Transcript Self-management support

Self-management support
Thomas Bodenheimer MD
with lots of help from
Improving Chronic Illness Care
Self-management support is
more than patient education
• Patient education
– Information and skills are
taught
– Usually disease-specific
– Assumes that knowledge
creates behavior change
– Goal is compliance
– Health care professionals
are the teachers
• Self-management
support
– Skills to solve patientidentified problems are
taught
– Skills are generalizable to
all chronic conditions
– Assumes that confidence
yields better outcomes
– Goal is increased selfefficacy
– Teachers can be
professionals or peers
Why is self-management support
important?
• Every person self-manages his/her
chronic condition. 99% of chronic care
decisions are made by the patient away
from the health care system
• The question is, does the person selfmanage well or poorly?
• Managing well improves clinical
outcomes
Self-management support and
compliance/adherence
• Compliance/adherence may not be
helpful concepts
• Noncompliance or non-adherence
assumes that 1) the patient has the
information needed to make healthy
decisions, and 2) the patient was involved
in the decisions
• Often, neither 1) nor 2) is true
Compliance/adherence
• Compliance: “the extent to which a person’s behavior
(in terms of taking medications, following diets, or
executing lifestyle changes) coincides with medical or
health advice.” Lutfey and Wishner, Diab Care
1999;22:635.
• Adherence “the extent to which a patient’s behavior (in
terms of taking medication, following a diet, modifying
habits, or attending clinics) coincides with medical or
health advice.” McDonald et al. JAMA 2002;288:2868.
Compliance/adherence
• Compliance and adherence are synonyms
• They are also the same as “patient selfmanagement behaviors” or “healthy
behaviors”
• Use the term “healthy behaviors” as having the
same meaning as compliance or adherence
• “Healthy behaviors” doesn’t compare patients
with some professionally-set standard
Compliance/adherence
• For doctors, the word “compliance” (with
practice guidelines) is appropriate
• Docs chose to be docs. They should held
to a standard: do what’s evidence-based
• Patients didn’t choose to be chronically
ill. They can’t be held to a standard
• For patients, the words “compliance/
adherence” are less appropriate
Many people fail to choose healthy
behaviors because they lack information
• One study: 76% of patients with type 2 diabetes
received limited or no diabetes education
• 300 medical encounters: doctors spent average 1.3
minutes giving information
• Another study: only 37% of patients were
adequately informed about medications they were
taking
Clement, Diab Care 1995;18:1204. Waitzkin. JAMA 1984;252:2441
Many people choose unhealthy behaviors
because they lack information
• 50% of patients leave office visit not understanding
what the doctor said
• Study of 264 visits to family physicians. During patient
initial statement of the problem, physician interrupted
after average of 23 seconds.
• Failure to provide information to patients about their
chronic condition is associated with unhealthy
behaviors. If people don’t know what to do, they don’t
do it
O’Brien et al. Medical Care Review 1992;49:435. Kravitz et al.
Arch Intern Med 1993;153:1869. Roter and Hall. Ann Rev
Public Health 1989;10:163. Marvel JAMA 1999;281:283.
Information is necessary but
not sufficient
• Information by itself does not improve clinical
outcomes; people with diabetes gaining
knowledge about their condition do not have
lower HbA1c than those uninformed. Norris et al. Diab
Care 2001;24:561
• An additional factor is needed
• That additional factor appears to be collaborative
decision making, which makes the patient an
active participant in his/her management.
Patients in empowerment classes have lower
HbA1c than controls. Anderson, Funnell. Diabetes Care
1995;18:943.
