Transcript Role of Pharmacists in Promoting Patient Treatment

Engaging and Sustaining Healthcare Providers
in Chronic Disease Self-Management Support
What, Why, and How Healthcare Professionals Can Do
Durhane Wong-Rieger, President
Institute for Optimizing Health Outcomes
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Institute for Optimizing Health Outcomes
March 2012
Disclosure of Potential for Conflict of
Interest
 Durhane Wong-Rieger, President & CEO, Institute for
Optimizing Health Outcomes
 FINANCIAL DISCLOSURE:
 Grants / Research Support: No Conflict
 Speaker bureau/Honoraria: Champlain Living Healthy
 Consulting Fees: None
 Other: None
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Institute for Optimizing Health Outcomes
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Learning objectives
After this program, the participant will be able to:
1. Define the importance of an engaged patient for treatment
adherence and health behaviour change
2. Identify the knowledge and skills of engaged self-managing
patients
3. Know the five-step model of patient engagement and concepts of
self-management support
4. Know role of motivational interviewing/decisional balance to
increase patient readiness to engage
5. Implement roles of patients and healthcare professionals as
partners in chronic disease self-management
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Case 1: What health problem?
 Greg: 54-year old finance manager for small municipality;
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high stress, long hours, two teenage children
Diagnosed: moderate hypertension (150/90); weight (210
lbs.)/height (5’11”) = BMI 29.2
Lifestyle: sedentary and overweight as child; as young adult
active runner and biker; now mostly sedentary
Diet: prefers meat and potatoes; tries to include fish and
vegetables; often fast food because of work schedule
Family history of heart disease (father died of heart attack at
age 54); cancer (both uncles); grandmother died at age 90
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Case 2: Ready to Self-Manage?
 Mark, 32-year-old financial advisor, married 2 years; no kids
 Indications: BP (130/80); Height/Weight/BMI (5’
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11”/160/22.3); FPG (200+ or 11.1); HA1C (7.5)
Lifestyle: High activity (30-90 mins aerobic exercise 46/week); high carb diet; low alcohol (3-5 drinks/week)
Family history: Thyroid, celiac; father died of ALS
Diagnosed 2 years ago with Diabetes (Type 1.5?)
Treatment: Compliant with low carb diet and exercise. Low
compliance with insulin (no pump) and blood glucose testing
4-6 times daily (rec.)
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Case 3: What’s Happening?
 Ursula, 14-year-old, grade 9 HS, mid-size community
 Indications: LDL cholesterol (2.6 mmol/L), SBP (120
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mmHg), BMI (23.6 kg/m2), HA1C (9.5%)
Diagnosed: Type 1 Diabetes diagnosed as infant
Lifestyle: Outgoing, likes music, drama, swimming, dance,
and internet activities
Family: Only child, mother primary caregiver for diabetes
Treatment: Self-administering since age 12; until recently,
compliant with diet, glucose testing and insulin 4-6 times
daily; recently, irregular testing, insulin, and diet control
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Is Chronic Disease Problem?
 About 50% of Canadians (16.5 million) have 1 or more
chronic conditions
 Globally, WHO identifies noncommunicable (chronic)
diseases as killing more people than all other causes
combined; 2/3 of 57 million deaths due to CVD, cancer,
diabetes, and chronic lung disease
 In developed countries, CD patients average 12 hours
with HCPs, leaving them to self-manage 364.5 days/year
 Globally, NCDs caused by four 21st-century lifestyle
behaviours: tobacco use, unhealthy diet, lack physical
activity, and alcohol over-use.
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Why Self-Management for
Chronic Disease?
 About 50% of Canadians (16.5 million) have 1 or more
chronic conditions
 Traditional provider-based acute care model not
appropriate to managing chronic conditions
 Patient need to take an active, informed role in managing
treatment and making lifestyle changes
 Patients who actively manage their own health feel better
and have better health outcomes
 Research indicates that self-management is important
but does not have lasting benefits without support from
the healthcare professional, that is, health coaching.
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Problem of Patients Not Adhering to
Treatment Recommendations?
14-21% of patients never fill prescription
30-50% don’t take medications in recommended manner
66% with hypertension have poor BP control due to non-adherence
50% adherence to chronic conditions treatment incl. lifestyle changes
WHO, 2003
21% Type 1 diabetes patients NEVER check Blood glucose levels
Polonsky, 1999
36-39% non-adherence to MS disease-modifying injection therapies
(among patients who choose to engage in treatment)
Treadaway et al, 2009
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Lack of Adherence to Diabetes
Management
 Lack of adherence to BG monitoring (Vicenze et al, 2004)
 Only 40% of patients with Type 1 diabetes measure as
frequently as recommended
 Only 33% of patients with Type 2 diabetes measure as
recommended
 Patients with diabetes (enrolled in diabetes management) do
not spend time on self-care (Safford et al, 2005)
 21% of diabetic patients never test blood glucose
 38% of diabetic patients never engage in foot care
 38% of diabetic patients never exercise
 54% of diabetic patients never spend time shopping and
cooking
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June 2011
Problems of Non-Adherence to
Medications
Responsible for:
 Up to 10 % of hospital admissions
 23% of nursing-home admissions
(McKenney and Harrison, 1976; Strandberg, 1984)
 22% of drug reaction hospitalizations
(McKenney, 73)
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Why Don’t Patients Make
Behaviour Changes?
