Patient as Partners Improving Health and Cost Outcomes with Self-Care and Chronic Disease Self-Management

1. Patient as PartnersImproving Health and Cost Outcomes with Self-Care and Chronic Disease Self-Management NatPaCT Conference Programme Learning from Kaiser Permanente – How can the NHS make better use of its resources and improve patient care? Tuesday 4 November 2003 – The Brewery, London

2. David S. Sobel, MD, MPHDirector, Patient Education and Health PromotionKaiser Permanente Northern California1950 Franklin Street., 13th Floor, Oakland, CA 94612Phone: 510-987-3579Fax: 510-873-5379E-mail: David.Sobel@kp.org

3. Strategy for Changing Culture and Practice • Look for • inefficiencies, mismatches, and capacity • overlooked evidence and data • “win, win, win” opportunities

4. Strategy for Changing Culture and Practice • Rethink Care • Patients as primary providers of acute illness • Self-management of chronic illness • Behavioral interventions to address psychosocial needs • Restructure Care • Telephone, group appointments, web-based care • Retrain for Collaborative Care • Enhance understanding, skills, and confidence of members and professional staff as partners in care

5. Patient as Provider Patient as Consumer Rethinking Care 1: Self-Care for Acute Illness

6. Hidden Health Care System 3 Professional Care 20% 2 1 Self-Care 80%

7. Self-Care: Patients as Providers • Over 80% of all medical symptoms are self-diagnosed and self-treated without professional care. • Patients are the true primary care providers of medical care for themselves and their families. • How can health care systems educate, equip, and empower the true primary care providers… patients?

8. Kaiser PermanenteSelf-Care Program Vision: “Partners in Health” • A system intervention that changes the culture of care and supports members making safe, appropriate, and informed health care choices • KP Healthwise Handbooks distributed to all members • Provider training and reinforcement • Continuing systemwide reinforcement

9. Kaiser PermanenteHealthwise Handbook

10. Kaiser PermanenteSelf-Care Program Results • High use of the KP Healthwise Handbook • 70% in previous 6 months • Improved member self-care confidence • 71% more confident • Increased member satisfaction • 60% more positive about Kaiser Permanente • More appropriate utilization & improved accessibility • 50% report saving a call or visit to MD • ê6% medical visits and ê5%telephone calls • Improved provider and staff satisfaction

11. Patient as Provider Patient as Consumer Rethinking Care 2: Self-Management of Chronic Illness

12. 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 E. Wagner

13. Living with Chronic Disease Managing the Illness • Taking medications • Changing diet and exercise • Managing symptoms of pain, fatigue, insomnia, shortness of breath, etc. • Interacting with the medical care system Managing Daily Activities and Roles • Maintaining roles as spouse, parent, worker, etc. Managing the Emotions • Managing anger, fear, depression, isolation, etc. Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M: Living a Healthy Life with Chronic Conditions, Palo Alto, CA: Bull Pub. Co., 2000

14. Healthier Living with Ongoing Health Conditions* • Lay-led, small interactive groups (2 hours/week for 7 weeks) • Mixed chronic disease and co-morbidities • Content • Goal setting and problem-solving • Cognitive symptom management • Design of exercise programs • Management of fatigue, sleep, pain, anger, depression • Appropriate use of medications • Patient/physician communication • Use of advanced directives Lorig K et al Medical Care 1999;37:5-14. *aka Chronic Conditions Self-Management Program, Expert Patient Programme http://patienteducation.stanford.edu/

15. Healthier Living with Ongoing Health Conditions • Improves health behaviors and health status • Cost effective (estimated 5:1 to 10:1 ROI) • Outcomes are long-lasting and robust (2+yrs.) • Replicable and dissemination can yield outcomes as good, or better. Lorig KR, Sobel DS, Effective Clin Practice 2001;4:256-262 Lorig KR, Medical Care 2001;39:1217-1223

16. Chronic Disease Self-Management Program LESSONS • General coping skills education for heterogeneous conditions complements disease specific information • Patients are the “experts” in living and coping with chronic illness • Modeling more effective than “save and rescue” • No significant difference in participants’ outcome with lay vs professional leaders • Confidence predicts improvement in health outcomes • People benefit themselves from helping other people • Process is more important than content

17. Mind as HMO Body as Machine Rethinking Care 3: Behavioral Medicine Sobel DS: The cost-effectiveness of mind-body medicine interventions. In The Biological Basis for Mind Body Interactions, Progress in Brain Research, Vol 122, EA Mayer and CB Saper (Eds.), Elsevier, 2000:393-412.

