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 are they critical components of good chronic illness care? • Strategies for engaging patients, developing wellness toolkits and working through symptom relapse

3. Definitions • Engagement – employing strategies to motivate patients to access and use services and tools to manage their illness. • Self Management - process patients can use to look at their health behaviors and then make choices to improve their health based on their knowledge, skills and attitudes. 

4. Barriers to Patient Engagement • System Barriers • Culture • Infrastructure • Financing • Patient Barriers • Activation • Literacy • Diversity • Unpredictability • Financing

5. System Strategies for Addressing Barriers to Patient Engagement • Culture • National thought leadership • Curriculum reform • Professional standards • Patient expectations for care • Infrastructure • Personal health information • Performance information • Patient safety improvements • Financing • Process based payment • Outcomes based payment • Patient financial responsibility

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

7. 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

8. Empowering the Patient

9. 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

10. 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”

11. Examples of Self-Management Action Plans

12. 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

13. 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

14. 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.

15. 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

20. Where Can I Learn More?

21. 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.

22. 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.

23. 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.