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Living Well with Chronic Conditions. Also known nationally as the Chronic Disease Self-Management Program - Developed by Stanford University - . Introductory Note. The Utah Approach to CDSMP and Diabetes Care : In no way is CDSMP to take the place of Diabetes Self-Management Education (DSME)

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Presentation Transcript
slide2

Introductory Note

  • The Utah Approach to CDSMP and Diabetes Care: In no way is CDSMP to take the place of Diabetes Self-Management Education (DSME)
  • DSME comes first and foremost for a patient with diabetes
  • We would like to view CDSMP as complementary/supportive to the DSME process
slide3

Utah Arthritis Program

Leads the administration of the Chronic Disease Self-Management Program in Utah

Funding sources are the Centers for Disease Control and Prevention (CDC) and the Administration on Aging (AoA)

Work in partnership with the CDC and AoA to address the burden of arthritis, and other chronic diseases, in Utah

Primary objective is to develop partnerships around the state to increase access to and use of evidence-based programs

slide6

Our Broad Goal

I love CDSMP and ADEU!

To improve the quality of life for people affected by arthritis and other chronic conditions.

slide7

The Chronic Disease Problem

Research has shown that an increasing number of U.S. families are experiencing high financial burdens from medical care expenses, as rapidly rising health care costs are passed on to families in the form of higher premiums, deductibles, co-payments, and even reduced benefits. For people with chronic health conditions, such burdens can be a long-term problem that threatens their families' financial well-being.

Commonwealth Fund (July 23, 2009)

slide8

The Chronic Disease Problem

Sources: BRFSS, 2007; Centers of Disease Control and Prevention (CDC)

Approximately 30% of Utahns have at least one chronic condition (similar number for U.S.)

Chronic diseases are the most prevalent and costly healthcare problems in the U.S.

More than two-thirds of all deaths are caused by one or more of five chronic conditions: heart disease, cancer, stroke, COPD, and diabetes

slide9

The Chronic Disease Problem

  • Source: Centers of Disease Control and Prevention (CDC)
  • Chronic disease not only affects health and quality of life, but is also a major driver of healthcare costs…
  • Chronic disease accounts for about 75% of the Nation’s aggregate healthcare spending, or about $5,300 per person in the U.S. each year
  • In taxpayer-funded programs, treatment of chronic disease constitutes an even larger proportion of spending:
      • 96 cents per dollar for Medicare
      • 83 cents per dollar for Medicaid
slide10

Chronic Disease Rates

U.S.

High Cholesterol 37.6%

Hypertension 26.7%

Arthritis: 26.1%

Asthma: 8.5%

Diabetes: 8.5%

Utah

High Cholesterol 25.9%

Hypertension 25.4%

Arthritis: 24.0%

Asthma: 7.9%

Diabetes: 6.9%

Age-adjusted Rates:

Utah Data: Utah BRFSS 2009

U.S. Data: National Center for Chronic Disease Prevention and Health Promotion, BRFSS Survey

slide12

Stanford’s CDSMP

In the past 20 years or so, the Stanford University, Patient Education Research Center has developed, tested, and evaluated self-management programs for people with chronic health problems

All programs are designed to help people gain self-confidence in their ability to control their symptoms and how their health problems affect their lives

Workshops are highly interactive, focusing on building skills, sharing experiences and support

slide13

Stanford’s CDSMP

Once a program is developed, it is evaluated for effectiveness through a randomized, controlled trial, which is 2-4 years in length

It is ONLY after a program has been shown to be safe and effective through these trials that it is released for dissemination

This was the procedure for the Chronic Disease Self-Management Program (CDSMP)

slide14

Chronic Conditions Represented in CDSMP Workshops

  • 17.2% Heart Disease
  • 14.3% Asthma
  • 13.2% Lung Disease
  • 12.8% Fibromyalgia
  • 8.0% Cancer
  • 7.6% Kidney Disease

