Engaging and Sustaining Healthcare Providers in Chronic Disease Self-Management Support

1. Engaging and Sustaining Healthcare Providers in Chronic Disease Self-Management Support What, Why, and How Healthcare Professionals Can Do Durhane Wong-Rieger, President Institute for Optimizing Health Outcomes Institute for Optimizing Health Outcomes

2. Disclosure of Potential for Conflict of Interest • Durhane Wong-Rieger, President & CEO, Institute for Optimizing Health Outcomes • FINANCIAL DISCLOSURE: • Grants / Research Support: No Conflict • Speaker bureau/Honoraria: Champlain Living Healthy • Consulting Fees: None • Other: None Institute for Optimizing Health Outcomes

3. Learning objectives After this program, the participant will be able to: • Define the importance of an engaged patient for treatment adherence and health behaviour change • Identify the knowledge and skills of engaged self-managing patients • Know the five-step model of patientengagement and concepts of self-management support • Know role of motivational interviewing/decisional balance to increase patient readiness to engage • Implement roles of patients and healthcare professionals as partners in chronic disease self-management Institute for Optimizing Health Outcomes

4. Case 1: What health problem? • Greg: 54-year old finance manager for small municipality; high stress, long hours, two teenage children • Diagnosed: moderate hypertension (150/90); weight (210 lbs.)/height (5’11”) = BMI 29.2 • Lifestyle: sedentary and overweight as child; as young adult active runner and biker; now mostly sedentary • Diet: prefers meat and potatoes; tries to include fish and vegetables; often fast food because of work schedule • Family history of heart disease (father died of heart attack at age 54); cancer (both uncles); grandmother died at age 90 Institute for Optimizing Health Outcomes

5. Case 2: Ready to Self-Manage? • Mark, 32-year-old financial advisor, married 2 years; no kids • Indications: BP (130/80); Height/Weight/BMI (5’ 11”/160/22.3); FPG (200+ or 11.1); HA1C (7.5) • Lifestyle: High activity (30-90 mins aerobic exercise 4-6/week); high carb diet; low alcohol (3-5 drinks/week) • Family history: Thyroid, celiac; father died of ALS • Diagnosed 2 years ago with Diabetes (Type 1.5?) • Treatment: Compliant with low carb dietand exercise. Low compliance with insulin (no pump) and blood glucose testing 4-6 times daily (rec.) Institute for Optimizing Health Outcomes

6. Case 3: What’s Happening? • Ursula, 14-year-old, grade 9 HS, mid-size community • Indications: LDL cholesterol (2.6 mmol/L), SBP (120 mmHg), BMI (23.6 kg/m2), HA1C (9.5%) • Diagnosed: Type 1 Diabetes diagnosed as infant • Lifestyle: Outgoing, likes music, drama, swimming, dance, and internet activities • Family: Only child, mother primary caregiver for diabetes • Treatment: Self-administering since age 12; until recently, compliant with diet, glucose testing and insulin 4-6 times daily; recently, irregular testing, insulin, and diet control Institute for Optimizing Health Outcomes

7. Is Chronic Disease Problem? • About 50% of Canadians (16.5 million) have 1 or more chronic conditions • Globally, WHO identifies noncommunicable (chronic) diseases as killing more people than all other causes combined; 2/3 of 57 million deaths due to CVD, cancer, diabetes, and chronic lung disease • In developed countries, CD patients average 12 hours with HCPs, leaving them to self-manage 364.5 days/year • Globally, NCDs caused by four 21st-century lifestyle behaviours: tobacco use, unhealthy diet, lack physical activity, and alcohol over-use. Institute for Optimizing Health Outcomes

8. Why Self-Management for Chronic Disease? • About 50% of Canadians (16.5 million) have 1 or more chronic conditions • Traditional provider-based acute care model not appropriate to managing chronic conditions • Patient need to take an active, informed role in managing treatment and making lifestyle changes • Patients who actively manage their own health feel better and have better health outcomes • Research indicates that self-management is important but does not have lasting benefits without support from the healthcare professional, that is, health coaching. Institute for Optimizing Health Outcomes

9. Problem of Patients Not Adhering to Treatment Recommendations? 14-21% of patients never fill prescription 30-50% don’t take medications in recommended manner 66% with hypertension have poor BP control due to non-adherence 50% adherence to chronic conditions treatment incl. lifestyle changes WHO, 2003 21%Type 1 diabetes patients NEVER check Blood glucose levels Polonsky, 1999 36-39% non-adherence to MS disease-modifying injection therapies (among patients who choose to engage in treatment) Treadaway et al, 2009 Institute for Optimizing Health Outcomes