Many people choose unhealthy
behaviors because they were not
involved in clinical decisions
• Study of 1000 physician visits, the patient did
not participate in decisions 91% of the time
• When patients are involved in decisions, healthrelated behavior is improved and clinical
outcomes (for example HbA1c levels) are better
than if patients are not involved
Braddock et al. JAMA 1999;282;2313. Heisler et al. J Gen Intern
Med 2002;17:243. Greenfield et al. J Gen Intern Med 1988;3:448
Back to compliance/adherence
• One cannot expect a patient to “comply” with a
physician’s advice if the patient doesn’t
understand the advice
• One cannot expect a patient to “adhere” to a
physician’s advice if the patient doesn’t agree
with the advice
• Much “noncomplance/nonadherence” (i.e.
unhealthy behaviors) is related to inadequate
information-giving and lack of collaborative
decision making
Does self-management support attempt
to improve patient
compliance/adherence?
• No, the purpose of self-management support is
to encourage patients to become informed and
activated
– By providing information
– By encouraging collaborative decision-making
– By assisting people to set their own goals
• Many (not all) patients will choose goals that do
improve their health-related behaviors
Chronic Care Model
Community
Resources and Policies
SelfManagement
Support
Informed,
Activated
Patient
Health System
Health Care Organization
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Informed, activated patient
Key conclusion:
Informed, activated patients have
healthier behaviors and improved
clinical outcomes
Golin et al. Diab Care 1996;19:1153. Piette et al. J Gen Intern Med 2003;18:624.
Francis et al. N Engl J Med 1969;280:535. Roter. Health Educ Monographs
1997;5:281. Greenfield, Kaplan et al. J Gen Intern Med 1988;3:448. Heisler et al. J
Gen Intern Med 2002;17:243.
Informed, activated patient
Requires:
Information-giving
Collaborative decision-making
These are the two parts of selfmanagement support
The 15-minute system
Short, unplanned MD visit, no team
Patient not taught about her illness
No collaborative decision making
Uninformed, passive
patient
Unprepared practice
team
We need to redesign primary care
delivery systems to provide selfmanagement support, which
creates informed, activated
patients
Information-giving
Collaborative decision-making
The 5 A’s
• A clinical algorithm used for tobacco
cessation
• Has become part of the US Public Health
Service guidelines on quitting smoking
www.surgeongeneral.gov/tobacco/5steps.htm
• It has been adopted for other healthrelated behaviors
Self-management support
in office practice
ASSESS
Knowledge
Beliefs,
Behavior,
Barriers,
Confidence
ADVISE
Provide personalized
information about
condition and
benefits of change
AGREE
Collaborative goal and action plan
ARRANGE
Follow-up and resources
ASSIST
Use motivational
techniques
and teach
problem-solving
Assess
•
•
•
•
•
•
•
Knowledge
Skills
Importance
Confidence
Supports
Barriers
Risk Factors
Let’s look at Importance and Confidence
Bubble chart
Kate Lorig’s question: “Is there anything you
would like to do this week to improve your
health?”
Other things?
Physical
activity
Healthy diet
Reducing
stress?
Taking
medications
Checking
sugars
If patient picks a domain, assess
readiness to make a change
• Readiness = importance and confidence
• If patient doesn’t think it’s important,
he/she won’t make a change. Give
information
• If patient thinks change is important, but
has no confidence that he/she can change,
assess and try to increase confidence
Assessing Importance
“How important do you think it is to exercise to
improve your blood sugar?”
Not at all 0 1 2 3 4 5 6 7 8 9 10
convinced
Patient says 4
“Why 4 and not zero?”
“What would it take to move it to a 8?”
(From Keller and White, 1997; Rollnick, Mason and Butler, 1999)
Totally
convinced
Assessing Confidence
How confident are you that you can exercise to
improve your blood sugar?
Not at all
confident
1 2 3 4 5 6 7 8 9 10
Totally
confident
Patient says 4
“Why 4 and not zero?
“What would it take to move it to an 8?”
Advise
Provide specific personalized
information about the chronic illness,
the health risks and the benefits of
change
Advise: provide information
• Information-giving is disease-specific
• Telling people 150 facts about diabetes does not
work. It is far more effective to find out what
people want to know, and give them the
information they want.
