Advanced Self-Management Support

1. Advanced Self-Management Support Developing Personal Action Plans with Patients RWJ Depression in Primary Care Annual Conference

2. What Is Self-Management? • “The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.” Barlow et al, Patient education Counseling 2002; 48:177 Reference the work of Kate Lorig, Stanford. Evidence SMS improves health while reducing utilization, costs: Randomized trial. Medical Care. 37 (1):5-14, 1999

3. Self-Management Support: Patient Activation • Empower and Prepare the patient to manage their health and mental health care. • Emphasize the patient’s central role. • Very different from “health education.” Technical skills vs. problem-solving/activation. • The 5 (or 6) A’s: Assess, Advise, Agree, Assist, Arrange (Address emotions) • Organize your practice to provide ongoing SMS to all patients.

4. Information and skills are taught Usually disease-specific Assumes that knowledge creates behavior change Goal is compliance Health care professionals are the teachers Skills to solve pt. Identified problems are taught Skills are generalizable Assumes that confidence yields better outcomes Goal is increased self-efficacy Teachers can be professionals or peers Patient Education vs. Self-Management Support Bodenheimer et al JAMA 2002;288:2469

5. 5 As and Self-Management ASSESS : Beliefs, Behavior & Knowledge ARRANGE : Specify plan for follow-up: visits, phone calls, mailed reminders ADVISE : Provide specific Information about health risks and benefits of change Personal Action Plan 1. List specific goals behavioral terms 2. List barriers and strategies to address barriers 3. Specify Follow-up Plan 4. Share plan with practice team and patient’s social support ASSIST : Identify personal barriers, strategies, problem-solving techniques and Social / environmental support AGREE: Collaboratively set goals based on patient’s conviction and confidence in their ability to change or adhere Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87

6. Challenge: Integrating Self-Management into the routine of a busy primary care practice.The Opportunities: • Before the patient visit • During the patient visit • After the patient visit The entire care team should be aware of the patient’s self-management goal (s)

7. Before the Encounter • trigger interest: Assess • Why?depression is de-energizing • Pre-visit contact (phone, mail, email) • Waiting room assessments (PHQ) • Patient education material, i.e. “physical activity helps depression” in exam room • Posters : “Ask Me 3” • Pamphlets: Talking to your provider, How’s my Health.com • Community outreach: dep screening day; depression info to local media

8. During the Encounter • Advise, Agree, Assist, Arrange • Review assessments (PHQ, Depression Action Plan) • Advise behavior change in personal, meaningful way • Feedback on achievements vs. goals • Identify priorities for visit • Develop/Revise Patient Action Plan • Targeted patient educ. materials • Referral for Group

9. After the Encounter • Referrals: (Depression peer support, Arthritis or Diabetes groups) • Additional 5A’s counseling w/CM or BH specialist • Phone calls for follow-up/reinforcement • Mailed patient education • Newsletters • Follow-up visits, email • Link the information back to the care team (chart)

10. Quality of Self Management Goal Setting • SM goal setting should be patient-centered (not paper-centered) Tools help to highlight EB guidelines for behavioral change to facilitate optimal outcomes, but should not be prescriptive. • However, because depression is de-energizing, a SM tool can help trigger behavioral action.

11. Goal setting should be concrete and behaviorally specific AND Manageable • Goals that are too general, such as, “I will take my medication,” are not very helpful for motivating self-action. • Example of a behaviorally specific goal, “ I will take my medication every evening before I go to bed and my confidence level is 8 on a 1-10 scale that I will meet this goal.” • Goals that are too big: “I want to lose 20 pounds” must be broken down into an action plan.

12. Quality of Goal Setting • Specify the Activity (e.g. physical activity) • Specify the duration (how long each period of physical activity) • Specify the frequency (how often will the physical activity occur) • Specify the location (where the activity will occur) • Specify the confidence level (patient’s confidence on a 1-10 scale in being able to accomplish the goal)Excellent opportunity for problem-solving

13. From general to specific(From meaningless to meaningful) • I am going to walk more this week. • I plan to take 20-minute walks this week. • I plan 20-minute walks Monday, Wednesday and Friday this week. • I plan 20-minute walks to the store and back on Monday, Wednesday and Friday this week. • My confidence level is 9 that I will walk for 20 minutes to the mall and back on Monday, Wednesday and Friday this week.

14. Personal Action Plan 1. Something you WANT to do 2. Describe How Where What Frequency When 3. Barriers 4. Plans to overcome barriers 5. Confidence rating (1-10) 6. Follow-Up plan Source: Lorig et al, 2001

15. Personal Action Plan 1. Something you WANT to do: “Get more physical activity.” 2. Describe: How: “Walk with a friend.” Where: “From house to corner.” What: “Walk comfortable pace.” Frequency: “Once a day on Monday, Weds. and Friday.” When: “After morning TV show.” 3. Barriers? “I might forget.” 4. Plans to overcome barriers? “Put a note by remote, and ask friend to call me.” 5. Confidence level? (1-10) “7” 6. Follow-Up plan: “CM will call me next Weds @ 3 PM.

16. PATIENT-ACTION PLAN[ ultra-brief ] 1.“What would you like to do for your depression from now to our next appt?” or “What is your most important problem?” • concrete • patient-centered • very specific 2. “How confident are you on a 1 to 10 scale that you will be able to carry out this goal?” • must be >7 or • review barriers (develop solutions) or • revise goal 3. “Let’s arrange a way to check on how you are doing?” • Phone call, email • Involve CM or family • visit to the clinic

17. CareSouth Carolina Outcome Measures for depression improvement and self-management goal setting • 67 % of Patients (in POF) and 41 % (of combined spread sites) with Major Depression (first PHQ over 10) achieve a 50% reduction in PHQ score within 4 months of treatment. National HDC Goal > 40 %. and • 90.7 % of patients with depression have documented Self Management goals. National HDC goal > 70%.

18. Practice Setting Goals andMeasuring Confidence: 1.Think of a problem or a goal you would like to achieve (something you want to do.) 2.Pair with someone next to you. 3.Determine a goal which would lead to problem-resolution or goal attainment. “Have you thought of anything that might help….” 4.Use the quality criteria to develop a meaningful action plan. 5. Take turns with goal setting.

19. ARRANGE FOLLOW-UP! By email, phone, mail, or visit. Schedule follow-up contacts to provide ongoing assistance and support to adjust the plan as needed, including referrals to more intensive treatment or other community resources. Always review the plan at next visit. Think how bad it would feel to set a goal and never have anyone review your progress!

20. Crossing The Quality ChasmRules for Patient-Centered Care • Customization based on patient needs and values. • The patient as the source of control. • Shared knowledge and the free-flow of information. • The need for transparency. • Anticipation of Needs. The health system should anticipate patient needs, rather than react to events.