10. Lack of Adherence to Diabetes Management • Lack of adherence to BG monitoring (Vicenze et al, 2004) • Only 40% of patients with Type 1 diabetes measure as frequently as recommended • Only 33% of patients with Type 2 diabetes measure as recommended • Patients with diabetes (enrolled in diabetes management) do not spend time on self-care (Safford et al, 2005) • 21% of diabetic patients never test blood glucose • 38% of diabetic patients never engage in foot care • 38% of diabetic patients never exercise • 54% of diabetic patients never spend time shopping and cooking Institute for Optimizing Health Outcomes

11. Problems of Non-Adherence to Medications Responsible for: • Up to 10 % of hospital admissions • 23% of nursing-home admissions (McKenney and Harrison, 1976; Strandberg, 1984) • 22% of drug reaction hospitalizations (McKenney, 73) Institute for Optimizing Health Outcomes

12. Why Don’t Patients Make Behaviour Changes? • Knowledge is not enough • Who here has perfect health (behaviour)? • Who knows what he/she needs to do to live more healthily? • Behaviour change is hard • Who here prefers to do things that give pleasure rather than things that cause pain? • Have you ever continued to do something that has “bad” consequences? Have you ever stopped doing something that is “good” for you? Institute for Optimizing Health Outcomes

13. Not Enough or Too Much Information? GP Diet’n Patient Diab Ed Pathology Take Meds Quit Smoking Attend Groups Practice Nurse Self- manage Use Aids OT Psych Monitor Symptoms Diet’n Physio Nutrition Ex Phys Pod’st Rehab Program Exercises Attend Appoint’s Move More Institute for Optimizing Health Outcomes

14. Common Responses to Treatment Advice? Fear Hopelessness Guilt Resistance Frustration Despair Confusion Anger Shame Institute for Optimizing Health Outcomes

15. Cognitive, Behavioral & Emotional Avoidance Response Institute for Optimizing Health Outcomes

16. Empowered Patients = Self-Managing Patients = Better Outcomes • Self-management involves [the person with the chronic health condition] engaging in activities that protect & promote health, monitoring and managing symptoms & signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes. (Gruman & Von Korff, 1966) • Patients who self‑monitor their condition have been shown to have better outcomes. Self-care programmes aim to increase the interest and involvement of people in their own care, and by doing so, empower them to manage their condition. (WHO, 2010) Institute for Optimizing Health Outcomes

17. To make behavioural changes (adhere to treatment, make lifestyle changes), patients must: • Know what to do(treatment recommendations) • Be ready to make necessary changes = believe change is important and do-able • Have the capacity to carry out the chosen actions: • Have the skills and resources to initiate and maintain health behaviour changes • Identify and use problem-solving skills to address barriers to change Institute for Optimizing Health Outcomes

18. HCPs “Coach” Patients to Self-Management • To achieve better health outcomes, patients must adhere to treatment recommendations and lifestyle changes • To self manage, patients need to know their conditions and treatment options, commit to making healthy behaviour choices, have confidence that they can carry out desired actions, and can problem solve barriers • To sustain self-management (behaviour change), patients need support from health providers (and the system) • Health providers who use health coaching support patients with knowledge, motivation, and problem-solving skills Institute for Optimizing Health Outcomes

19. Myth: Evidence-Based Recommendations Lead to Better Health Outcomes? Institute for Optimizing Health Outcomes

20. Reality: Long Road from Evidence-Based Recommendations to Health Outcomes Institute for Optimizing Health Outcomes

21. 5 Steps of Patient Engagement Institute for Optimizing Health Outcomes

22. Why Should HCPs Support Patient Self-Management? • What are the most important issues affecting your practice (ability to deliver good care to patients)? • How important is it to change your “usual care”, given everything else that is going on right now? • What are the options for a SMS/health coaching approach in your healthcare practice or setting? Institute for Optimizing Health Outcomes

23. Pros and Cons of SMS/Health Coaching • What are the benefits of continuing to treat patients with chronic disease with the “usual care? • What do you think would be the challenges of adopting a SMS/health coaching approach? • If you were to introduce SMS/health coaching, what might be the long-term benefits, to the patients, to your practice, to your clinic? • If you don’t change your approach with CD patients, what might be the long-term impact on patients, your practice, your clinic? Institute for Optimizing Health Outcomes