Source: Utah Arthritis Program, 2010

52.7% Arthritis

41.0% High Blood Pressure

36.6% Chronic Joint Pain

34.8% Diabetes

33.2% High Cholesterol

27.4% Chronic Pain

23.5% Depression

slide15

Chronic Conditions Represented in CDSMP Workshops

Source: Utah Arthritis Program, 2011

slide17

Living Well with Chronic ConditionsStanford Model of CDSMP

Program Description

  • Designed for people who live with any chronic condition
  • Based on the symptoms of chronic conditions
  • Participants learn tools that enable them to self-manage their symptoms
  • Community or healthcare-based settings
slide18

Living Well with Chronic ConditionsStanford Model of CDSMP

Patient Engagement Activities

  • Participants learn how to identify problems
  • Participants learn how to act on problems
  • Participants learn how to generate short-term action plans
  • Participants learn problem-solving skills related to chronic conditions in general
slide19

Living Well with Chronic ConditionsStanford Model of CDSMP

Program Subject Matter:

  • Dealing with frustration, fatigue, pain and isolation
  • Exercise for maintaining and improving strength, flexibility and endurance
  • Appropriate use of medication and proper nutrition
  • Communicating effectively with family, friends and health professionals
  • Evaluating new treatments
slide20

Living Well with Chronic ConditionsStanford Model of CDSMP

Program Structure

  • Series of 6 sessions, 1 session per week, 2 hours per session
  • Held in community settings (including healthcare)
  • Highly scripted curriculum
slide21

Living Well with Chronic ConditionsStanford Model of CDSMP

Program Structure

  • Designed to be lay-led; 2 leaders facilitate each class; at least 1 facilitator also has a chronic condition
  • Workshops offered at no charge (free!)
  • Available in Utah in English, Spanish, Tongan
slide22

Living Well with Chronic ConditionsStanford Model of CDSMP

    • Healthy eating
    • Communication skills
    • Problem solving
  • Week 5
    • Medication usage
    • Making informed treatment decisions
    • Depression management
    • Positive thinking
    • Guided imagery
  • Week 6
    • Working with your healthcare professional
    • Planning for the future
  • Week 1
    • Difference between acute and chronic conditions
    • Short term distractions
    • Introduce action plans
  • Week 2
    • Dealing with difficult emotions
    • Physical activity and exercise
  • Week 3
    • Better breathing techniques
    • Muscle relaxation
    • Pain and fatigue management
  • Week 4
    • Future plans for healthcare
slide23

Living Well with Chronic ConditionsStanford Model of CDSMP

Improved Outcomes

6 mo. 2 yrs.

Self efficacy √ √

Self rated health √ √

Disability √

Role activity √

Energy/fatigue √ √

Health distress √ √

MD/ER visits √ √

Hospitalization √

Lorig, et al 1999, 2001

slide24

Living Well with Chronic ConditionsStanford Model of CDSMP

Improved Outcomes

1 2 3 4 5

Self-efficacy X X X X

Self-rated health X X

Fatigue X X X

Anxiety/Distress X X X

Role limitation X X

HRQOL X

Pain X

Exercise X X X

Cog. Symp mgmt X X X

1=Lorig 05, 2=Barlow 05, 3=Goeppinger 07, 4=Kennedy 07, 5=Gitlin 08

slide25

Living Well with Chronic ConditionsStanford Model of CDSMP

  • Action Specific
    • What
    • How much
    • When
    • How often

Action Plans

  • Something they want to do
  • Achievable
  • Confidence Level
  • Problem Solving
slide26

Living Well with Chronic ConditionsStanford Model of CDSMP

Workshop Resources

  • Resource book: Living a Healthy Life with Chronic Conditions
  • CD: Time for Healing
  • Weekly action plans and feedback
  • Groups are small: 10-15 people
    • Share information, interactive learning activities, problem-solving, decision-making, social support for change
slide27

