Transcript Living Well with Chronic Conditions

Living Well with
Chronic Conditions
Also known nationally as the
Chronic Disease Self-Management Program
- Developed by Stanford University -
Introductory Note
• The Utah Approach to CDSMP and Diabetes
Care: In no way is CDSMP to take the place of
Diabetes Self-Management Education (DSME)
• DSME comes first and foremost for a patient with
diabetes
• We would like to view CDSMP as
complementary/supportive to the DSME process
Utah Arthritis Program
• Leads the administration of the Chronic Disease SelfManagement Program in Utah
• Funding sources are the Centers for Disease Control
and Prevention (CDC) and the Administration on Aging
(AoA)
• Work in partnership with the CDC and AoA to address
the burden of arthritis, and other chronic diseases, in
Utah
• Primary objective is to develop partnerships around the
state to increase access to and use of evidence-based
programs
CDC Arthritis Funded States
AoA Funded States for CDSMP
Our Broad Goal
To improve the
quality of life for
people affected by
arthritis and other
chronic conditions.
I love
CDSMP
and
ADEU!
The Chronic Disease Problem
Research has shown that an increasing number of
U.S. families are experiencing high financial burdens
from medical care expenses, as rapidly rising health
care costs are passed on to families in the form of
higher premiums, deductibles, co-payments, and even
reduced benefits. For people with chronic health
conditions, such burdens can be a long-term problem
that threatens their families' financial well-being.
Commonwealth Fund (July 23, 2009)
The Chronic Disease Problem
• Approximately 30% of Utahns have at least one
chronic condition (similar number for U.S.)
• Chronic diseases are the most prevalent and
costly healthcare problems in the U.S.
• More than two-thirds of all deaths are caused by
one or more of five chronic conditions: heart
disease, cancer, stroke, COPD, and diabetes
Sources: BRFSS, 2007; Centers of Disease Control and Prevention (CDC)
The Chronic Disease Problem
• Chronic disease not only affects health and quality of
life, but is also a major driver of healthcare costs…
• Chronic disease accounts for about 75% of the
Nation’s aggregate healthcare spending, or about
$5,300 per person in the U.S. each year
• In taxpayer-funded programs, treatment of chronic
disease constitutes an even larger proportion of
spending:
• 96 cents per dollar for Medicare
• 83 cents per dollar for Medicaid
Source: Centers of Disease Control and Prevention (CDC)
Chronic Disease Rates
Utah
High Cholesterol 25.9%
Hypertension 25.4%
Arthritis: 24.0%
Asthma: 7.9%
Diabetes: 6.9%
U.S.
High Cholesterol 37.6%
Hypertension 26.7%
Arthritis: 26.1%
Asthma: 8.5%
Diabetes: 8.5%
Age-adjusted Rates:
Utah Data: Utah BRFSS 2009
U.S. Data: National Center for Chronic Disease Prevention and Health Promotion, BRFSS Survey
Prevalence of Arthritis Among
Persons With Other Conditions, Utah
Source: BRFSS, 2009
Stanford’s CDSMP
• In the past 20 years or so, the Stanford University,
Patient Education Research Center has developed,
tested, and evaluated self-management programs for
people with chronic health problems
• All programs are designed to help people gain selfconfidence in their ability to control their symptoms
and how their health problems affect their lives
• Workshops are highly interactive, focusing on building
skills, sharing experiences and support
Stanford’s CDSMP
• Once a program is developed, it is evaluated for
effectiveness through a randomized, controlled
trial, which is 2-4 years in length
• It is ONLY after a program has been shown to
be safe and effective through these trials that it
is released for dissemination
• This was the procedure for the Chronic Disease
Self-Management Program (CDSMP)
Chronic Conditions Represented in
CDSMP Workshops
•
•
•
•
•
•
•
52.7% Arthritis
41.0% High Blood Pressure
36.6% Chronic Joint Pain
34.8% Diabetes
33.2% High Cholesterol
27.4% Chronic Pain
23.5% Depression
Source: Utah Arthritis Program, 2010
•
•
•
•
•
•
17.2% Heart Disease
14.3% Asthma
13.2% Lung Disease
12.8% Fibromyalgia
8.0% Cancer
7.6% Kidney Disease
Chronic Conditions Represented in
CDSMP Workshops
3.1%
(68)
9.5%
(211)
12.9%
(286)
20.9%
(465)
20.4%
(454)
15.7%
(350)
17.6%
(391)
Source: Utah Arthritis Program, 2011
Five or More
Four
Three
Two
One
Missing
None
Living Well with Chronic Conditions
Stanford Model of CDSMP
Living Well with Chronic Conditions
Stanford Model of CDSMP
