Transcript Self Management Support

Making Brief Action
Planning Work for You
—Coaching Staff for
Successful Self Management
Presenters:
• Kristin Yeoman, MD, MPH, Clinical Consultant
• LCDR Gwenivere Rose, MS,RD, USPHS, Program Director
• Candice Donald, BS, Improving Patient Care Program National Team
• Connie Davis, MN, RN, ARNP, Institute for Healthcare Improvement
Presentation Objectives:
1) Review use of Brief Action Planning.
2) Learn methods for incorporating Menu of
Options and Brief action planning into routine
care.
3) Describe a model of care team sequencing
and plan for on-going staff coaching.
IPC Care Model
Community
Health Care Organization
SelfManagement
Support Delivery System
Design
Safe
Efficient
Activated Family
and Community
Informed
Activated
Patient
Decision
Support
Patient-Centered
Equitable
Clinical
Information
Systems
Effective
EFFECTIVE
RELATIONSHIPS
Improved health and wellness
for American Indian and Alaska
Native individuals, families,
and communities
Timely
Prepared,
Proactive
Community Partners
Prepared
Proactive
Care
Team
Patient
Condition
specific skills
and
information
Condition
specific skills
and
information
Self-management
ß
education
Condition
specific skills
and
information
Condition
specific skills
and
information
Definitions
Self-care: The care of oneself without medical,
professional or other assistance or oversight.
(American Heritage Medical Dictionary, 2007)
Self-management: The individual’s ability to
manage the symptoms, treatment, physical
and social consequences and lifestyle changes
inherent in living with a chronic condition.
(Barlow)
Definitions
• Self-management support: the assistance
caregivers give patients and their self-defined
circle of support so patients can manage their
conditions on a day-to-day basis and develop
the confidence to sustain healthy behaviors
for a lifetime.
-Bodenheimer, 2005
Definitions
• Self-management education: programs that
are based on patient-perceived problems and
address three self-management tasks (medical
or behavioral management, role management,
emotional management) and build skills in
problem-solving, decision making, taking
action, forming a patient/health care provider
partnership and resource utilization. These
skills can be applied in any chronic condition.
-based on Lorig & Holman, 2003
Patient Education
• Information and technical
skills are taught
• Information is diseasespecific
• Assumes that knowledge
creates behavior change
• Goal is compliance
• Health care professionals
are the teachers
Bodenheimer et al JAMA 2002;288:2469
Self-Management Support
• Skills to solve patient
Identified problems are
learned
• Skills are generalized and
can apply to all areas
• Assumes that confidence
yields better outcomes
• Goal is increased selfefficacy and self-reliance
• Teachers can be
professionals or peers
Stepped Care for Self-management
Support
Expert
Techniques
Advanced Techniques
(MI, PST, Care Mgr, Group, etc.)
Self-management Support Basics:
Goal Setting, Action Planning,
Problem solving, Follow up
Patient Role in Self-management
Cultural Humility
Health Literacy
Making Brief Action Planning Work for You—
Coaching Staff for Successful Self Management
Kristin Yeoman, MD, MPH, Clinical Consultant
LCDR Gwenivere Rose, MS,RD, USPHS, Program Director
Indian Health Service, Chinle Service Unit ,
Diabetes Program
Chinle Service Unit Facilities
Chinle Comprehensive Healthcare Facility
Pinon Health Center
Tsaile Health Center
Demographics
298,000 Navajo Nation members across U.S., 57% live on the Reservation
Encompasses 27,ooo square miles—the size of West Virginia
CSU serves 30 rural communities, 16 Chapters, 34,817 user population
4251 active DM patients on the registry
Phone coverage is limited
Many elders do not speak or understand English
Large % of population lives without running water/electricity
Diabetes Program Goal
Create Systems of Care That Support Healthy, Happy
Generations Living In Balance and Harmony With Hope
and Belief For a Better Tomorrow
“Táá hwí’ájítéego – It’s Up To You!”
Clinical Teams and Community Partners Trained
Cedar Team
Ghad ni eełíí
Yucca Team
Tsá’ásze’
Sage Team
Tsááh
Juniper Team
Ghád
Each Clinical Team Includes: Nursing Assistants, Health Techs (MAs), Medical Support Assistant,
Nurses and Providers
Other Teams and Groups To Be Trained:—Pinon and Tsaile Health Center
Team, CHRs, Special Diabetes, PHNs, Wellness Center, Dietitians, etc.
