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Clinical Tools and Strategies for Supporting Self-Management. IBHP Webinar March 18, 2009. Michael G. Goldstein, MD Chief, Mental Health and Behavioral Sciences Service Providence VA Medical Center Professor, Psychiatry and Human Behavior, Alpert Medical School of Brown University.

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Clinical tools and strategies for supporting self management

Clinical Tools and Strategies for Supporting Self-Management

IBHP Webinar

March 18, 2009

Michael G. Goldstein, MD

Chief, Mental Health and Behavioral Sciences Service

Providence VA Medical Center

Professor, Psychiatry and Human Behavior,

Alpert Medical School of Brown University


Objectives
Objectives

By the end of the session, participants will be able to:

  • Describe the key concepts and principles of self-management and self-management support

  • Identify specific strategies, tools and resources for engaging and activating patients and families in chronic illness care

  • Describe strategies for redesigning care to enhance the efficient delivery of self-management support


Outline
Outline

  • Self-Management

  • Self-Management Support (SMS)

  • Key Components of SMS

    • Core Clinical Competencies/Tools & Resources

    • Health Care System Redesign

    • Community Linkages

  • Questions and Discussion


Self management tasks
Self-Management Tasks

  • To take care of the illness (medical management)

  • To carry out normal activities (role management)

  • To manage emotional changes (emotional management)

(Corbin & Strauss, 1998Bodenheimer et al, 2002; Lorig et al, 2003)


Self-Management Tasks for Diabetes

  • Blood glucose monitoring

  • Managing high/low blood sugars

  • Diet

  • Physical activity/exercise

  • Medication taking

  • Medical monitoring/visits

  • Coping with emotions

  • Foot care

  • Eye care

  • Dental care


What is self management support
What is Self-Management Support?

Institute of Medicine Definition:

  • “The systematic provision of education and supportive interventions

  • to increase patients’ skills and confidence in managing their health problems,

  • including regular assessment of progress and problems, goal setting, and problem-solving support.”

(IOM, 2003)


What works research evidence
What Works – Research Evidence?

  • Addressing knowledge is necessary but not sufficient to produce changes in chronic illness care outcomes

  • Key strategies for improving outcomes of educational and behavior change interventions:

    • assessment of patient-specific needs and barriers

    • goal setting

    • enhancing skills, problem-solving

    • follow-up and support

    • increasing access to resources

(Bodenheimer et al, 2002 ; Glasgow et al, 2003; Fisher et al, 2005)


What are the desired outcomes of self management support
What are the Desired Outcomes of Self-Management Support?

People with chronic conditions (and their families) are more:

  • Aware and Informed

  • Engaged

  • Activated

  • Empowered

  • Confident they can self-manage

  • Partners with health care providers


What is self management support1
What is Self-Management Support?

A collaborativeprocessto help people to:

  • Understand

  • Choose among treatments

  • Identify and set goals

  • Adopt and change behaviors

  • Cope and overcome barriers

  • Follow-through


Self management support is not
Self-Management Support is NOT

  • Didactic Patient Education

  • Lecturing

  • Inducing fear

  • Finger-wagging

  • “You should”

  • Shaming

  • Waiting for a patient to ask


Assumes knowledge drives change

Clinician sets agenda

Goal is compliance

Decisions made by caregiver

Assumes knowledge + confidence drives change

Patient sets agenda

Goal is enhanced confidence

Decisions made collaboratively

Self-Management Support

A Fundamental Shift in the Process of Care

Traditional Care

Collaborative Care

(Bodenheimer et al, CA Health Care Foundation, 2005)


Sms key components
SMS: Key Components

  • Core Clinical Competencies and Tools and Resources for Teams, Patients & Families

  • System redesign to efficiently deliver SMS within the context and flow of clinical care

  • Meaningful links to community resources and community-based programs and campaigns

(New Health Partnerships: www.newhealthpartnerships.org)


Sms key components1
SMS: Key Components

  • Core Clinical Competencies and Tools and Resources for Teams, Patients & Families

  • System redesign to efficiently deliver SMS within the context and flow of clinical care

  • Meaningful links to community resources and community-based programs and campaigns

(New Health Partnerships: www.newhealthpartnerships.org)


Sms core clinical competencies

(New Health Partnerships, 2007)

SMS: Core Clinical Competencies

  • Relationship Building

  • Exploring patients’ needs, expectations and values

  • Information Sharing

  • Collaborative Goal Setting

  • Action Planning

  • Skill Building & Problem Solving

  • Follow-up on progress


Sms core clinical competencies1

(New Health Partnerships, 2007)

SMS: Core Clinical Competencies

  • Relationship Building

  • Exploring patients’ needs, expectations and values

  • Information Sharing

  • Collaborative Goal Setting

  • Action Planning

  • Skill Building & Problem Solving

  • Follow-up on progress


Motivational interviewing
Motivational Interviewing

“Definition”

“a skillful clinical style for eliciting from patients their own motivation for making changes in the interest of their health.”

(Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)


  • Evocative

    • Understand patient goals; evoke arguments for change

  • Honoring patient autonomy

    • Patients ultimately decide what to do

  • The “Spirit of MI”

    (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)


    Motivational interviewing1
    Motivational Interviewing

    “Principles”

    • Resist the Righting Reflex (Directing)

    • Understand Patient Motivations

    • Listen to Your Patient with Empathy

    • Empower Your Patient

    (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)


    Mi style
    MI Style

    A refined form of guiding, rather than directing or following……

    helping the patient make his or her own decision about behavior change

    (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)


    Motivational interviewing2
    Motivational Interviewing

    • Asking

    • Listening

    • Informing

    Guiding - balancing skills, flexibly applied

    (Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)


    Explore agenda needs expectations
    Explore: Agenda, Needs, Expectations

    • “What are you hoping to accomplish today?”

    • “What do you think is most important for us to talk about?”

    • What concerns do you have about your health?

    • What reasons do you have to change?

    • Where would you like to start?


    Blood glucose

    monitoring

    Taking medications

    to help control

    blood sugar

    Skin care

    Taking insulin

    Diet

    Depression

    Losing weight

    Daily foot care

    Smoking

    (RI Dept of Health Chronic Care Collaborative)


    Explore Conviction/Importance about with your

    “How convinced are you that it is important to monitor your blood sugars?”

    Totally

    convinced

    Not at all convinced

    0 1 2 3 4 5 6 7 8 9 10

    “What makes you say 4?”

    “What leads you to say 4 and not zero?”

    “What would it take (or have to happen) to move it to a 6?”

    (From Keller and White, 1997; Rollnick, Mason and Butler, 1999)


    Share information
    Share Information about with your

    Ask Permission

    Ask Understanding

    Tell(Personalize)

    Ask Understanding

    Benefits of Physical Activity


    Collaboratively set goals
    Collaboratively Set Goals about with your

    • Share clinician priorities

    • Offer options

    • Agree on something to work on

    • Negotiate a specific action plan


    Sms core clinical competencies2

    (New Health Partnerships, 2007) about with your

    SMS: Core Clinical Competencies

    • Relationship Building

    • Exploring patients’ needs, expectations and values

    • Information Sharing

    • Collaborative Goal Setting

    • Action Planning

    • Skill Building & Problem Solving

    • Follow-up on progress


    Action planning starts with smart goals
    Action Planning – about with your Starts with SMART Goals

    • Specific and behavioral

    • Measurable

    • Attractive

    • Realistic

    • Timely


    Action plan
    Action Plan about with your

    1. Goals: Something you WANT to do

    2. Describe

    How Where

    What Frequency

    When

    3. Barriers -

    4. Plans to overcome barriers -

    5. Conviction and Confidence ratings (0-10) -

    6. Follow-Up:


    Action plan1
    Action Plan about with your

    1. Goals: Something you WANT to do Begin Exercise

    2. Describe

    How Walking Where Neighborhood

    What 20 min Frequency 3x/week

    When After dinner

    3. Barriers - Dishes, safety (no sidewalks)

    4. Plans to overcome barriers - get kids to clean up, ask neighbor or husband to join me, wear reflective vest

    5. Conviction and Confidence ratings (0-10) - 9/8

    6. Follow-Up: Will keep log and bring to next visit in 1 month


    Action planning
    Action Planning about with your

    • Review past experience - especially successes

    • Define small steps that are likely to lead to success


    Action Planning: about with your

    Assess and Enhance Confidence

    “How confident are you that you can meet your goal of exercising 5 days a week?

    Totally

    confident

    Not at all confident

    0 1 2 3 4 5 6 7 8 9 10

    “What makes you say 6?

    “What might help you to get to a 7 or 8?”

    “What could I do to help you to feel more confident?”

