Patient as Partners
1 / 45

- PowerPoint PPT Presentation

  • Uploaded on

Patient as Partners Improving Health and Cost Outcomes with Self-Care and Chronic Disease Self-Management. NatPaCT Conference Programme Learning from Kaiser Permanente – How can the NHS make better use of its resources and improve patient care? Tuesday 4 November 2003 – The Brewery, London.

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

PowerPoint Slideshow about '' - tavita

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
Slide1 l.jpg

Patient as PartnersImproving Health and Cost Outcomes with Self-Care and Chronic Disease Self-Management

NatPaCT Conference Programme

Learning from Kaiser Permanente – How can the NHS make better use of its resources and improve patient care?

Tuesday 4 November 2003 – The Brewery, London

Slide2 l.jpg

David S. Sobel, MD, MPHDirector, Patient Education and Health PromotionKaiser Permanente Northern California1950 Franklin Street., 13th Floor, Oakland, CA 94612Phone: 510-987-3579Fax: 510-873-5379E-mail: [email protected]

Strategy for changing culture and practice l.jpg
Strategy for Changing Culture and Practice

  • Look for

    • inefficiencies, mismatches, and capacity

    • overlooked evidence and data

    • “win, win, win” opportunities

Strategy for changing culture and practice4 l.jpg
Strategy for Changing Culture and Practice

  • Rethink Care

    • Patients as primary providers of acute illness

    • Self-management of chronic illness

    • Behavioral interventions to address psychosocial needs

  • Restructure Care

    • Telephone, group appointments, web-based care

  • Retrain for Collaborative Care

    • Enhance understanding, skills, and confidence of members and professional staff as partners in care

Rethinking care 1 self care for acute illness l.jpg


as Provider


as Consumer

Rethinking Care 1: Self-Care for Acute Illness

Hidden health care system l.jpg
Hidden Health Care System


Professional Care






Self care patients as providers l.jpg
Self-Care: Patients as Providers

  • Over 80% of all medical symptoms are self-diagnosed and self-treated without professional care.

  • Patients are the true primary care providers of medical care for themselves and their families.

  • How can health care systems educate, equip, and empower the true primary care providers… patients?

Kaiser permanente self care program l.jpg
Kaiser PermanenteSelf-Care Program

Vision: “Partners in Health”

  • A system intervention that changes the culture of care and supports members making safe, appropriate, and informed health care choices

  • KP Healthwise Handbooks distributed to all members

  • Provider training and reinforcement

  • Continuing systemwide reinforcement

Kaiser permanente healthwise handbook l.jpg
Kaiser PermanenteHealthwise Handbook

Kaiser permanente self care program10 l.jpg
Kaiser PermanenteSelf-Care Program


  • High use of the KP Healthwise Handbook

    • 70% in previous 6 months

  • Improved member self-care confidence

    • 71% more confident

  • Increased member satisfaction

    • 60% more positive about Kaiser Permanente

  • More appropriate utilization & improved accessibility

    • 50% report saving a call or visit to MD

    • ê6% medical visits and ê5%telephone calls

  • Improved provider and staff satisfaction

  • Rethinking care 2 self management of chronic illness l.jpg


    as Provider


    as Consumer

    Rethinking Care 2: Self-Management of Chronic Illness

    Slide12 l.jpg

    Chronic Care Model


    Health System

    Health Care Organization

    Resources and Policies


    Self-Management Support







    Practice Team






    Improved Outcomes

    E. Wagner

    Living with chronic disease l.jpg
    Living with Chronic Disease

    Managing the Illness

    • Taking medications

    • Changing diet and exercise

    • Managing symptoms of pain, fatigue, insomnia, shortness of breath, etc.

    • Interacting with the medical care system

      Managing Daily Activities and Roles

    • Maintaining roles as spouse, parent, worker, etc.

      Managing the Emotions

    • Managing anger, fear, depression, isolation, etc.

    Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M: Living a Healthy Life with Chronic Conditions, Palo Alto, CA: Bull Pub. Co., 2000

    Healthier living with ongoing health conditions l.jpg
    Healthier Living with Ongoing Health Conditions*

    • Lay-led, small interactive groups (2 hours/week for 7 weeks)

    • Mixed chronic disease and co-morbidities

    • Content

      • Goal setting and problem-solving

      • Cognitive symptom management

      • Design of exercise programs

      • Management of fatigue, sleep, pain, anger, depression

      • Appropriate use of medications

      • Patient/physician communication

      • Use of advanced directives

    Lorig K et al Medical Care 1999;37:5-14.

    *aka Chronic Conditions Self-Management Program, Expert Patient Programme

    Healthier living with ongoing health conditions15 l.jpg
    Healthier Living with Ongoing Health Conditions

    • Improves health behaviors and health status

    • Cost effective (estimated 5:1 to 10:1 ROI)

    • Outcomes are long-lasting and robust (2+yrs.)

    • Replicable and dissemination can yield outcomes as good, or better.

    Lorig KR, Sobel DS, Effective Clin Practice 2001;4:256-262

    Lorig KR, Medical Care 2001;39:1217-1223

    Chronic disease self management program l.jpg
    Chronic Disease Self-Management Program


    • General coping skills education for heterogeneous conditions complements disease specific information

    • Patients are the “experts” in living and coping with chronic illness

    • Modeling more effective than “save and rescue”

    • No significant difference in participants’ outcome with lay vs professional leaders

    • Confidence predicts improvement in health outcomes

    • People benefit themselves from helping other people

    • Process is more important than content

    Rethinking care 3 behavioral medicine l.jpg


    as HMO


    as Machine

    Rethinking Care 3: Behavioral Medicine

    Sobel DS: The cost-effectiveness of mind-body medicine interventions. In The Biological Basis for Mind Body Interactions, Progress in Brain Research, Vol 122, EA Mayer and CB Saper (Eds.), Elsevier, 2000:393-412.

    Somatic symptom superhighway l.jpg

    Psychiatric Disorder

    Emotional Distress

    Medical Illness

    Somatic Symptom Superhighway

    Final Common Pathway

    Somatic Symptoms

    Psychological status of primary care patients l.jpg
    Psychological Status of Primary Care Patients

    Causes of common symptoms in primary care medicine l.jpg
    Causes of Common Symptoms in Primary Care Medicine

    Chest pain, fatigue, dizziness, headache, back pain, edema, dsypnea, insomnia, abdominal pain, numbness

    Kroenke, Am J Med 1989:86:262-6

    Depressive symptoms l.jpg
    Depressive Symptoms

    Depressive symptoms more debilitating in terms of physical and social functioning than:

    • diabetes

    • arthritis

    • gastrointestinal disorders

    • back problems

    • hypertension

    Wells et al. JAMA 1989;262:914-930

    Psychosocial dysfunction in medical care l.jpg
    Psychosocial Dysfunctionin Medical Care

    • Common

    • Undiagnosed or inadequately treated

    • Significant impact on:

      • functional status and disability

      • medical utilization and costs

      • medical morbidity and mortality

    • Health Care services mismatched to needs

      • Need to develop integrated behavioral health education services

    Sobel DS: Rethinking medicine: Improving health outcomes with cost-effective psychosocial interventions. Psychosomatic Medicine 57:234-244, 1995.

    Mind body medicine program evaluation pre and post class l.jpg
    Mind/Body Medicine Program EvaluationPre- and Post-Class

    12 NCal Facilities










    % Classifed as Psych Outpatient Cases on SCL-90











    SCL-90 Sub-scale Measures

    Nancy Gordon - DOR (June, 2000)

    Utilization change for mind body medicine participants l.jpg
    Utilization Change for Mind/Body Medicine Participants

    6-Mo. Pre

    6-Mo. Post














    - 45%






    - 41%

    Ngissah, Levine, & Walsh (1998 - N. Valley)

