Self-management support and patient education for chronic conditions at Group Health
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Self-management support and patient education for chronic conditions at Group Health. Small steps to big changes. May 10, 2012 | Kim Wicklund, MPH. Randy’s story. Whether you think you can do a thing or you can’t do a thing, you’re right. – Henry Ford. Chronic Conditions in U.S.

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May 10, 2012 | Kim Wicklund, MPH

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May 10 2012 kim wicklund mph

Self-management support and patient education for chronic conditions at Group Health

Small steps to big changes

May 10, 2012 | Kim Wicklund, MPH


Randy s story

Randy’s story

Whether you think you can do a thing or you can’t do a thing, you’re right.

– Henry Ford


Chronic conditions in u s

Chronic Conditions in U.S.

Among the American adult population:

  • 50% have at least one chronic condition

  • 25% have multiple chronic conditions

  • 75% of people age ≥65 have multiple chronic conditions

  • ½ of those with hypertension, and over 60% of those with diabetes and hyperlipidemia do not have conditions well controlled

Vogeli, Shields, Lee 2007 JGIM

Medical Panel Expenditure Survey 2006

Schneider et al. 2009

Bodenheimer, Wagner, Grumbach 2002 JAMA


Chronic care model

Chronic Care Model


Rationale for self management support

Rationale for self-management support

  • Through SMS people gain knowledge, skills, and self-confidence

  • Majority of care for chronic conditions is complex and challenging self care

  • SMS improves patient outcomes and controls costs

  • Various SMS approaches: care managers, one-on-one, group, telephonic coaching, online, peer

  • Need effective models that are affordable and have population level impact


Chronic disease self management program

Chronic Disease Self-Management Program

  • Developed at Stanford Patient Health Education Research Center

  • 6-week workshop (2.5 hrs/wk) based on self-efficacy theory

  • Designed for people with one or more chronic conditions

  • Leaders have personal experience with chronic conditions

  • Premise– people with chronic conditions share similar challenges and need to master a generic set of self-management skills

  • Contributes to improvements in psychological health status, self-efficacy and select health behaviors. Modest effects can have significance across large population. (CDC 5/2011)


Cdsmp at group health

CDSMP at Group Health

  • Started in 1998

  • 18 medical centers

  • 65 volunteer leaders

  • Average age: 65

  • Most common conditions: diabetes, arthritis, asthma/COPD, heart disease, depression

  • Reach 2009-2011: 1,615 Group Health patients

  • Recruitment: letters, care team, ghc.org, flyers, word of mouth


Challenges of scaling cdsmp

Challenges of scaling CDSMP

  • Limited access for network members in eastern and central Washington

  • Capacity determined by volunteer leader and room availability

  • Schedule is sporadic

  • Chronic condition flare-ups can impact attendance

  • Difficult to commit to weekly 2 ½ hour sessions

  • Discomfort discussing sensitive topics face to face


Online cdsmp

Online CDSMP


Online cdsmp pilot

Online CDSMP pilot

  • Funded by GHF

  • Partners: NCOA, Stanford, GHRI

  • Target: 500 participants

  • Timeline: June, 2009-June, 2011

  • Eligibility:

    • Adult Group Health member

    • Any chronic condition

    • Enhanced access to MGH


Intervention

Intervention

  • Follows structure of in-person program

    • 6-week highly interactive online workshop

    • 25 participants per workshop

    • Two peer moderators

    • New lessons posted each week

  • Participants log on at their convenience 2-3 times/week

  • Time commitment of 2-3 hours/week


  • Home page

    Home page


    Evaluation questions

    Evaluation questions

    • Will the online program expand CDSMP’s reach to Group Health members who are not reached by the in-person workshops?

    • Will participants in the online program at Group Health experience similar benefits to those reported in Stanford’s evaluation?

    • What resources and expertise are needed to administer the online program at Group Health?

    • Is the online format a viable strategy for bringing the CDSMP intervention to scale at Group Health?