Patient visit Feedback Survey
SMS Baseline Questionnaire Survey
Staff vs Patient Survey Comparison
Sample Self Management Agenda
•
Welcome & Introductions
• Overview of training
• SMS Rationale
• Welcoming the Patient
• Building Rapport
• Menu of Options
• Making a Brief Action Plan
• SMART objectives
• Problem Solving
• Patient Follow-up and Feedback
• Patient Potholes on the Road to Change
• Provider Potholes on the Road to Change
• Ask, Tell, Ask, Teach Back
• SMS Documentation
• Fitting SMS into the Office Practice
• Coaching Model
• Training Review & Evaluations
• Close the Loop & Adjournment
Menu of Options
5 Key Elements in Brief Action Planning (BAP)
1. Being patient-centered, including assessing
patient’s needs
2. Helping a patient make a behaviorally specific
action plan
3. Eliciting a commitment statement (have patient
restate the plan)
4. Assessing confidence and problem-solving to
improve confidence regarding plan
5. Providing regular follow-up
Steve Cole, MD Stoneybrook University, Adapted from AMA tip sheet for SMS
Personal Action Plan 3 Core Questions
1. Elicit patient preference for change: Is there anything you
would like to do for your health over the next few days
(weeks) until we visit again?
2. Check confidence: Changing behavior and sticking with a plan
is very hard for most of us. How sure are you that you will be
able to carry out this plan?
3. Arrange follow-up: Let's plan when and how we can check on
how you're doing with your plan.
Ultra-brief personal Action Planning Steven Cole, MD Professor of Psychiatry, Stony Brook
University Medical Center, [email protected]
Behavioral
Menu
Brief Action Planning (B.A.P.)
“Is there anything you would like to do for your health
In the next week or two?”
Behavioral
Menu
SMART Behavioral Contracting
Elicitation of Commitment Statement
“How confident (on a scale from 0 to 10) do you
feel about carrying out your plan?”
If Confidence <7, “Problem Solve” Barriers
“When would you like to check in with me to
review how you are doing with your plan?”
Steven Cole, et. al.
MY HEALTH PLAN
•Something I have been thinking about doing to improve my health:
_______
•My plan for success includes;
What I will do:
_______
When I will do it:
_______
Where I will do it: ____________________________________________________
How often I will do it:
_______
•My activity plan for the next two weeks is:
_______
•How sure am I about this plan?
•If I am not sure or pretty sure:
What could get in the way:
What could I change to make it work:
____________
•My follow up plan (how and when):
•These are the things that will let me know I am successful with my plan:
SMART Commitment Statements
SMART Commitment Statements (Goals)
Specific: Include what you will do, when you will do it & how often you will do it.
Measurable: Is there a measure of success?
Attainable: Is this goal realistic?
Relevant: Will this plan help to improve your life?
Time-Oriented: What is the timeline for this goal?
Can you find the SMART Statement (s)?:
Nutrition
I will eat better.
I will eat more fruit.
Starting the week of 12/20, I will decrease my soda intake from 3 cans per day to 2 cans per day.
Starting tomorrow, I will eat lunch at Burger King 3 times per week rather than 5 times per week.
I will eat breakfast every morning before I leave home at 7 am for the next 2 weeks.
Exercise
I will get more exercise.
I will walk more often.
I will walk 1 mi at the high school track three times a week.
I will take a spinning class once a week at the wellness center.
I will walk 10 laps around the outside of my house four times a week.
I will walk to the end of my road and back on Monday, Wednesday and Saturday morning for the next 2 weeks.
Medications
I will take my medications every day.
I will put my medicine bottles by the sink in the bathroom so that I remember to take my pills twice a day when I brush
my teeth.
I will take 2 metformin tablets in the morning with breakfast and 2 at night when I eat dinner for the next 2 weeks.
Documentation of SMS Education
WELLNESS TAB
•Click ADD under Education
•Click on “Name Lookup” under “Select by” at the top
•Type in “Diabetes” or “Health” for Health Promotion-Disease Prevention
•Highlight “Diabetes-Lifestyle Adaptations” or “HPDP-Lifestyle Adaptations”
EDUCATION BOX
•Comments box: discuss what education you provided for pt
•Level of comprehension box: click on patient’s comprehension level; if low comprehension
level, do not set goal and see if patient is willing to see diabetes educators
•Readiness to learn box: click on appropriate tab that highlights patient’s readiness
•If patient sets a goal: click on “goal set”, write goal in box below (use patient’s own words,
such as, “I will walk three times per week for 30 minutes.”