 Knowledge is not enough
 Who here has perfect health (behaviour)?
 Who knows what he/she needs to do to live more
healthily?
 Behaviour change is hard
 Who here prefers to do things that give pleasure rather
than things that cause pain?
 Have you ever continued to do something that has
“bad” consequences? Have you ever stopped doing
something that is “good” for you?
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Not Enough or Too Much Information?
Pathology
Attend
Groups
Selfmanage
Take
Meds
Quit
Smoking
Practice
Nurse
GP
Patient
Diet’n
Psych
Diab Ed
Diet’n
Nutrition
Ex Phys
Exercises
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Use
Aids
OT
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Physio
Move
More
Monitor
Symptoms
Pod’st
Attend
Appoint’s
Rehab
Program
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Common Responses to Treatment Advice?
Fear
Hopelessness
Guilt
Frustration
Anger
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Resistance
Despair
Confusion
Shame
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Cognitive, Behavioral & Emotional
Avoidance Response
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Empowered Patients = Self-Managing
Patients = Better Outcomes
 Self-management involves [the person with the chronic
health condition] engaging in activities that protect &
promote health, monitoring and managing symptoms & signs
of illness, managing the impacts of illness on functioning,
emotions and interpersonal relationships and adhering to
treatment regimes. (Gruman & Von Korff, 1966)
 Patients who self-monitor their condition have been shown
to have better outcomes. Self-care programmes aim to
increase the interest and involvement of people in their own
care, and by doing so, empower them to manage their
condition. (WHO, 2010)
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To make behavioural changes (adhere to treatment,
make lifestyle changes), patients must:
1. Know what to do (treatment recommendations)
2. Be ready to make necessary changes = believe
change is important and do-able
3. Have the capacity to carry out the chosen actions:
Have the skills and resources to initiate and maintain
health behaviour changes
b) Identify and use problem-solving skills to address barriers
to change
a)
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HCPs “Coach” Patients to SelfManagement
 To achieve better health outcomes, patients must adhere
to treatment recommendations and lifestyle changes
 To self manage, patients need to know their conditions
and treatment options, commit to making healthy
behaviour choices, have confidence that they can carry
out desired actions, and can problem solve barriers
 To sustain self-management (behaviour change), patients
need support from health providers (and the system)
 Health providers who use health coaching support
patients with knowledge, motivation, and problemsolving skills
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Myth: Evidence-Based Recommendations
Lead to Better Health Outcomes?
HCP Recommends
Evidence-Based Treatment &
Lifestyle Changes
Patient Achieves Better
Health Outcomes
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Reality: Long Road from Evidence-Based
Recommendations to Health Outcomes
HCP Recommends
Evidence-Based
Treatment &
Lifestyle Changes
Patient Achieves
Better Health
Outcomes
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HCP Coaches to
Increase Readiness
to Change
HCP and Patient
Co-create
Achievable Action
Plan
Patient Achieves
Physiological
Targets
Patient Adheres to
Treatment & New
Behaviours
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5 Steps of Patient Engagement
1. Facilitate client identification of health issue
2. Increase client readiness to change health behaviour (choose behaviours that
are important)
3. Increase client confidence (set SMART goals, ie, specific, measurable, achievable, realistic,
time-based)
4. Facilitate client action plan
5. Assist in developing strategies to address barriers to maintain change
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Why Should HCPs Support Patient
Self-Management?
 What are the most important issues affecting your
practice (ability to deliver good care to patients)?
 How important is it to change your “usual care”,
given everything else that is going on right now?
 What are the options for a SMS/health coaching
approach in your healthcare practice or setting?
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Pros and Cons of SMS/Health
Coaching
 What are the benefits of continuing to treat patients
with chronic disease with the “usual care?
 What do you think would be the challenges of
adopting a SMS/health coaching approach?
 If you were to introduce SMS/health coaching,
what might be the long-term benefits, to the
patients, to your practice, to your clinic?
 If you don’t change your approach with CD
patients, what might be the long-term impact on
patients, your practice, your clinic?
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 2010 Health Change Associates
Usual Best Practice or SMS/Coaching
Question: What are Pros & Cons of Current Practice vs. Health Coaching for CDM Patients?
Continue Usual Care
1. What’s working now?
Good
Outcomes
•
•
•
•
Patient education
Staff time and skills
Number of patients served
Available emergency care
4. What are long-term
consequences if no change?