    Participant flow

    Participant flow


    Evaluation

    Evaluation


    May 10 2012 kim wicklund mph

    Demographics


    Conclusions

    Conclusions

    • Online program expanded CDSMP’s reach

    • Benefits were similar to but not consistent with Stanford’s

    • Resources and expertise needed to administer the online program are reasonable

      • Mixed staffing model– GH Administrator; NCOA mentor and facilitators

      • Costs– per workshop: $4350; per participant: $174; per completer: $255

    • Online format is a viable strategy for helping to bring the CDSMP to scale at Group Health


    Other strategies

    Other strategies


    Employer pilots

    Employer pilots

    Testing 3 approaches:

    • Worksite-based workshops (King County)

      • 4 workshops- 56 employees

      • Gold status for documented attendance of ≥4 sessions

    • Formal reporting of participation (SHWT)

      • GH/SHWT reporting process for incentivizing employees attending ≥4 sessions online or in person

    • Employee self report on participation (Group Health)

      • ≥4 sessions in person or online for 400 wellness points

      • 317 reported met goal


    Disease specific pilot

    Disease-specific pilot

    • Living Well with Diabetes (DSMP)

    • GHF Partnership for Innovation grant to pilot 8-10 workshops

    • To date offered 8 workshops to 128 people (14 scheduled)

    • Evaluating impact on self-management behaviors, blood sugar knowledge, medication management

      “Today I received my latest blood and kidney test results, and for the first time in my adult life they all were within normal ranges. My A1c was 5.7….”


    Integrating referrals into care

    Integrating referrals into care

    • Point of care prompts in EMR

    • CMEs and nursing education

    • Clinical Pearls

    • Standard tools

      • Health Profile

      • After Visit Summaries

      • Brochures

      • MyGroupHealth


    Reach 1999 2011

    Reach 1999-2011


    Patient education resources

    Patient education resources


    Myths about patient education

    Myths about patient education

    • If patients have more information, they’ll have better outcomes.

    • If I don’t share everything I know with my patients, they won’t fully understand their condition and what they need to do.

    • If my patients hear medical jargon, that’s ok. They’ll be able to understand it from the context.

    • My patient is well educated, so s/he will understand complex words and ideas.

    • My patient didn’t ask any questions so s/he must have understood my instructions.


    The reality for many patients

    Most patients forget up to 80% of what their clinician tells them as soon as they leave the office

    Nearly 50% of what patients do remember they remember incorrectly 

    Implications:

    – Non-adherence and disengagement

    – Patient safety concerns

    – Medication errors

    – Missed surgeries and other appointments

    The reality for many patients


    Strategies for providing information

    Strategies for providing information

    • Break the information into understandable chunks

    • Use plain language

    • Limit key points to 3 or fewer

    • Focus on action-oriented messages

    • Repeat key messages

    • Use analogies to help explain concepts

    • Use images and graphics

    • Tailor the message to the patient

    • Give consistent messages


    Modular approach

    Modular approach


    Graphics clarify key concepts

    Graphics clarify key concepts


    Action planning

    Action planning


    May 10 2012 kim wicklund mph

    Action plan for diabetes management


    Patient instructions provided in avs

    Patient instructions provided in AVS


    Lessons learned

    Lessons Learned


    Lessons learned1

    Lessons learned

    We have an ethical obligation to provide effective SMS

    Patients want and need different options for engaging in SMS

    People cycle through readiness and need to hear about SMS from different sources at different times

    Clinical teams need ongoing reminders about the program

    Employers are an underutilized resource for promoting SMS

    Incorporating SMS concepts into patient education supports awareness of care team and patients about SMS


    Future directions

    Future directions


    Next steps

    Next steps

    • Continue exploring how to integrate referrals into standard work

    • Continue to identify alternative ways to reach network members

    • Update functionality and design of online program

    • Further analyze evaluation data

    • Explore more partnerships with employers (SU, Puyallup Tribe)

    • Partner with community programs to address gap areas

    • Create online community of LWCC alumni to provide ongoing support

    • Considering SMS program for youth or young adults


    Discussion

    Discussion


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