Living Well with Chronic ConditionsStanford Model of CDSMP

Infrastructure

  • Master Trainers – 11 in state of Utah as of October 2011 (8 English, 2 Spanish)
    • Attend 4 ½ day training at Stanford University
    • Teach classes and train leaders
  • Peer Leaders / Instructors
    • Complete 4-day training taught by 2 Master Trainers in order to teach classes
  • Stanford License
    • Each organization teaching this program must purchase a license from Stanford
  • Training Material
    • Resource books and CDs for participants and leaders
slide28

Living Well with Chronic ConditionsStanford Model of CDSMP

Source: Class participants of Wasatch and Summit County courses

What participants are saying. . . .

  • “I know I can self-manage a few problems and make life better for me and my husband.”
  • “It gave me some important coping mechanisms.”
  • “This class has helped me get my life in order.”
  • “I recommend this course and handbook to all seniors.”
  • “We have set goals, accomplished them and will continue to manage our lives better due to this class.”
slide29

Tomando Control de Su SaludStanford Model of Spanish CDSMP

Spanish Program Development

  • Not a translation but an independent development in Spanish
  • Developed to be culturally appropriate
  • Focus groups conducted in Spanish
  • Health care professionals working with persons with chronic conditions
slide30

Tomando Control de Su SaludStanford Model of Spanish CDSMP

Spanish Program Development

  • Participants incorporate healthy habits into their lives:
    • Healthy eating habits
    • Exercise (physical activity)
    • Cognitive management of symptoms
    • Better communication with health care providers
    • Overall perception of better health
slide31

Tomando Control de Su SaludStanford Model of Spanish CDSMP

Week One

  • Overview/
  • Responsibilities
  • Acute/chronic
  • Proactive in management,
  • Importance of food & exercise
  • Healthy food
  • Spanish
  • Overview/

responsibilities

  • Acute/chronic
  • Using mind/symptoms
  • Action plans

English

slide32

Tomando Control de Su SaludStanford Model of Spanish CDSMP

Week Two

  • Share diaries/problem solve
  • Formula for a healthy menu
  • Action plans
  • Intro to physical activity/exercise
  • Exercise practice
  • Spanish
  • Action plan rpt/problem solve
  • Difficult emotions
  • Intro to physical activity/exercise
  • Action plan

English

slide33

Tomando Control de Su SaludStanford Model of Spanish CDSMP

Week Three

  • Action plan rpt/problem solve
  • Prepare a low fat menu
  • Managing symptoms
  • Muscle relaxation
  • Better breathing
  • Action plan
  • Spanish
  • Action plan report/problem solve
  • Better breathing
  • Muscle relaxation
  • Pain/fatigue management
  • Endurance activities
  • Action plan

English

slide34

Tomando Control de Su SaludStanford Model of Spanish CDSMP

Week Four

  • Action plan rpt/problem solve
  • Reading nutrition labels
  • Finding health care
  • Managing depression
  • Positive thinking
  • Action plan
  • Spanish
  • Action plan report/problem solve
  • Future plans for health care
  • Healthy eating
  • Communication skills
  • Problem solving
  • Action plan

English

slide35

Tomando Control de Su SaludStanford Model of Spanish CDSMP

Week Five

  • Action plan
  • report/problem solve
  • Communication skills
  • Future plans for healthcare
  • Increasing physical activity
  • intensity
  • Medication usage
  • Working with healthcare
  • professional 
  • Action plan
  • Spanish
  • Action plan

report/problem solve

  • Medication usage
  • Informed treatment

decisions

  • Depression management
  • Positive thinking Guided

imagery

  • Action plan

English

slide36

Tomando Control de Su SaludStanford Model of Spanish CDSMP

Week Six

  • Action plan rpt/problem solve
  • Evaluating home remedies
  • Guided imagery
  • Sharing successes/plan future
  • Celebration
  • Spanish
  • Action plan rpt/problem solve
  • Working with health care Professional/health care system
  • Looking back and plan future

