________ • _____________________________________________________ • My goal is to ___________________________________________ • ______________________________________________________ • How Likely Are You To Follow Through With These Activities • Prior to Your Next Visit? • Not Likely 1 2 3 4 5 6 7 8 9 10 Very Likely

28. Depression Self-Care Action PlanDEPRESSION IS TREATABLE! Things to Know About Your Antidepressant Medication • Your antidepressant medication is NOT ADDICTIVE OR HABIT FORMING. They are NOT uppers or downers. It is safe for you to take your medication according to your provider’s orders. If you are using alcohol or other drugs, please discuss this with your provider. • Target symptoms for antidepressant medications are: Sleep, Appetite, Concentration, Mood and Energy. • It takes time for your medication to work. Most people begin to feel better in 1-4 weeks. Don’t give up if you don’t feel better right away. Important things for you to do: • Keep all of your appointments. • Take the medicine exactly as your provider prescribes – even if you feel better. • If you forget a dose DO NOT DOUBLE DOSE – Take your next dose at the regular time.

29. What Are You Using… • To educate patients about their illness (e.g. one-pagers, brochures, web-sites) • To engage patients in taking a more active role in managing their illness (e.g. goal-setting, reward system for achieving goals) • To give patients the tools they need when they go home to better manage their disease

30. Where Can I Learn More?

31. Self-Management Tools on the Web • New Health Partnerships (http://www.collaborativeselfmanagement.org/) • Designed to facilitate collaborative self-management engaging patients, family members, and health care providers who want to work together as partners in care. • Institute for Healthcare Improvement (http://www.ihi.org/IHI/Topics/PatientCenteredCare/SelfManagementSupport/Resources/) • Features links to websites and publications focusing on self-management and patient-centered care. • Massachusetts Consortium on Depression in Primary Care (www.mcdpc.org/ConsumerInfo): • Includes consumer information in English and Spanish on medications used to treat depression and suggestions for managing their illness. • MacArthur Foundation Initiative on Depression (www.depression-primarycare.org/clinicians/toolkits/materials/patient_edu/self_mgmt_2/. • Provides downloadable self-management tools in English and Spanish. • Hope to Healing (http://www.hopetohealing.com): • Forum for patients to share personal stories about challenges they face, how they sought help and ongoing efforts to manage their disease.

32. Suggested Reading: Engagement • Wang et al. (2008) Disruption of Existing Mental Health Treatments and Failure to Initiate new Treatment after Hurricane Katrina, The American Journal of Psychiatry, 165(1):34-42. • Cavaleri et al. (2007) The Sustainability of a Learning Collaborative to Improve Mental Health Service Use among Low-Income Urban Youth and Families, Best Practices in Mental Health, 3(2):52-61. • McKay et al. Integrating Evidence-Based Engagement Interventions into “Real World” Child Mental health Settings (2004) Brief Treatment and Crisis Intervention, 4:177-186. • Wagner et al. (1998) Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice, 93:239-243.

33. Suggested Reading: Self-Management • Brownson et al. (2007) A Quality Improvement Tool to Assess Self-Management Support in Primary Care. The Joint Commission Journal on Quality and Patient Safety, 33(7):408-416. • Bachman et al. (2006) Patient self-management in the primary care treatment of depression. Administration Policy and Mental Health, 33(1):76-85. • Pincus HA et al. (2005) Depression in primary care: Bringing behavioral health safely into the main stream. Health Affairs, 24:271-276. • Battersby MW. (2004) Community models of mental care warrant more governmental support. British Medical Journal, 329:1140-1141. • Bodenheimer et al. (2002). Patient self-management of chronic disease in primary care. Journal of the American Medical Association, 288:2469-2475. • Wagner et al. (2001). Improving chronic illness care: Translating evidence into action. Health Affairs, 20, 64-78. • Copeland ME. (2001). The Depression Workbook: A Guide to Living With Depression and Manic Depression. Oakland, CA: New Harbinger Publications.