    Rethinking health improvement interventions l.jpg









    RethinkingHealth Improvement Interventions

    Confidence Counts

    Lorig K, Arthritis and Rheumatism. 1989;32:91-95

    Targeting core attitudes beliefs and moods l.jpg

    Behavioral Risk Reduction

    Problems in Living

    • CORE

    • Attitudes

    • Beliefs

    • Moods

    Psychosocial Skills

    Mental Illness

    Medical Conditions

    Targeting CoreAttitudes, Beliefs, and Moods

    • Ornstein R, Sobel D: Healthy Pleasures. Addison-Wesley, 1989

    Restructuring care l.jpg






    Medical Office Visits

    Restructuring Care

    Medical group appointments group visits cluster visits etc l.jpg
    Medical Group Appointments(Group Visits, Cluster Visits, etc.)

    • Scheduled or ‘drop-in’ visit for group of patients with similar or mixed health conditions

    • Under direction of physician or other licensed health care professional

    • Provision of individualized clinical services

      • Medical Assessment

        • history, physical assessment, triage, referral

      • Medical Intervention

        • medication prescription/adjustment, lab tests

    Diabetes cooperative care clinic l.jpg
    Diabetes Cooperative Care Clinic

    Randomized clinical trial, n=185, f/u 1yr, 2hr group monthly x 6


    • lower HgbA1C ( 1.3% vs. 0.22% controls, p<0.0001)

    • more home blood glucose monitoring

    • reduced hospital and outpatient utilization

      • hospitalizations 80% more frequent in control

      • fewer physician and nonphysician visits

    • increased self-efficacy

      • diet, management of low BG and BG when sick

    • increased satisfaction

    Sadur CN, Diabetes Care, 1999;12:2011-2017

    Restructure care web based care at kp org l.jpg
    Restructure Care:Web-Based Care at

    Slide33 l.jpg

    Physician Personal Home Page:

    A Personal Portal to Kaiser Permanente Online Services

    Retraining for collaborative care l.jpg



    Traditional, PaternalisticCare

    Retraining for Collaborative Care

    How traditional care differs from collaborative care l.jpg
    How Traditional Care Differs from Collaborative Care

    adapted from Bodenheimer, Lorig, et al JAMA 2002;288:2469.

    Retraining for collaborative care36 l.jpg
    Retraining for Collaborative Care

    • Thriving in a Busy Practice: Clinician-Patient Communication

      (“Four Habits of Effective Clinicians”)

    • Brief Negotiation

    • Practice Essentials for Care Managers

    • Education for Health Action

    • Group Appointment Toolkit

    Retraining for collaborative care key strategies l.jpg
    Retraining for Collaborative Care:Key Strategies

    • Address member’s needs in 3 domains:

      1. Disease and Health Management

      2. Role Management

      3. Emotional Management

    • Use state-of-art communication/educational strategies:

      • Transform didactic, information-based approaches into interactive, self-efficacy/confidence enhancing communication that strengthens patients’ skills in problem-solving, goal setting and action planning, self-tailoring, using available resources, forming a partnership with clinician

      • Ask questions and elicit patient perspective and engagement in action planning and problem-solving

      • Use nonjudgmental and positive tone

      • Link back to member’s routine source of care and team care and peer support

    Patients as partners changing culture and practice l.jpg
    Patients as Partners: Changing Culture and Practice

    • Rethink Care

      • Patients as primary providers of acute illness

      • Self-management of chronic illness

      • Behavioral interventions to address psychosocial needs

    • Restructure Care

      • Telephone, group appointments, web-based care

    • Retrain for Collaborative Care

      • Enhance understanding, skills, and confidence of members and professional staff as partners in care

    Four habits of highly effective clinicians l.jpg
    Four Habits of Highly Effective Clinicians

    • Invest in the Beginning

    • Elicit the Patient’s Perspective

    • Demonstrate Empathy

    • Invest in the End

    Frankel RM, Stein T. Getting the Most out of the Clinical Encounter: The Four Habits Model. The Permanente Journal, Fall 1999, Vol 3, No. 3

    2003 cmi evidence linked recommendations l.jpg
    2003 CMI Evidence-Linked Recommendations

    Embed Self-Mgt into Pop Mgt:

    • Lower intensity interventions(automated phone messages, staged mailings, videos, online) for all patients

    • Higher intensity(e.g. multi-session programs) for those with higher needs

      Robert Wood Johnson Foundation and Center for the Advancement of Health. Essential Elements of Self-Management Interventions, 2002.