18. Psychiatric Disorder Emotional Distress Medical Illness Somatic Symptom Superhighway Final Common Pathway Somatic Symptoms

19. Psychological Status of Primary Care Patients

20. Causes of Common Symptoms in Primary Care Medicine Chest pain, fatigue, dizziness, headache, back pain, edema, dsypnea, insomnia, abdominal pain, numbness Kroenke, Am J Med 1989:86:262-6

21. Depressive Symptoms Depressive symptoms more debilitating in terms of physical and social functioning than: • diabetes • arthritis • gastrointestinal disorders • back problems • hypertension Wells et al. JAMA 1989;262:914-930

22. Psychosocial Dysfunctionin Medical Care • Common • Undiagnosed or inadequately treated • Significant impact on: • functional status and disability • medical utilization and costs • medical morbidity and mortality • Health Care services mismatched to needs • Need to develop integrated behavioral health education services Sobel DS: Rethinking medicine: Improving health outcomes with cost-effective psychosocial interventions. Psychosomatic Medicine 57:234-244, 1995.

23. Mind/Body Medicine Program EvaluationPre- and Post-Class 12 NCal Facilities Intake Post-Program 70% 60% 62.1% 61.2% 60.0% 50% 40% % Classifed as Psych Outpatient Cases on SCL-90 30% 31.7% 28.2% 20% 21.5% 10% 0% Depression(n=124) Anxiety(n=121) Somatization(n=120) SCL-90 Sub-scale Measures Nancy Gordon - DOR (June, 2000)

24. Utilization Change for Mind/Body Medicine Participants 6-Mo. Pre 6-Mo. Post 3000 N=609 2500 2000 Total Visits 1500 1000 500 0 ADP +34% ER - 45% Med -37% Urg -22% Psy - 41% Ngissah, Levine, & Walsh (1998 - N. Valley)

25. Attitudes Beliefs Moods Health Behavior Change Health Outcomes RethinkingHealth Improvement Interventions Confidence Counts Lorig K, Arthritis and Rheumatism. 1989;32:91-95

26. Quality of Life Behavioral Risk Reduction Problems in Living • CORE • Attitudes • Beliefs • Moods Psychosocial Skills Mental Illness Medical Conditions Targeting CoreAttitudes, Beliefs, and Moods • Ornstein R, Sobel D: Healthy Pleasures. Addison-Wesley, 1989

27. Group Appointments and Web-based Care Medical Office Visits Restructuring Care

28. Medical Group Appointments(Group Visits, Cluster Visits, etc.) • Scheduled or ‘drop-in’ visit for group of patients with similar or mixed health conditions • Under direction of physician or other licensed health care professional • Provision of individualized clinical services • Medical Assessment • history, physical assessment, triage, referral • Medical Intervention • medication prescription/adjustment, lab tests

29. Diabetes Cooperative Care Clinic Randomized clinical trial, n=185, f/u 1yr, 2hr group monthly x 6 Outcomes • lower HgbA1C ( 1.3% vs. 0.22% controls, p<0.0001) • more home blood glucose monitoring • reduced hospital and outpatient utilization • hospitalizations 80% more frequent in control • fewer physician and nonphysician visits • increased self-efficacy • diet, management of low BG and BG when sick • increased satisfaction Sadur CN, Diabetes Care, 1999;12:2011-2017

30. Restructure Care:Web-Based Care at kp.org www.kaiserpermanente.org

31. Get Health Advice

32. Appointment/Rx Refills

33. Physician Personal Home Page: A Personal Portal to Kaiser Permanente Online Services

34. Collaborative Care Traditional, PaternalisticCare Retraining for Collaborative Care

35. How Traditional Care Differs from Collaborative Care adapted from Bodenheimer, Lorig, et al JAMA 2002;288:2469.

36. Retraining for Collaborative Care • Thriving in a Busy Practice: Clinician-Patient Communication (“Four Habits of Effective Clinicians”) • Brief Negotiation • Practice Essentials for Care Managers • Education for Health Action • Group Appointment Toolkit

