Transcript Slide 1

NYS HIVQUAL Workshop:
Supporting Patient SelfManagement
July 17, 2009
Nanette Brey Magnani [email protected]
&
Meera Vohra [email protected]
NYSDOH AIDS Institute
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National Quality Center (NQC)
Agenda
• Group Exercise: Health Care Self-Management
Continuum
• Presentation: Literature Review
• Group Exercise: Case Study
• Group Exercise: The “To Do” List
• Group Exercise: Patient Self-Management Support
• Presentation: Harlem Hospital
• Group Discussion
• Evaluation and Wrap up
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Activity 1: Personalizing Self-Management
9:15am
• Health care self-management continuum
• Share personal experiences with managing
health and health care
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Presentation
9:35am
Literature Review
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Patient self-management is…
“The capability of patients with chronic illnesses, in a
complementary partnership with their health care
providers, to manage the symptoms, treatment,
lifestyle behavior changes, and the many physical and
psycho-social challenges that they face each day.”
A composite of definitions in the literature
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The Problem
• Patients often have difficulty in taking care of the longterm, day-to-day management of their own health. They
may:
 Miss appointments or follow-up referrals
 Not follow diet or activity recommendations
 Take medications or supplements that interfere with
prescribed therapies
 Ignore or not recognize signs of adverse events or disease
progression
 Behave in ways that put themselves at risk including not
adhering with prescribed medical therapies
• Clinicians have limited time to address these issues
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Growing Support for Patient Self-Management
“Increasing evidence shows that self-management support
reduces hospitalizations, emergency department use, and
overall managed care costs.”
“Physician support of patient self-management is one of the
key elements of a system’s-oriented chronic care model.”
Coleman and Newton. Supporting self-management in patients
with chronic illness. Am Fam Physician 2005;72(8):1503-10
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Patient self-management is used
effectively in many chronic illnesses and
is an essential component of the Chronic
Care Model (CCM)
Asthma
Studies of asthma patient self management programs show that they
can…
 reduce morbidity
 improve lung function
 enhance feelings of self control
 reduce absenteeism from school and number of days with restricted
activity
 reduce nocturnal episodes
 reduce visits to an emergency department
Guevarra P et al.Effects of educational interventions for self management of asthma in children and adolescents: a
systematic review and meta-analysis. BMJ 2003;326:1308-13
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Arthritis
• In multiple randomized trials, the Arthritis Patient Self-management
Program has been found to improve
 health behaviors
 self-efficacy
 health status
 cost savings1,2
• Patient self-management of arthritis reduced anxiety and depression
and improved participants’ perceived self-efficacy to manage
symptoms.3
1. Lorig K and Holman H. Arthritis Self-Management Studies: A Twelve-Year Review.
Health Education Quarterly. 1993;20(1):17-28
2. Lorig K, et al. Arthritis Self;Management Program Variations: Three Studies. Arthritis Care and Research. 1998;11(6):448-454
3. Buszewicz M et al. Self management of arthritis in primary care:
randomised controlled trial. BMJ 2006;Online First bmj.com
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Diabetes
 Most well-studied disease category
 Group visits and individualized problem- solving are
effective self-management tools resulting in
• Improved recommended prevention behaviors
• Improved health status (SF-36)
• Fewer specialty and ED visits
• Enhanced patient satisfaction and self-efficacy
• Improved HbA1c levels
Wagner E et al. Chronic care clinics for diabetes in primary care. Diabetes Care 2001;25:695-700; Anderson R et
al. Patient empowerment: results of randomized controlled trial. Diabetes Care 1995;18(7):943-949
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Systematic Review of 39 Diabetes Studies
Using at least one component of the CCM
• 17 of 20 studies that included a patient selfmanagement component found positive
outcomes
 ↓ health care costs
 ↓ length of hospital stay
 ↑ health outcomes (e.g., improved HbA1c)
Bodenheimer T, et al. Improving Primary care for Patients with Chronic Illness:
The Chronic care Model, Part 2. JAMA. 2002;288(15): 1909-1914
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The body of evidence shows that
supporting patient self-management…
 reduces hospitalizations
 reduces ER visits
 reduces overall managed care costs
 increases patient satisfaction with care
 improves health outcomes (e.g.,)
• Glycemic control
• Nocturnal asthma symptoms
• Blood pressure control
Coleman and Newton, Am Fam Physician, 2005
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Few Self-Management Studies
with HIV Patients
• No strong evidence yet of efficacy
• Only pilot studies have been done
• Increase in self efficacy correlated with increase
in CD4 count and decrease in viral load*
• More studies needed of in-office interventions
and system supports
*Ironson G, Weiss S et al(2005) The impact of improved self-efficacy on HIV viral load and distress in culturally
diverse women living with AIDS: the SMART/EST Women’s Project. AIDS Care 17:222-36
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Stanford HIV S-M Education Pilot Study
• Pilot test of a group self-management course for HIV/AIDS patients
 ↓ symptom severity index in the education session group and ↓
in the control group.