Not so
Good
Outcomes
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Make Some Changes
3. What wuld be long-term
benefits
• For patients—better outcomes?
• For HCPs—job satisfaction, less time
in future?
• For clinic or healthcare facility—better
performance and appropriate usage?
2. What are the challenges of
implement SMS/health coaching?
• For patients—continued
• Time for training and practice
dependence and lack change
• For HCPs—frustration of increasing • Time needed for counselling
• Pressures of 24/7 staffing
patient load and basic care
• ?
• For facility—no improvements in
“Isperformance
anything you and
haveusage
mentioned important enough to make you want to work on this?”
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Examples
Patient Knowledge (Risks, Benefits, Options, Resources)
Role of HCP Depends on Patient
Readiness (to Self-Manage)
Self-Manages (HiKnowHiMotiv)
“Patient Self-Directed”
Patient seeks information; makes
plans, responsible for choice
HCP listens, informs, supports
Guidance: Patient peers, caregivers
Rely on family and peer support
Patient feels empowered
Patient MIA (HiKnowLoMotiv)
“Patient Missing In Action”
Patient seeks reassurance; hesitates,
seeks more options
HCP challenges, supports
Guidance: Support group, counsellor
Rely on peers, HCPs, family
Patient can but won’t
HCP Directs (LoKnowLoMotive)
“Doctor Knows Best”
HCP diagnoses, chooses, directs
Patient does not question; complies
with prescribed treatment
Guidance: Healthcare professional
Rely totally on professional judgment
Patient trusts, follows orders
HCP Educates
(LoKnow;HiMotive)
“HCP Educator”
HCP educates on disease and options
Patient learns what and how to do
HCP clarifies & recommends
Guidance: Healthcare professionals
Rely on professional advice
Patient learns tools and strategies
Patient Motivation (Problem Solving, Self-Confidence)
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Evidence that CDSM Works
 Treatment vs Control: improvements at 6 months in weekly exercise,
cognitive symptom management. communication with physicians,
self-reported. health, health distress, fatigue, disability, and
social/role activities limitations.
 They had fewer hospitalizations and days, In hospital. No differences
were found in pain/physical discomfort, shortness of breath, or
psychological well being.
Lorig, K., Sobel, D., Stewart, A., Brown, B., Bandura, A., Ritter, P., Gonzalez,V., Laurent, D. & Holman,
H. (1999). Evidence suggesting that a Chronic Disease Self-Management Program can improve
health status while reducing hospitalization. Medical Care, 37(1), 5 – 14.
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Evidence of CDSM Long-Term
 Compared with baseline for each of the 2 years, Emergency Room
and outpatient visits and health distress were reduced (P<0.05).
Self-efficacy improved (P<0.05). No other significant changes.
Lorig, K.et al. (2001). Chronic Disease Self-Management Program:Two year health status and health care
utilization outcomes. Medical Care, 39(11), 1217 – 1223.
 Maintenance of change only about 6 months without regular
reinforcement and collaboration with healthcare professional;
counseling and SMBG device introduction improved HbA over 6month follow-up
Siebolds et al (2006). Self-monitoring of blood glucose-psychological aspects relevant to changes in HbA1C in
type 2 diabetic patients treated with diet or diet plus oral antidiabetic medicaiton. Patient Educ Couns, 629(1),
104 – 110.
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Evidence Health Coaching Works - 1
 Health coaching improves patient self-efficacy, adherence to
treatment and behaviour changes as well as health service
utilization and health outcomes. (Kreindler, 2008, Lindner et al,
2003)
 Coaches working with families of children with asthma on lifestyle
and behaviour changes were able to decrease hospitalization,
emergency room, and primary care visits (by 45% to 17%) as well
as use of medications by 20% (Axelrod et al, 2001).
 A randomized control trial using health coaching for six months
with cardiovascular patients showed improvement in health
behaviours and, importantly, a significant decrease in cholesterol
levels (Vale et al, 2002).
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Evidence Health Coaching Works - 2
 RCT comparing health coaching with usual care for patients with
diabetes found significant improvements in HbA1C levels, selfreported treatment adherence, exercise, stress and health status
(Wolever et al, 2010).
 UK Diabetes Year of Care transforms diabetes annual review into
constructive dialogue between HCP and patent. Outcomes:
 Improved experience of care and real changes in self care behaviour.
 Professionals report improved knowledge and skills, and greater job
satisfaction.
 Practices report better organisation and team work.
 Productivity is improved: care planning is cost neutral or yields savings
(www.diabetes.nhs.uk/year_of_care)
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Summary
 There are legitimate reasons why people don’t adhere to treatment
and lifestyle recommendations
 Patient engagement can increase adherence rates and improve patient
self-management
 A health coaching approach can guide practitioners in engaging
patients in self-care in a time efficient manner, to address barriers to
change and achieve better patient health outcomes
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Thank You
For more information contact
The Institute for Optimizing Health Outcomes
www.optimizinghealth.org