English

slide37

Ideas for Linking CDSMP with Diabetes Education

The Utah Approach to CDSMP and Diabetes Care: In no way is CDSMP to take the place of Diabetes Self-Management Education (DSME)

DSME comes first and foremost for a patient with diabetes

That said, we would like to encourage referrals from Diabetes Programs into local CDSMP classes for some of the following reasons….

slide38

Ideas for Linking CDSMP with Diabetes Education

Self-management support option for post-DSME (National DSME Standard #7)

Great option for follow up work with patients with diabetes (National DSME Standard #8)

Supports and complements self-management efforts of diabetes educators/healthcare providers

Continuous quality improvement opportunity??

slide39

Ideas for Linking CDSMP with Diabetes Education

  • Powerful evidence-based program for patients with co-morbid conditions
    • CDSMP is successful at addressing mental health issues as well
  • Excellent self-management option for uninsured patients; if you have to turn away uninsured patients, please send them to a free CDSMP workshop
  • Addresses income issues by offering classes at no charge
slide40

Ideas for Linking CDSMP with Diabetes Education

Opportunity to connect to community resources (perhaps as part of a planned care model)

Reinforces lifestyle behaviors so that patients continue implementing healthy choices such as regular physical activity and nutrition

Other ideas?

slide41

Living Well with Chronic ConditionsStanford Model of CDSMP

General Patient and Provider Benefits

  • An evidence-based program such as Living Well/CDSMP can capture many chronic diseases through this one channel
  • Self-management support option
  • Can improve self-rated health and energy levels
  • Reduced healthcare utilization (ED visits)
  • As the New Jersey program puts it: Feel Better!
slide42

Living Well with Chronic ConditionsStanford Model of CDSMP

Program Partnerships

  • University of Utah Community Clinics
  • Arthritis Foundation, Utah/Idaho Chapter
  • Area Agencies on Aging/Senior Centers:
    • Weber-Morgan
    • Davis County
    • Salt Lake County
    • Mountainlands (Summit/Wasatch/Utah Counties)
    • Five County (Southwest Utah)
    • Tooele County
    • San Juan County
slide43

Living Well with Chronic ConditionsStanford Model of CDSMP

  • Southwest
  • Tri County
  • Utah County
  • Weber-Morgan

Program Partnerships

  • Community-based Organizations:
    • National Tongan American Society
    • Alliance Community Services (Spanish)
  • Local Health Departments:
    • Bear River
    • Central Utah
    • Davis County
    • Salt Lake Valley
slide44

Living Well with Chronic ConditionsStanford Model of CDSMP

Program Partnerships

  • Dixie Regional Medical Center in St. George
  • Valley View Medical Center in Cedar City
  • Salt Lake VA Medical Center
  • Valley Mental Health
    • SL County, Park City, Tooele
  • Utah Partnership for Healthy Weight
    • Healthy weight project in Magna
slide45

Living Well with Chronic ConditionsStanford Model of CDSMP

Resources

  • Stanford University’s site on CDSMP http://patienteducation.stanford.edu
  • Utah Arthritis Program (class schedules) http://health.utah.gov/arthritis
  • Administration on Aging: www.aoa.gov
  • National Council on Aging: http://healthyagingprograms.org
slide46

Living Well with Chronic ConditionsStanford Model of CDSMP

Contact Information

  • Utah Arthritis Program: www.health.utah.gov/arthritis (for class schedules)
  • Rebecca Castleton: rcastlet@utah.gov;

801-538-9340

  • Christine Weiss: cweiss@utah.gov;