•If patient not ready to set goal, click on “Not ready” under “Readiness to learn” box
•In bottom box, put date of education, then click on “Other” under location and write CCHCF
FOLLOW-UP PATIENTS WHO HAVE SET GOAL
•Click on previous education tab that states “goal set” and review goal
•Add new education tab as above, but click on “goal met” or “goal not met”
•If goal not met, discuss reasons and barriers, restructure action plan and determine if patient
wants to set new goal. If they set new goal, add new education tab as above for this new goal.
•If goal met, find out if patient want to set new goal and restart whole process from above.
Roles and Sequencing
Morning Huddle
1. HT prints out icare template
2. Review all pts, decide what
preventive care to focus on
General
Translation by either NA or
HT, whoever is available
NA rooms pt
1.Greets patient
2. Vital signs
3. Determines chief complaint
4. Determines and does appropriate
GPRA screenings
5. Performs POC testing (a1c etc)
6. Writes exams/tests that pt needs from
prescreening onto PCC
7. Provides and briefly discusses menu of
options; tells them we’re trying
something new
8. Empanels patients
9. Has pt sign release of information,
send it to appropriate facility for records
Nurse
1. Greets patient
2. Provides follow-up on
action plan
3. Take phone calls re med
refills, questions
4. Leader of PI projects,
reviews data and
determines where to
improve
5. Team leader for SMS;
helps with coaching,
monitoring education
codes etc
6. Sees pts in f/u
HT sees pt
1. Greets patient
2. Gives immunizations
3. Provides education based on menu of
options
4. Makes action plan
5. Determines appropriate f/u
6. At follow-up session provides
feedback on previous action plan
7. Reviews plan agreed on by pt and
provider to ensure pt understanding
8. Make f/u appt if MSA can’t do it
9. Send pt to lab if needed
Provider sees pt
1. Greets patient
2. Evaluates chief complaint
3. Follows up chronic medical
problems
4. Orders labs/exams needed on pt
5. Discusses pt’s choice on menu of
options
6.Provides pt education
7.Provides teach back
8.Fills out f/u appt sheet with
provider, MR#, and when f/u should
be set; leaves in chart or in room for
HT to set appt
SMS Training Feedback Survey
Coaching Guidelines
What to look for in each patient encounter:
• Did staff establish rapport?
• Did staff offer and discuss menu of options?
• Did staff recognize patient’s level of readiness?
• Did patient set the goal him/herself and repeat it back?
• Was the goal specific?
• Did the patient seem confident with the plan?
• Was the education/goal documented in EHR?
• How was communication between NA/HT/provider?
• How was flow? Did staff follow roles/sequencing developed during
training?
Coaching Schedule
McGarvey, Salay,
Kobernick, Tamra
Begay off
8am-12 noon
1-5 pm
Monday 4/4
Tuesday 4/5
Wednesday 4/6
Debriefing with
Henrietta/Brenda:
8:15 Kristin
Caroline and
Lanora (Rountree
provider): Kristin,
Shirley
Caroline and
Lanora with
Henrietta
(Rountree
provider)
Cassandra
Thursday 4/7
Friday 4/8
Coaching in
observation room:
10-11 nursing
assistants
Ivan
Duane
Debriefing with
Henrietta/Brenda
8:15
Gwenivere
B.A.P. Monitoring Patient Project
Response to the Question: “Is there anything you’ve been thinking about doing to
improve your health?”
Pt
(date)
Demographics,
diagnosis
(age, gender)
Category of Response to Question One
(fill in brief details or comments)
2/8/2011
Healthy, Makes a Plan
Doesn’t
need a
plan
1
45 male,
diabetes
2
80 female, heart
disease
3
30 male, high
blood pressure
4
5
6
Needs more
information, not
interested, not familiar
with taking on role in
self-management
Very challenging
situation, very
complex life or social
situations
says you’re the
nurse, I just do what
you tell me
Has some memory
loss. Might have to
work with daughter
Exercise at gym
Contact Information
• Kristin Yeoman, 928-674-7452, [email protected]
• Gwenivere Rose, 928-674-7080, [email protected]
Corn Pollen Path Garden Harvest