    (From Keller and White, 1997; Rollnick, Mason and Butler, 1999)


    Enhancing confidence
    Enhancing Confidence about with your

    • Provide tools, strategies, resources, skills

    • Address barriers

    • Attend to progress and to perceive slips as occasions for problem solving rather than as failure


    Enhancing confidence1
    Enhancing Confidence: about with your

    Identifying Barriers & Problem-Solving

    • What will get in the way?

    • Anything else?

    • What might help you to overcome that barrier?

    • Anything help in the past?

    • Here is what others have done...

    • Ok, now what is your plan?

    • Reassess confidence


    Self-Management about with your Support Cycle

    EXPLORE:

    Needs, Expectations, Values,

    Behavior, Progress

    SHARE:

    Provide specific

    Information about

    health risks,

    benefits of change, and strategies to self-manage

    ARRANGE:

    Specify plan for

    follow-up (e.g., visits,

    phone calls, mailed

    reminders

    Personal Action Plan

    1. List specific goals

    in 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

    SET GOALS:

    Collaboratively set

    goals based on patient’s

    conviction and confidence

    in their ability to change

    BUILD SKILLS :

    Identify personal

    barriers, strategies, problem-solving

    techniques and

    social/environmental

    support

    Adapted from: Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87


    Sms key components2
    SMS: Key Components about with your

    • Core Clinical Competencies and Tools and Resources for Teams, Patients & Families

    • System redesign to efficiently deliver SMS within the context and flow of clinical care

    • Meaningful links to community resources and community-based programs and campaigns

    (New Health Partnerships: www.newhealthpartnerships.org)


    Community about with your

    Resources and Policies

    Health System

    Organization of Health Care

    Self-

    Management

    Support

    Decision

    Support

    Delivery

    System

    Design

    Clinical

    Information

    Systems

    A Model for Planned Care*

    Informed,

    Activated

    Patient

    Prepared,

    Proactive

    Practice Team

    Productive

    Interactions

    Functional and Clinical Outcomes

    *E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound


    Delivery system redesign
    Delivery System Redesign about with your

    • Determine process and define roles for delivering SMS among members of the care team

    • Planned Care visits

    • Medical Group visits

    • Chronic Disease Self-Management groups

    • Planned peer interactions

    • Provide support and coordination according to level of need


    Opportunities for sms when where and by whom
    Opportunities for SMS: about with your When, Where and By Whom

    • Before the Encounter

    • During the Encounter

    • After the Encounter


    Chronic disease self management program
    Chronic Disease Self-Management Program about with your

    • Developed and studied by Kate Lorigand colleagues at Stanford

    • Lay-leaders, 6 sessions, 2 1/2 hours each

    • Single or multiple conditions

    • Focus on collaborative goal-setting, personalized problem solving, skill acquisition

    • Outcomes: improved health behaviors and health status, fewer hospitalizations

    • Limitations: limited population

    (Lorig et al, Med Care 1999, 37:5-14; Lorig, et al., Med Care, 2001, 39: 1217-1223)


    Clinical information systems
    Clinical Information Systems about with your

    • Provide access to educational materials and tools

    • Create capacity to identify and contact relevant subpopulations for proactive care

    • Monitor and share SMS performance data.


    Community linkages
    Community Linkages about with your

    • Identity community programs and resources

    • Partner with community organizations

    • Partner with employers

    • Raise community awareness: community campaigns


    Implementing health system changes to support self management
    Implementing Health System Changes to Support Self-Management

    • Quality Improvement Collaboratives: with focus on SMS (e.g., New Health Partnerships) and Patient Activation (MN)

    • Educational Outreach – QIOs, DOQ-IT, Voluntary Agencies

    • Provider education and training - Core Competencies, Motivational Interviewing

    • Incentives, rewards for provider delivery of SMS, system change


    Sms key components3
    SMS: Key Components Self-Management

    • Core Clinical Competencies and Tools and Resources for Teams, Patients & Families

    • System redesign to efficiently deliver SMS within the context and flow of clinical care

    • Meaningful links to community resources and community-based programs and campaigns

    (New Health Partnerships: www.newhealthpartnerships.org)


    Sms core clinical competencies3

    (New Health Partnerships, 2007) Self-Management

    SMS: Core Clinical Competencies

    • Relationship Building

    • Exploring patients’ needs, expectations and values

    • Information Sharing

    • Collaborative Goal Setting

    • Action Planning

    • Skill Building & Problem Solving

    • Follow-up on progress


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