801-538-9458

help your clients quit tobacco

Help Your Clients Quit Tobacco

Marci Nelson, B.S., CHES

Tobacco Prevention and Control Program

Utah Department of Health

marcinelson@utah.gov

http://www.tobaccofreeutah.org/healthcare.html

(801) 538-7002

objectives
Objectives
  • Discuss the risks of tobacco use especially the effects of smoking on diabetes
  • Present a brief intervention to quit
  • Discuss procedures for implementation
  • Supply information on free tobacco cessation services
tobacco use in utah the problem
Tobacco Use in Utah:The Problem

More than 200,000 Utahns use tobacco

More than 1,330 die annually from their smoking

Nearly 17,150 children exposed to secondhand smoke in their homes

$663 million each year in smoking-attributable medical and lost productivity costs

Source: Tobacco Prevention and Control in Utah Tenth Annual Report - August 2010

tobacco health effects
Long-term

Heart disease

Stroke

Lung function

Cancers

Ulcer

Infertility

Short-term

Respiratory illness

Decreased lung capacity

High blood pressure & cholesterol

Nervousness

Mouth problems

Reduced taste & smell

Tobacco Health Effects

Responsible for more than 400,000 premature deaths each year in the U.S.

health effects of secondhand smoke
Stillbirth; miscarriage

Premature Birth

Cleft palates and lips

Sudden Infant Death

Infertility

Tooth Decay

Cancer

Bronchitis; pneumonia

Asthma

Upper Respiratory Tract Disease

Ear Infections

Coughs

Health Effects of Secondhand Smoke

Secondhand smoke affects loved ones & is a powerful motivator to quit!

effect of smoking on diabetes
Effect of Smoking on Diabetes
  • Tobacco raises blood sugar levels
  • Tobacco use increases the risk of heart attack or stroke
  • Increased chance of getting gum disease and may suffer tooth loss
  • Tobacco use can make foot ulcers, foot infections, and blood vessel disease in the legs worse
why should clinicians address tobacco
WHY SHOULD CLINICIANS ADDRESS TOBACCO?
  • Tobacco users expect to be encouraged to quit by health professionals.
      • 72% of Utahns saw a healthcare provider in the last year
  • Screening for tobacco use and providing tobacco cessation counseling are positively associated with patient satisfaction (Barzilai et al., 2001).
  • Advice from a healthcare provider can double the chances of successful quitting.
clinical practice guideline for treating tobacco use and dependence
Clinical Practice Guideline for Treating Tobacco Use and Dependence
  • Update released May 2008
  • Sponsored by the Agency for Healthcare Research and Quality of the U.S. Public Heath Service with
    • Centers for Disease Control and Prevention
    • National Cancer Institute
    • National Institute for Drug Addiction
    • National Heart, Lung, & Blood Institute
    • Robert Wood Johnson Foundation
brief counseling ask advise refer
Brief Counseling: ASK, ADVISE, REFER

ASK

about tobacco USE

ADVISE

tobacco users to QUIT

REFER

to other resources

ASSIST

Patient receives assistance, with follow-up counseling arranged, from other resources such as the Utah Tobacco Quit Line

ARRANGE

step 1 ask 1 min
Step 1: ASK 1 min

Ask EVERY patient about tobacco use status at

EVERY visit.

  • Current
  • Former
  • Never

This occurs most consistently when there are systems in place, such as question on intake form, chart stickers, or electronic prompts on electronic medical records. Chart stickers are available.

step 2 advise 1 min
Step 2: Advise 1 min

Clinicians should urge all tobacco users to quit.

Even brief advice to quit by a clinician results in greater

quit rates. Smokers cite a clinician's advice to quit as an

important motivator for attempting to stop smoking.

Advice should be:

  • clear
  • strong
  • personalized

Specific to the individual 's own situation

(e.g. oral health condition, family status, costs of tobacco).

what if they are not willing
What if they are not willing?

Offer a motivational intervention, the “5 R's”

Relevance

Risks

Rewards

Roadblocks

Repetition

the 5 r s
The “5 R’s”

Relevance:Why is quitting important to their own personal situation?