      Von Korff M, Tiemens B. West J Med 2000; 172(2):133-137.

      Piette JD,e al. Am J Med 2000; 108(1):20-27.

      Serxner S, et al. Congestive Heart Failure; 1998. May/June:23-28.

    2003 cmi evidence linked recommendations cont d l.jpg
    2003 CMI Evidence-Linked Recommendations, cont’d.

    During clinical encounter, support member’s central role in health:

    • Collaborative communication (Brief Negotiation, 4 Habits)

    • Assess member’s self-mgt needs; provide tailored feedback and behavioral advise

    • Collaboratively set behavioral goals and action plan. Document and share with member.

    • Offer self-mgt resources; refer to programs

    • F/up to adapt plan and address relapse

      Glasgow RE et al. Ann Behav Med 2002; 24(2):80-87.

      Stewart MA. CMAJ 1995; 152(9):1423-1433.

      Petrella RJ, Lattanzio CN. Can Fam Physician 2002; 48:72-80.

      Rice VH. Heart Lung 1999; 28(6):438-454.

      Boulware LE, et al. Am J Prev Med 2001; 21(3):221-232.

    2003 cmi evidence linked recommendations cont d43 l.jpg
    2003 CMI Evidence-Linked Recommendations, cont’d.

    Strengthen Adherence to Prescribed Medications:

    • Anticipate nonadherence: “Have you ever missed or forgot to take your pills?”

    • Identify personal barriers and problem solve. Avoid assuming causes of nonadherence

    • Collaboratively develop a regimen pt is willing and able to follow. Praise efforts to adhere.

    • As needed, refer for pharmacist consultation

      McDonald HP, et al. JAMA 2002; 288(22):2868-2879.

      Haynes RB , et al. JAMA 2002; 288(22):2880-2883.

      Yuan Y, et al. Am J Manag Care 2003; 9(1):45-56.

    2003 cmi evidence linked recommendations cont d44 l.jpg
    2003 CMI Evidence-Linked Recommendations, cont’d.

    Turn didactic pt education into self-mgt education

    Beyond knowledge to skills & confidence:

    • Problem solving training (incl. medication adherence)

    • Goal setting and action planning

    • Peer modeling and support

    • Experiential exercises (relaxation session, read peak flow meter, pick from a menu)

    • Forming partnership with clinician

      Bodenheimer T et al. JAMA 2002; 288(19):2469-2475.

      Norris S et al. Diabetes Care 2002; 25(7):1159-1171.

      Gibson PGM et al. Cochrane Database Syst Rev 2002;2.

      Barlow J, et al.Patient Educ Couns 2002; 48(2):177-187.

    2003 cmi evidence linked recommendations cont d45 l.jpg
    2003 CMI Evidence-Linked Recommendations, cont’d.

    Offer multiple options to receive self-mgt education:

    • Staged mailings based on readiness to change

    • Telephone group sessions

    • Group visits

    • Internet-based programs

    • Community and work site programs

      Serxner S, et al. Congestive Heart Failure 1998; May/June:23-28.

      Boucher, JL et al. Diabetes Spectrum 1999 12(2).121-123.

      Wagner EH et al. Diabetes Care 2001; 24(4):695-700.

      McKay HG, et al. Diabetes Care 2001; 24(8):1328-1334.

      Norris SL et al. J Prev Med 2002; 22(4 Suppl):39-66.

      Pelletier KR. Am J Health Promot 2001; 16(2):107-116.