 ↑ self-efficacy in the educational group and ↓ in the control
group.
 secondary outcomes (pain fatigue, psychosocial symptoms,
changes in stress/relaxation exercises, and HIV/AIDS
knowledge were not significantly different in the two groups.
• No follow-up of this pilot study reported to date.
Gifford A, Pilot Randomized Trial of Education to Improve Self-Management Skills
of Men with Symptomatic HIV/AIDS. JAIDSHR. 1998;18136-144.
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Limitations of Patient
Self-Management Education
In a meta-analysis of 71 trials of self-management education across
several chronic disease states the authors concluded that…
• While self-management education programs are conceptually
appealing, the findings of this review suggest that not all selfmanagement education programs for all diseases or for all patients
are effective.
 Patient self-management programs which tailor educational content
and methodology to individual patients and which are integrated into
medical care may prove to be more effective than structured selfmanagement education courses, for which only specific patient
subgroups may be ready.
Warsi A, et al. Self-management Education Programs in
Chronic Disease. Arch Inter Med. 2004;164:1641-1649.
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In summary
Helping patients be better self-managers can…
• Improve
 Patient health outcomes
 Patient health-promoting behaviors
 Patient self-efficacy
 Communication with providers
 Utilization of community resources
 Containment of health care costs
 The quality and efficacy of HIV care
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Activity 2: Patient Case Study
9:50am
• Andy and Zeke
 Brothers with similar health challenges
 Different degrees of success with self-management
 Different health outcomes
 Different concerns
• Small group brainstorming activity
Case study based on Bodenheimer et al, JAMA 2002
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Activity 3: The To-Do List
10:20am
• Small group activity to plan an approach to
collaborative care with Zeke
• Primary care issues
• Assessing Zeke’s concerns, needs, strengths and
priorities
• Zeke is HIV-positive
 How does this affect his care?
 What are the key management tasks?
 Whose responsibility? (Zeke, providers, both?)
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Activity 4: Patient Self-Management Supports
10:50am
• Identifying the need for patient selfmanagement supports
• Brainstorming the most appropriate supports for
individual tasks
• Review of patient self-management supports
 Patient-centered
 Provider-centered
 System-centered
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Integrating Patient Self Management into
Clinical Practice
Harlem Hospital
New York City
Jenny Knight, FNP
Harlem Hospital Center, NY
[email protected]
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Harlem Hospital
• Our team was part of a one-year national learning
community sponsored by the Institute for
Healthcare Improvement on patient selfmanagement (included 20 sites, 2 other HIV)
• The Family-Centered Care Program (FCP) was
our target population
• Participated in extended follow-up project to
measure sustainability of change
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Population of Focus
• 25% of FCP patients are
recent immigrants from West
Africa
• The remaining 75% of FCP
patients are predominantly
African-American or Hispanic
• Many face legal, linguistic and
cultural barriers to care
• The self-management model is
well-suited to assist these
patients in overcoming barriers
and achieving better health
outcomes
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Introducing Self-Management
• Developed a goal setting tool to set a patientdriven healthcare goal and develop an action
plan during the clinic visit
• Developed a model to accomplish this within
the time constraints of the clinic setting
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My Action Plan for Better Health
Harlem Family Center
This month I will:
Improve my food
Choices
Describe it: (How, where, what, when, how
often)
Reduce my stress
Take my meds everyday
Attend a support group
Exercise more often
Follow up with a medical
appointment
(go to the dentist)
Cut down or stop
smoking (or drinking or
drug use)
Other:
Barriers (what might get in the way):
Plans to over come barriers (what could you do
to handle the barriers?):
On a scale of 1 – 10: How important is this goal:
________
(1 = Not important at all, 5 = somewhat important, 10
= the most important)
On a scale of 1 – 10: How sure am I that I can
make this goal: ______
(1 = Not sure at all, 5 = somewhat sure,
10 = 100% sure)
Follow up Plan:
Signature:
Clinician Signature:
