Transcript Self Management - Stonechurch Family Health Centre

Self-management:
A Practical Primer for
Family Practitioners
Lisa McCarthy RPh BScPhm PharmD
Michele MacDonald-Werstuck RD MSc CDE
Inge Schabort MB ChB CCFP
October 29, 2009
Disclosure
• Presenters perceive no conflict of interest
with this presentation.
• Slides will be available at:
www.stonechurchclinic.ca
Introducing Susan...
• 41 year old female, Type 1 diabetes
– Attended all diabetes education in the area,
sent back to you by the specialist due to nonadherence
• A1c 0.095
• Progressing retinopathy, neuropathy
• eGFR 15
A source of frustration to you and your team,
what do you do?
Today’s Goal
• Discuss some strategies that you can try
with your Susan’s when you get home...
– And your not-so-challenging folks too! 
Burden of Chronic Illness in
Canada
• 2/3 deaths in Canada due to chronic
disease
– cancer, CVD, type 2 diabetes, chronic
obstructive lung disorders
• Significant impact on health care system,
economy, quality of life
Improving the Health of Canadians. Chronic Disease Prevention
Alliance of Canada, 2007.
Burden Cont’d
• Through healthier diet, regular activity and
avoidance of tobacco
– Estimates 80% premature heart disease,
stroke, diabetes and 40% cancers could be
prevented
• This is not news to health care providers
or patients, yet there is still a gap
Improving the Health of Canadians. Chronic Disease Prevention
Alliance of Canada, 2007.
Objectives
• At the end of the session, participants will
be able to:
1) Define self-management.
2) Describe the rationale for its gaining
momentum as means for empowering
patients.
3) Explain how family physicians can support
patient self-management efforts
efficiently in day-to-day practice.
3 Terms to Know
• Self-Management
• Self-Efficacy
• Self-Management Support
Self-Management Defined
• “The tasks that an individual must undertake to
live well with one or more chronic conditions.
– These tasks include having confidence to deal with:
• 1) medical management (tasks associated with the
condition)
• 2) role management (tasks required for everyday living)
• 3) emotional management (coping with anger, fear,
frustration and sadness).”
Institute of Medicine, Report of a Summit, Sept 2004
Self-Efficacy
• Confidence that one
can carry out a
behaviour necessary
to reach a desired
goal (Bandura 1986)
• **Successful
achievement of a goal
is more important
than the goal itself**
Bodenheimer, T et al. JAMA 2002;288(19):2469-2475.
WAIT! Not all of my patients
want to be self-managers...
• Patient self-management is inevitable
– Patients decide what they eat, to exercise or
not and whether to take prescribed
medications
• “The question is not whether patients with chronic
conditions can manage their illness, but how they
manage (Bodenheimer et al 2002)”
Bodenheimer, T et al. JAMA 2002;288(19):2469-2475.
Self-management Support
(SMS)
• “requires a provider or health care team to
perform a certain set of tasks to create the selfefficacy necessary for a patient to deal
confidently with their own range of emotional,
physical, + physiological symptoms of their
chronic disease”
McGowan P. In: Dorland J, McColl MA, editors. Emerging Approaches to Chronic
Disease Management in Primary Health Care: Managing chronic disease in the
twenty-first century. Queens University School of Policy; 2007.
SMS Cont’d
• SMS is not the same as patient education.
• Helps patients to adopt healthy behaviours
and problem solve.
• Overall goal of SMS
– Increase patients’ confidence in their ability to
change their own health behaviours
Supporting Patient Self-Management Module,
www.practicesupport.bc.ca
“That’s great, does it work?”
The Evidence
• Literature supporting patient selfmanagement has many limitations
– Differing definitions of SMS + multifactor
interventions
• 2006 systematic review of systematic
reviews
– Compiled 11 systematic reviews
• Diabetes (6)
• Asthma, COPD, Hypertension, Arthritis (2 each)
Zwar N et al. 2006. Available at:
http://www.anu.edu.au/aphcri/Domain/ChronicDisea
seMgmt/Approved_25_Zwar.pdf
Outcome Measures
Number of
Number of
Studies Positive
Studies
Findings
HCP Guideline Adherence
Patient Service Use
1
0
1
3
Patient Physiologic
Measure of Disease
9
11
Patient Quality of Life
Patient Medication
Adherence
Patient knowledge
2
2
3
3
5
5
Zwar N et al. 2006. Available at:
http://www.anu.edu.au/aphcri/Domain/ChronicDiseaseMgmt/Approved_25_Zwar.pdf
Goal Setting and Action Plans
Let’s Share
• What are some of the goals you have for
“your Susan’s”?
