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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.

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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


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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]


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Strategy for Changing Culture and Practice

  • Look for

    • inefficiencies, mismatches, and capacity

    • overlooked evidence and data

    • “win, win, win” opportunities


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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


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Patient

as Provider

Patient

as Consumer

Rethinking Care 1: Self-Care for Acute Illness


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Hidden Health Care System

3

Professional Care

20%

2

1

Self-Care

80%


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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?


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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


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Kaiser PermanenteHealthwise Handbook


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Kaiser PermanenteSelf-Care Program

Results

  • 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


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    Patient

    as Provider

    Patient

    as Consumer

    Rethinking Care 2: Self-Management of Chronic Illness


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    Chronic Care Model

    Community

    Health System

    Health Care Organization

    Resources and Policies

    ClinicalInformationSystems

    Self-Management Support

    DeliverySystem

    Design

    Decision

    Support

    Prepared,

    Proactive

    Practice Team

    Informed,

    Activated

    Patient

    Productive

    Interactions

    Improved Outcomes

    E. Wagner


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    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


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    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

    http://patienteducation.stanford.edu/


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    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


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    Chronic Disease Self-Management Program

    LESSONS

    • 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


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    Mind

    as HMO

    Body

    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.


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    Psychiatric Disorder

    Emotional Distress

    Medical Illness

    Somatic Symptom Superhighway

    Final Common Pathway

    Somatic Symptoms


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    Psychological Status of Primary Care Patients


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    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


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    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


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    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.


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    Mind/Body Medicine Program EvaluationPre- and Post-Class

    12 NCal Facilities

    Intake

    Post-Program

    70%

    60%

    62.1%

    61.2%

    60.0%

    50%

    40%

    % Classifed as Psych Outpatient Cases on SCL-90

    30%

    31.7%

    28.2%

    20%

    21.5%

    10%

    0%

    Depression(n=124)

    Anxiety(n=121)

    Somatization(n=120)

    SCL-90 Sub-scale Measures

    Nancy Gordon - DOR (June, 2000)


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    Utilization Change for Mind/Body Medicine Participants

    6-Mo. Pre

    6-Mo. Post

    3000

    N=609

    2500

    2000

    Total

    Visits

    1500

    1000

    500

    0

    ADP

    +34%

    ER

    - 45%

    Med

    -37%

    Urg

    -22%

    Psy

    - 41%

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


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    Attitudes

    Beliefs

    Moods

    Health

    Behavior

    Change

    Health

    Outcomes

    RethinkingHealth Improvement Interventions

    Confidence Counts

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


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    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


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    Group

    Appointments

    and

    Web-based

    Care

    Medical Office Visits

    Restructuring Care


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    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


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    Diabetes Cooperative Care Clinic

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

    Outcomes

    • 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


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    Restructure Care:Web-Based Care at kp.org

    www.kaiserpermanente.org




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    Physician Personal Home Page:

    A Personal Portal to Kaiser Permanente Online Services


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    Collaborative

    Care

    Traditional, PaternalisticCare

    Retraining for Collaborative Care


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    How Traditional Care Differs from Collaborative Care

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


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    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


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    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. 3http://www.kaiserpermanente.org/medicine/permjournal/fall99pj/frhabits.html


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    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.


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    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.


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    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.


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    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.


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    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.


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