Risks:Outline the risks of continued tobacco use.

Rewards:Outline the benefits of quitting.

Roadblocks:What are the barriers preventing this person from quitting? What are some solutions to these barriers?

Repetition:Repeat this discussion frequently, until the person is ready to quit.

step 3 refer 1 min
Step 3: Refer 1 min

Referral options:

  • A doctor, nurse, pharmacist, or other clinician, for additional counseling
  • The Utah Tobacco Quit Line
  • Utah QuitNet
  • Text to Quit
  • Local Services

- Ending Nicotine Dependence (youth)

- First Step (pregnant women)

utah tobacco quit line
Utah Tobacco Quit Line
  • Toll free: 1.800.QUIT.NOW

- Spanish: 1.877.629.1585

- TTY: 1-877-777-6534

  • Monday-Sunday, 6:00 am to 11:00 pm
  • FREE
  • For adults and youth
  • Services available in English, Spanish and translation in 140 other languages
utah tobacco quit line62
Utah Tobacco Quit Line
  • Professional counseling sessions by telephone – up to five 40-minute sessions
  • Individualized Quit Plan
  • NRT upon qualification (patch, gum or lozenge)
  • Tailored resources for Utah residents
  • 1.800.QUIT.NOW
slide63
Fax Referral System

“Would you like the Utah Tobacco

Quit Line to help you quit?”

slide64

3 Simple Steps

  • Personalize your forms online at: www.tobaccofreeutah.org/utqlprofax.html
  • 2. 2 A’s and R with client. For those ready to quit give them the form to fill out. Verify signature!
  • Fax form in to the Utah Tobacco Quit Line: 1-800-483-3076
  • *The Quit Line will fax you to inform you of services your patient received.
slide65
http://utahquitnet.com
  • Quitting guide
  • Medication guide
  • Expert counseling
  • Personalized quit plan
  • 24 hour community support
  • Online NRT purchase

Lifetimemembership!

slide66

Text messaging service that offers Utahns daily quit tips to help them get through the quitting process

    • Users text READY to 53535 to receive two quit tips per day via cell phone for 21 days.
      • Users will be asked to answer simple questions regarding age, gender and zip code.
  • New research suggests that motivational text messages more than double the odds that smokers will be able to kick the habit.

Source: The Lancet, news release, June 29, 2011

tobacco dependence a 2 part problem

The addiction to nicotine

The habit of using tobacco

Treatment

Treatment

Medications for cessation

Behavior change program

Tobacco Dependence:a 2-Part Problem

Tobacco Dependence

Physiological

Behavioral

Treatment should address the physiological and the behavioral aspects of dependence.

smoking cessation medications
Smoking Cessation Medications

Nicotine polacrilex gum

  • Nicorette (OTC)
  • Generic nicotine gum (OTC)

Nicotine lozenge

  • Commit (OTC)
  • Generic nicotine lozenge (OTC)

Nicotine transdermal patch

  • Nicoderm CQ (OTC)
  • Nicotrol (OTC)
  • Generic nicotine patches (OTC, Rx)

Nicotine nasal spray

  • Nicotrol NS (Rx)

Nicotine inhaler

  • Nicotrol (Rx)

Bupropion SR (Zyban)

Varenicline (Chantix)

These are the only medications that are

FDA-approved for smoking cessation.

what about a relapse
What About A Relapse?
  • Viewed as a learning experience
  • Not a sign of personal or clinician failure
  • Continue to provide encouragement

It takes an average of 7 quit attempts to successfully quit using tobacco!

make a commitment
Make a Commitment

Address tobacco use with all patients.

At a minimum, make a commitment to incorporate brief tobacco interventions as part of routine patient care.

Ask, Advise, and Refer.

For more information, contact:

Tobacco Free Resource Line: 1-877-220-3466 or

http://www.tobaccofreeutah.org/healthcare1.html