• Also, make sure people understand the information
given them
• 2 tools
– Ask-tell-ask
– Closing the loop
Advise: Ask-Tell-Ask
• When patients are given a lot of information,
they regain only a small amount
• Ask-tell-ask: Ask patients: “What do you know
about your diabetes, and what would you like
to know? When patients say what they want to
know, tell them. Then ask again: what do you
think about what you heard, and are there
other things you want to know?
Advise
• A study of patients with diabetes found that in
only12% of patient visits, the clinician checked
to see if the patient understood what the
clinician had told the patient
• This is called “closing the loop”
• In 47% of cases of closing the loop, the patient
had not understood what the physician said
• When closing the loop took place, HbA1c levels
were lower than when it did not take place
• Closing the loop should be an integral part of
advising patients
Schillinger et al. Arch Intern Med 2003;163:83.
Agree
Collaboratively select goals and an
action plan to meet those goals
Action plan
1. Something you WANT to do
2. Describe
How
Where
What
Frequency
When
3. Barriers
4. Plans to overcome barriers
5. Confidence rating (1-10)
6. Follow-Up plan
Source: Lorig et al, 2001
Action plan: example
1. Something you WANT to do: Get more activity
2. Describe:
How: With friend
Where: 3 times around block
What: Walk
Frequency: Mon, Wed, Fri, Sat
When: After lunch
3. Barriers: Forget
4. Plan to overcome barriers: Put a note on fridge
5. Confidence rating (1-10): 7
6. Follow-Up plan: medical assistant will call me next week
Action plan
• Base goals on patient priorities
• Action plans are specific steps to help
achieve goals
• Action plans should be easily achievable
with confidence level 7 or greater
• Purpose is to increase self-efficacy: a
person’s confidence that he/she can make
changes to improve life
Assist
Problem-solving to help overcome barriers to
achieving goals
Problem Solving
1.
2.
3.
4.
5.
6.
7.
Identify the problem.
List all possible solutions.
Pick one.
Try it for 2 weeks.
If it doesn’t work, try another.
If that doesn’t work, find a resource for ideas.
If that doesn’t work, accept that the problem may not
be solvable now.
Source: Lorig et al, 2001
Arrange
Schedule follow-up to provide
ongoing assistance and support to
adjust or change or problem-solve
the action plan as needed
Arrange: follow-up
• Try a wide variety of methods, whichever patient
prefers (in-person, phone, email)
• Make sure follow-up happens, patient trust can
be destroyed by missed follow-up
• Use outreach and community opportunities
• Easiest is to see if patient wants to go a group, in
which case follow-up takes place in the group
• Follow-up can be done by other patients (buddy
system)
Opportunities for self
management support
• Before the Encounter
• During the Encounter
• After the Encounter
From Russ Glasgow, PhD
Opportunities for self
management support
Before the Encounter
• Pre-visit contact (phone,
mail, e-mail, PDA, touchscreen computer, student,
medical assistant)
• Pamphlets on “Talking to
Your Provider”
Pre-activation of patients
• 10 minute meeting with health educator to help patients
formulate questions for physician led to more patient
involvement in decisions [Roter. Health Educ Monographs
1997;5:281]
• Interactive pre-visit booklet -- to write down agenda
topics and learn techniques for recalling physician
advice -- led to better retention of information and
healthier behaviors -- lifestyle changes and medication
use [Cegala et al. Arch Fam Med 2000;9:57]
Pre-activation of patients
• 20-minute pre-visit meeting to prepare
patients with diabetes to participate in
decision-making
• Pre-activated patients had greater control
over visit agenda (shown by audiotapes)
than control patients
• Pre-activated patients had better HbA1c
levels than control patients
Greenfield, Kaplan et al. J Gen Intern Med 1988;3:448
Opportunities for self
management support
During the Encounter
• Assess what goals patient
wants to work on
• See if patient willing to discuss
action plan
• Information-giving (ask-tellask)
• Closing the loop
• Referral to community resource
Planned chronic care visits
• Group diabetes visits at Kaiser/Permanente led by
nurse educator: significantly lower HbA1c levels and
lower hospital use compared with controls [Sadur et al.Diab
Care 1999;22:2011]
• Diabetes “mini-clinics” at Group Health in Seattle: for
patients who regularly attended the clinics, better
glycemic control than usual care patients [Wagner et al.