24.  2010 Health Change Associates Usual Best Practice or SMS/Coaching Question: What are Pros & Cons of Current Practice vs. Health Coaching for CDM Patients? “Is anything you have mentioned importantenough to make you want to work on this?” Institute for Optimizing Health Outcomes Examples

25. Role of HCP Depends on Patient Readiness (to Self-Manage) Patient MIA (HiKnowLoMotiv) “Patient Missing In Action” Patient seeks reassurance; hesitates, seeks more options HCP challenges, supports Guidance: Support group, counsellor Rely on peers, HCPs, family Patient can but won’t Self-Manages (HiKnowHiMotiv) “Patient Self-Directed” Patient seeks information; makes plans, responsible for choice HCP listens, informs, supports Guidance: Patient peers, caregivers Rely on family and peer support Patient feels empowered Patient Knowledge (Risks, Benefits, Options, Resources) HCP Directs (LoKnowLoMotive) “Doctor Knows Best” HCP diagnoses, chooses, directs Patient does not question; complies with prescribed treatment Guidance: Healthcare professional Rely totally on professional judgment Patient trusts, follows orders HCP Educates (LoKnow;HiMotive) “HCP Educator” HCP educates on disease and options Patient learns what and how to do HCP clarifies & recommends Guidance: Healthcare professionals Rely on professional advice Patient learns tools and strategies Patient Motivation (Problem Solving, Self-Confidence) Institute for Optimizing Health Outcomes

26. Evidence that CDSM Works • Treatment vs Control: improvements at 6 months in weekly exercise, cognitive symptom management. communication with physicians, self-reported. health, health distress, fatigue, disability, and social/role activities limitations. • They had fewer hospitalizations and days, In hospital. No differences were found in pain/physical discomfort, shortness of breath, or psychological well being. Lorig, K., Sobel, D., Stewart, A., Brown, B., Bandura, A., Ritter, P., Gonzalez, V., Laurent, D. & Holman, H. (1999). Evidence suggesting that a Chronic Disease Self-Management Program can improve health status while reducing hospitalization. Medical Care, 37(1), 5 – 14. Institute for Optimizing Health Outcomes

27. Evidence of CDSM Long-Term • Compared with baseline for each of the 2 years, Emergency Room and outpatient visits and health distress were reduced (P<0.05). Self-efficacy improved (P<0.05). No other significant changes. Lorig, K.et al. (2001). Chronic Disease Self-Management Program: Two year health status and health care utilization outcomes. Medical Care, 39(11), 1217 – 1223. • Maintenance of change only about 6 months without regular reinforcement and collaboration with healthcare professional; counseling and SMBG device introduction improved HbA over 6-month follow-up Siebolds et al (2006). Self-monitoring of blood glucose-psychological aspects relevant to changes in HbA1C in type 2 diabetic patients treated with diet or diet plus oral antidiabeticmedicaiton. Patient EducCouns, 629(1), 104 – 110. Institute for Optimizing Health Outcomes

28. Evidence Health Coaching Works - 1 • Health coaching improves patient self-efficacy, adherence to treatment and behaviour changes as well as health service utilization and health outcomes. (Kreindler, 2008, Lindner et al, 2003) • Coaches working with families of children with asthma on lifestyle and behaviour changes were able to decrease hospitalization, emergency room, and primary care visits (by 45% to 17%) as well as use of medications by 20% (Axelrod et al, 2001). • A randomized control trial using health coaching for six months with cardiovascular patients showed improvement in health behaviours and, importantly, a significant decrease in cholesterol levels (Vale et al, 2002). Institute for Optimizing Health Outcomes

29. Evidence Health Coaching Works - 2 • RCT comparing health coaching with usual care for patients with diabetes found significant improvements in HbA1C levels, self-reported treatment adherence, exercise, stress and health status (Wolever et al, 2010). • UK Diabetes Year of Care transforms diabetes annual review into constructive dialogue between HCP and patent. Outcomes: • Improved experience of care and real changes in self care behaviour. • Professionals report improved knowledge and skills, and greater job satisfaction. • Practices report better organisation and team work. • Productivity is improved: care planning is cost neutral or yields savings (www.diabetes.nhs.uk/year_of_care) Institute for Optimizing Health Outcomes

30. Summary • There are legitimate reasons why people don’t adhere to treatment and lifestyle recommendations • Patientengagement can increase adherence rates and improve patient self-management • A health coaching approach can guide practitioners in engaging patients in self-care in a time efficient manner, to address barriers to change and achieve better patient health outcomes Institute for Optimizing Health Outcomes

31. Thank You For more information contact The Institute for Optimizing Health Outcomes www.optimizinghealth.org