• What are “your Susan’s” goals for herself?
SMART Goals
•
•
•
•
•
Specific
Measurable
Action-Oriented
Realistic & Relevant
Time-Based
Goal Setting Steps
•
•
•
•
1) What are you going to do?
2) How much are you going to do?
3) When are you going to do it?
4) How often are you going to do it?
Let’s Practice
1. Choose one behaviour change you would
like to embrace in your own life.
2. How could you make this into a SMART
goal?
Pick something you are
comfortable sharing with a
partner 
The Confidence Ruler
• On a scale of 0 to 10, with 0 being not at all
confident and 10 being as confident as you can
be, how confident are you that you can achieve
your goal?
0
1
2
Not At All
Confident 
3
4
A Little
Confident
5
6
Somewhat
confident
7
8
9
Very Confident
10
Extremely
Confident 
http://www.newhealthpartnerships.org
Pitfalls to Avoid
• Assumptions about
patient’s knowledge
• Avoid setting goals for
• If a patient is having a
your patients
hard time setting a
– Remember motivation
goal, it is OK to help
and confidence
by making
suggestions as to
what may improve
their condition
The Challenging Patient
• Any step toward a potential positive
behaviour change is something
• The goal could be to come up with a list of
pros and cons to the recommended
behaviour change
Strategies for Bringing
SMS To Your Practice
Before the Visit
Before the Visit
• Pre-visit contact by you or your staff
(phone, email, mail)
• Waiting room assessment forms
• Patient education materials
During the Visit
During the Visit
• Review waiting room assessments
• Goal setting and action planning
– If follow up visit, make sure to give feedback
on achievements and goals
• Referral for more SMS
• 5 A’s or 3 questions
Referrals for SMS
• You don’t need to be the expert!
• There are many out there, your job is to
find them
– e.g., Stanford Chronic Disease SelfManagement Program
Starting SMS in a Visit
• 1) What worries you most about your
health?
• 2) How do you feel about it?
• 3) What do you think you may be able to
do about it?
http://www.impactbc.ca/practicesupportprogram/resourcesforregionalsupportteam
s/cdmresources/patientself-management
Assessing Motivation
•
•
•
•
•
Ask
Assess
Advise
Assist
Arrange
•
•
•
•
•
Relevance
Risks
Rewards
Roadblocks
Repetition
From: Michael Valis 2009 Moving Mountains: Helping Patients with Lifestyle Change
From: Lewis J. 2008. Diabetes Self
Management Support Toolkit for Health
Professionals in Ontario
Tips
• Don’t rush into thinking it’s your job to
solve the problem
• Assess the situation and determine:
– Is this a problem of motivation?
– Is this a problem of behaviour?
– Is this a problem of stress or emotion?
After the Visit
After the Visit
• Referrals to other
supports
• Further 5 A’s
counseling
• Phone call follow-up
• Mailed patient
education
•
•
•
•
Peer support
Newsletters
Follow up visits
Email/web sites
Take Home Messages
• You don’t have to be an expert to support
self-management in your practice.
• If you set goals with your patients, critical
(and time saving!) to revisit at the next
follow-up.
Let’s Take It Home
SET A GOAL!
Over the next week, I will ___________ to
support self-management in my practice.
Examples...
• Ask patients their view of the challenges they
face (3 questions)
• Waiting room assessment form
• Help patients to generate simple and achievable
action plans
• Identify local resources for self-management
education
Goal Setting
•
•
•
•
1) What are you going to do?
2) How much are you going to do?
3) When are you going to do it?
4) How often are you going to do it?
Resources
• Review Articles
– Bodenheimer T et al. Patient Self-management of Chronic Disease
in Primary Care. JAMA 2002;288:2469-75.
– Coleman MT, Newton KS. Supporting Self-management in Patients
with Chronic Illness. Am Fam Physician 2005;72:1503-10.
• Tools
– Stanford Self-Management Programs. Stanford School of Medicine.
http://patienteducation.stanford.edu/programs/
– Institute for Healthcare Improvement.
http://www.ihi.org/IHI/Topics/PatientCenteredCare/SelfManagement
Support/
– Improving Chronic Illness Care
http://www.improvingchroniccare.org
–
Slides will be available at www.stonechurchclinic.ca
Contact Information
[email protected]
[email protected]
[email protected]