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Refine Goal Setting Delivery
Implement – Goal
Setting Delivery
Design
Optimize Goalsetting in
Mom/Baby Clinic
A P
S D
Cycle 4: Expand approach to two
RN/Provider teams in Adult HIV clinic
A P
S D
Cycle 3: Team approach implemented in Mom/Baby
Clinic. Case manager plays role in supporting plan
Cycle 2: RN uses goal-setting tool with patients prior to provider
Visit at one clinic session. Provider reinforces goals/plan
Cycle 1: Providers use goal-setting tools with patients
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Team Approach
• Piloted in Mom-Baby Clinic
 Later expanded to several providers in ID Clinic
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Nurse sets goal with pt during triage
Provider reviewed goals with pt during visit
Case manager available to reinforce goals
Goal and action plan filed in patients’ chart
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Goal-setting was Patient-Driven
• Easier than expected to generate goals from
patients
• Encouraged the patient to identify the goal
themselves, come with action plan, identify
barriers, come up with solution that worked
for them
• Skills included: asking opening ended
questions, reflective listening, summarizing
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Impact of Goal-Setting
• Can solve impasse around behavior change
• Gives providers deeper understanding of the
patient
• Improves relationship between patient-nurse
and patient-provider
• Empowers pt to make needed behavior
changes, or at least think about them if they
are not ready
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Case Study: Improving Adherence
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•
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•
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37 yr old female with AIDS, newborn at home, with recent
illnesses, weight loss, and depression. Stopped taking
her meds.
Goal: “To take my medicines every morning after eating”
Barriers: “Tired of taking pills”
Plans to overcome barrier: “Think about tomorrow!”,
“Remind myself why I am taking them”
Follow –up: Reported 100% adherence on self-reported
follow-up survey; a more positive outlook
Objective measures: CD4 increased from 153 to 360
and VL decreased from 15,400 copies to undetectable;
weight increased by 13 lbs
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Case Study: Substance Abuse
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28 yr old with HIV, relatively medically well, but with
depression, active marijuana use, multiple missed clinic
visits, and chaotic life circumstances. Active ACS case:
all three kids in mandated foster care
Goal: Stop marijuana use to get children back, “must
have clean urines”
Barriers: friends, depression, lack of activities
Plans to overcome barriers: attend parenting classes,
attend drug support group, take meds for depression
Follow-up: additional barriers identified as drug
supplying boyfriend and drug-infested neighborhood
Objective measures: persistently positive urines; but
improved compliance with follow-up visits; VL initially
showed a significant decrease (though not maintained);
CD4 stable
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Case Study: Coordination of Care
46 yr old male with AIDS with hx of substance use
and poor adherence.
• Returned to NYC 8/06 after several months of
incarceration in Virginia with CD4 277 and VL <50
and reengaged in care
• By 11/06 CD4 180, VL > 100,000. Pt was at the
hospital daily attending support programs (HATS,
COBRA, HABARI, Harm Reduction, Nutrition, Hep
C)
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Setting a Goal
• Held case management meeting with all
programs, provider and patient
• At that meeting developed goal and action
plan with pt
• Goal: Take medications every day
• Plan: Take my pills every morning at home
after breakfast
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Problem-Solving
• Barriers: Forgetting/Frustration/Substance Abuse
• Plans to overcome barriers:
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
Keep dose in bag/jacket
Check in with HATS (adherence support daily)
Continue 1:1 counseling with Habari (Housing, psych referral)
Continue 1:1 counseling with Harm Reduction Program
• Follow up:
 At next medical visit, pt reported 100% adherence
 1/07 CD4 233, VL 2,880
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Group Discussion
11:35am
Participant exchange and discussion on
activities and tools/resources for supporting
patient self-management.
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Evaluation and Wrap up
11:50-12:00 noon
Thank you for your
participation.
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