37. Retraining for Collaborative Care:Key Strategies • Address member’s needs in 3 domains: 1. Disease and Health Management 2. Role Management 3. Emotional Management • Use state-of-art communication/educational strategies: • Transform didactic, information-based approaches into interactive, self-efficacy/confidence enhancing communication that strengthens patients’ skills in problem-solving, goal setting and action planning, self-tailoring, using available resources, forming a partnership with clinician • Ask questions and elicit patient perspective and engagement in action planning and problem-solving • Use nonjudgmental and positive tone • Link back to member’s routine source of care and team care and peer support

38. Patients as Partners: Changing Culture and Practice • Rethink Care • Patients as primary providers of acute illness • Self-management of chronic illness • Behavioral interventions to address psychosocial needs • Restructure Care • Telephone, group appointments, web-based care • Retrain for Collaborative Care • Enhance understanding, skills, and confidence of members and professional staff as partners in care

39. Appendices

40. Four Habits of Highly Effective Clinicians • Invest in the Beginning • Elicit the Patient’s Perspective • Demonstrate Empathy • Invest in the End Frankel RM, Stein T. Getting the Most out of the Clinical Encounter: The Four Habits Model. The Permanente Journal, Fall 1999, Vol 3, No. 3http://www.kaiserpermanente.org/medicine/permjournal/fall99pj/frhabits.html

41. 2003 CMI Evidence-Linked Recommendations Embed Self-Mgt into Pop Mgt: • Lower intensity interventions(automated phone messages, staged mailings, videos, online) for all patients • Higher intensity(e.g. multi-session programs) for those with higher needs Robert Wood Johnson Foundation and Center for the Advancement of Health. Essential Elements of Self-Management Interventions, 2002. Von Korff M, Tiemens B. West J Med 2000; 172(2):133-137. Piette JD,e al. Am J Med 2000; 108(1):20-27. Serxner S, et al. Congestive Heart Failure; 1998. May/June:23-28.

42. 2003 CMI Evidence-Linked Recommendations, cont’d. During clinical encounter, support member’s central role in health: • Collaborative communication (Brief Negotiation, 4 Habits) • Assess member’s self-mgt needs; provide tailored feedback and behavioral advise • Collaboratively set behavioral goals and action plan. Document and share with member. • Offer self-mgt resources; refer to programs • F/up to adapt plan and address relapse Glasgow RE et al. Ann Behav Med 2002; 24(2):80-87. Stewart MA. CMAJ 1995; 152(9):1423-1433. Petrella RJ, Lattanzio CN. Can Fam Physician 2002; 48:72-80. Rice VH. Heart Lung 1999; 28(6):438-454. Boulware LE, et al. Am J Prev Med 2001; 21(3):221-232.

43. 2003 CMI Evidence-Linked Recommendations, cont’d. Strengthen Adherence to Prescribed Medications: • Anticipate nonadherence: “Have you ever missed or forgot to take your pills?” • Identify personal barriers and problem solve. Avoid assuming causes of nonadherence • Collaboratively develop a regimen pt is willing and able to follow. Praise efforts to adhere. • As needed, refer for pharmacist consultation McDonald HP, et al. JAMA 2002; 288(22):2868-2879. Haynes RB , et al. JAMA 2002; 288(22):2880-2883. Yuan Y, et al. Am J Manag Care 2003; 9(1):45-56.

44. 2003 CMI Evidence-Linked Recommendations, cont’d. Turn didactic pt education into self-mgt education Beyond knowledge to skills & confidence: • Problem solving training (incl. medication adherence) • Goal setting and action planning • Peer modeling and support • Experiential exercises (relaxation session, read peak flow meter, pick from a menu) • Forming partnership with clinician Bodenheimer T et al. JAMA 2002; 288(19):2469-2475. Norris S et al. Diabetes Care 2002; 25(7):1159-1171. Gibson PGM et al. Cochrane Database Syst Rev 2002;2. Barlow J, et al.Patient Educ Couns 2002; 48(2):177-187.

45. 2003 CMI Evidence-Linked Recommendations, cont’d. Offer multiple options to receive self-mgt education: • Staged mailings based on readiness to change • Telephone group sessions • Group visits • Internet-based programs • Community and work site programs Serxner S, et al. Congestive Heart Failure 1998; May/June:23-28. Boucher, JL et al. Diabetes Spectrum 1999 12(2).121-123. Wagner EH et al. Diabetes Care 2001; 24(4):695-700. McKay HG, et al. Diabetes Care 2001; 24(8):1328-1334. Norris SL et al. J Prev Med 2002; 22(4 Suppl):39-66. Pelletier KR. Am J Health Promot 2001; 16(2):107-116.