clinical tools and strategies for supporting self management
Download
Skip this Video
Download Presentation
Clinical Tools and Strategies for Supporting Self-Management

Loading in 2 Seconds...

play fullscreen
1 / 45

Clinical Tools and Strategies for Supporting Self-Management - PowerPoint PPT Presentation


  • 123 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Clinical Tools and Strategies for Supporting Self-Management' - peyton


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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)

slide5
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
slide11
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)

slide17
Collaborative
      • Partnership, shared decision making
  • 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?
slide22
If you have DIABETES, here are some things you can talk about with your health care provider
  • Choose to talk about changing any of these and add other concerns in the blank circles.

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)

slide23
Explore Conviction/Importance

“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

Ask Permission

Ask Understanding

Tell(Personalize)

Ask Understanding

Benefits of Physical Activity

collaboratively set goals
Collaboratively Set Goals
  • Share clinician priorities
  • Offer options
  • Agree on something to work on
  • Negotiate a specific action plan
sms core clinical competencies2
(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
action planning starts with smart goals
Action Planning – Starts with SMART Goals
  • Specific and behavioral
  • Measurable
  • Attractive
  • Realistic
  • Timely
action plan
Action Plan

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

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
  • Review past experience - especially successes
  • Define small steps that are likely to lead to success
slide31
Action Planning:

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
  • 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:

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
slide34
Self-ManagementSupport 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
  • 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)

slide36
Community

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
  • 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:When, Where and By Whom
  • Before the Encounter
  • During the Encounter
  • After the Encounter
chronic disease self management program
Chronic Disease Self-Management Program
  • 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
  • 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
  • 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
  • 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)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
ad