Transcript FROM PATIENT TO PARTNER The Missing Ingredient for

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
David S. Sobel, MD, MPH
Director, Patient Education and Health Promotion
Kaiser Permanente Northern California
1950 Franklin Street., 13th Floor, Oakland, CA 94612
Phone: 510-987-3579
Fax: 510-873-5379
E-mail: [email protected]
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 Practice
 Rethink Care
1. Patients as primary providers of acute illness
2. Self-management of chronic illness
3. 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
Patient
as Consumer
Patient
as Provider
Hidden Health Care System
3
2
Professional Care
20%
1
Self-Care
80%
Self-Care:
Patients as Providers
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Over 80% of all medical symptoms are selfdiagnosed 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
Vision: “Partners in Health”
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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
Kaiser Permanente
Self-Care Program
Results

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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
 6% medical visits and 5%telephone calls
Improved provider and staff satisfaction
Rethinking Care 2:
Self-Management of Chronic Illness
Patient
as Consumer
Patient
as Provider
Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
E. Wagner
Living with Chronic Disease
Managing the Illness
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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*

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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
*aka Chronic Conditions Self-Management
Program, Expert Patient Programme
Lorig K et al Medical Care 1999;37:5-14.
http://patienteducation.stanford.edu/
Healthier Living with
Ongoing Health Conditions
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Improves health behaviors and health status
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Cost effective (estimated 5:1 to 10:1 ROI)
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Outcomes are long-lasting and robust (2+yrs.)
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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
LESSONS
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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
Body
as Machine
Mind
as HMO
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
Final Common Pathway
Psychiatric Disorder
Emotional
Distress
Medical Illness
Somatic Symptoms
Psychological Status of
Primary Care Patients
90
80
70
60
50
40
30
20
10
0
Psychiatric Disorder
Psychological Distress
Causes of Common Symptoms
in Primary Care Medicine
Chest pain, fatigue, dizziness, headache, back pain,
edema, dsypnea, insomnia, abdominal pain, numbness
Unknown
74%
Organic
16%
Psycholo
gical
10%
Kroenke, Am J Med 1989:86:262-6
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
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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.
% Classifed as Psych
Outpatient Cases on SCL-90
Mind/Body Medicine Program Evaluation
Pre- and Post-Class
70%
60%
Intake
62.1%
Post-Program 12 NCal Facilities
61.2%
60.0%
50%
40%
30%
20%
31.7%
28.2%
21.5%
10%
0%
Depression
(n=124)
Anxiety
(n=121)
Somatization
(n=120)
SCL-90 Sub-scale Measures
Nancy Gordon - DOR (June, 2000)
Utilization Change for
Mind/Body Medicine Participants
6-Mo. Pre
6-Mo. Post
3000
N=609
2500
Total
Visits
2000
1500
1000
500
0
ADP
+34%
ER
- 45%
Med
-37%
Urg
-22%
Psy
- 41%
Ngissah, Levine, & Walsh (1998 - N. Valley)
Rethinking
Health Improvement Interventions
Attitudes
Beliefs
Moods
Health
Behavior
Change
Health
Outcomes
Confidence Counts
Lorig K, Arthritis and Rheumatism. 1989;32:91-95
Targeting Core
Attitudes, Beliefs, and Moods
Quality of Life
Behavioral
Risk
Reduction
Problems
in Living
CORE
Attitudes
Beliefs
Moods
Mental
Illness
Psychosocial
Skills
Medical
Conditions
Ornstein R, Sobel D: Healthy Pleasures. Addison-Wesley, 1989
Restructuring Care
Medical
Office Visits
Group
Appointments
and
Web-based
Care
Medical Group Appointments
(Group Visits, Cluster Visits, etc.)
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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
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
Restructure Care:
Web-Based Care at kp.org
www.kaiserpermanente.org
Get Health Advice
Appointment/Rx Refills
Physician
Personal
Home Page:
A Personal
Portal to
Kaiser
Permanente
Online
Services
Retraining for
Collaborative Care
Traditional,
Paternalistic
Care
Collaborative
Care
How Traditional Care Differs
from Collaborative Care
Issue
Traditional Care/
Patient Education
Relationships Professional are expert.
Patients are passive.
Needs
Assessment
Content
Provider defines what
patients need to know.
Disease management
Process
Prescribed behavior change.
Provider solves problems.
External motivation. Didactic
presentations.
Knowledge and behavior
Outcomes
Collaborative Care/
Self-Management Education
Shared expertise with active
patients. Patient expert in their
experience of disease
Patient defined problems
Disease, role, and emotional
management
Self-defined goals. Patient
learns problem-solving skills.
Focus on internal motivation
and self-efficacy. Interactive.
Health status and appropriate
utilization
adapted from Bodenheimer, Lorig, et al JAMA 2002;288:2469.
Retraining for Collaborative Care
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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
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Address member’s needs in 3 domains:
1. Disease and Health Management
2. Role Management
3. Emotional Management
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Use state-of-art communication/educational strategies:
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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
 Rethink Care
1. Patients as primary providers of acute illness
2. Self-management of chronic illness
3. 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
Appendices
Four Habits of Highly Effective Clinicians
1.
2.
3.
4.
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
http://www.kaiserpermanente.org/medicine/permjournal/fall99pj/frhabits.html
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.
During clinical encounter, support
member’s central role in health:
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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’d.
Strengthen Adherence to
Prescribed Medications:
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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’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)
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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’d.
Offer multiple options to receive
self-mgt education:
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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.