Diab Care 2001;25:695]
Planned chronic care visits
• Nurse-led diabetes planned visit clinic had
better HbA1c levels than controls [Peters, Davidson.
Diab Care 1998;21:1037]
• Planned diabetes visits with nurse and
endocrinologist had lower mortality and lower
incidence of MI, revascularization, angina,
ESRD than control patients; median follow-up
was 7 years [So et al. Am J Managed Care 2003;9:606]
• Patients attending planned diabetes
empowerment classes had lower HbA1c levels
compared with controls [Anderson, Funnell et al. Diab
Care 1995;18:943]
Planned chronic care visits
• Planned visits are essential to assist
people to adopt healthy behaviors
• Planned visit is antidote to “tyranny of
the urgent” -- acute issues crowding out
chronic care management
• Visits can be with nurses, pharmacists,
health educators, nutritionists,
promotoras, or trained patients
• Group or individual visits
Opportunities for self
management support
After the Encounter
• Referrals (health educator,
medical assistant, community
resource)
• Phone, e-mail, web follow-up
• Peer support (buddy system)
• Chronic disease selfmanagement course
Regular, sustained follow-up
• VA system: nurse-initiated phone contacts
between visits improved glycemic control
compared with usual care [Weinberger et al. J Gen
Intern Med 1995;10:59]
• Cochrane Review: 5 RCTs -- better HbA1c
levels in patients with regular follow-up
compared with controls [Griffin, Kinmouth. Cochrane
Library, Issue 3, 2001]
• Regular follow-up is a predictor of proper
medication use [Dunbar-Jacob. Health Psychology
1993;12:91]
Regular, sustained follow-up
• Diabetes education without regular
follow-up is unlikely to result in longterm behavior change success [Clement. Diab
Care 1995;18:1204]
• Follow-up can be done by visits with any
caregiver, in groups, patient buddies,
promotoras, telephone, e-mail, web
Chronic Disease SelfManagement Program
• Developed and studied by Kate Lorig and colleagues at Stanford
• Peer-leaders (patients with chronic illness), 6 sessions, 2 1/2
hours each
• Addresses multiple conditions
• Goal-setting, action plans, problem solving, skill acquisition
• Patients call each other between sessions
• Outcomes: improved health behaviors and health status, fewer
hospitalizations; some improvements sustained for 2 yrs
Lorig et al. Medical Care 1999;37:5, 2002;39:1217
Who can do goal-setting, action
plans, follow-up?
•
•
•
•
•
•
•
Trained peers
Health educators
Nurses
Physicians
Medical assistants
Students
Any caring person...
Resources
• Book: Rollnick et al. Health Behavior Change. 1999.
• Book: Lorig, Holman, Sobel et al. Living a Healthy
Life with Chronic Conditions. 2nd edition. Palo Alto,
Bull Publishing, 2001.
• Bibliography on self-management:
www.improvingchroniccare.org
• Download Action Plan forms in English, Spanish and
Chinese: www.action-plans.org
Web resources
• www.bayerinstitute.com provides provider
training in “Choices and Changes”
• www.motivationalinterview.org has books, videos
and training
• www.stanford.edu/group/perc home of Chronic
Disease Self-Management Program
Take-home points
• Self-management support includes
– Information-giving
– Collaborative decision-making
– Goal-setting/problem-solving
• It can be done before, during, and after a
primary care visit. Planned chronic care visits
are the ideal place
• A primary care physician cannot do selfmanagement support alone. It takes a team.