Program Description
– Designed for people who live with any chronic
condition
– Based on the symptoms of chronic conditions
– Participants learn tools that enable them to
self-manage their symptoms
– Community or healthcare-based settings
Living Well with Chronic Conditions
Stanford Model of CDSMP
Patient Engagement Activities
– Participants learn how to identify problems
– Participants learn how to act on problems
– Participants learn how to generate short-term
action plans
– Participants learn problem-solving skills related
to chronic conditions in general
Living Well with Chronic Conditions
Stanford Model of CDSMP
Program Subject Matter:
– Dealing with frustration, fatigue, pain and
isolation
– Exercise for maintaining and improving
strength, flexibility and endurance
– Appropriate use of medication and proper
nutrition
– Communicating effectively with family, friends
and health professionals
– Evaluating new treatments
Living Well with Chronic Conditions
Stanford Model of CDSMP
Program Structure
• Series of 6 sessions, 1 session per week, 2 hours
per session
• Held in community settings (including healthcare)
• Highly scripted curriculum
Living Well with Chronic Conditions
Stanford Model of CDSMP
Program Structure
• Designed to be lay-led; 2 leaders facilitate each
class; at least 1 facilitator also has a chronic
condition
• Workshops offered at no charge (free!)
• Available in Utah in English, Spanish, Tongan
Living Well with Chronic Conditions
Stanford Model of CDSMP
•
Week 1
– Difference between acute and
chronic conditions
– Short term distractions
– Introduce action plans
•
Week 2
– Dealing with difficult emotions
– Physical activity and exercise
•
Week 3
– Better breathing techniques
– Muscle relaxation
– Pain and fatigue management
•
Week 4
– Future plans for healthcare
– Healthy eating
– Communication skills
– Problem solving
•
Week 5
– Medication usage
– Making informed treatment
decisions
– Depression management
– Positive thinking
– Guided imagery
•
Week 6
– Working with your
healthcare professional
– Planning for the future
Living Well with Chronic Conditions
Stanford Model of CDSMP
Improved Outcomes
Self efficacy
Self rated health
Disability
Role activity
Energy/fatigue
Health distress
MD/ER visits
Hospitalization
Lorig, et al 1999, 2001
6 mo.
2 yrs.
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Living Well with Chronic Conditions
Stanford Model of CDSMP
Improved Outcomes
1
Self-efficacy
Self-rated health X
Fatigue
Anxiety/Distress
Role limitation
X
HRQOL
Pain
Exercise
X
Cog. Symp mgmt
2
3
4
5
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
1=Lorig 05, 2=Barlow 05, 3=Goeppinger 07, 4=Kennedy 07, 5=Gitlin 08
Living Well with Chronic Conditions
Stanford Model of CDSMP
Action Plans
– Something they
want to do
– Achievable
– Confidence Level
– Problem Solving
– Action Specific
– What
– How much
– When
– How often
Living Well with Chronic Conditions
Stanford Model of CDSMP
Workshop Resources
• Resource book: Living a Healthy Life with
Chronic Conditions
• CD: Time for Healing
• Weekly action plans and feedback
• Groups are small: 10-15 people
– Share information, interactive learning
activities, problem-solving, decision-making,
social support for change
Living Well with Chronic Conditions
Stanford Model of CDSMP
Infrastructure
• Master Trainers – 11 in state of Utah as of
October 2011 (8 English, 2 Spanish)
– Attend 4 ½ day training at Stanford University
– Teach classes and train leaders
• Peer Leaders / Instructors
– Complete 4-day training taught by 2 Master Trainers in order to
teach classes
• Stanford License
– Each organization teaching this program must purchase a
license from Stanford
• Training Material
– Resource books and CDs for participants and leaders
Living Well with Chronic Conditions
Stanford Model of CDSMP
What participants are saying. . . .
– “I know I can self-manage a few problems and make
life better for me and my husband.”
– “It gave me some important coping mechanisms.”
– “This class has helped me get my life in order.”
– “I recommend this course and handbook to all
seniors.”
– “We have set goals, accomplished them and will
continue to manage our lives better due to this class.”
Source: Class participants of Wasatch and Summit County courses
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP
Spanish Program Development
• Not a translation but an
independent development in
Spanish
• Developed to be culturally
appropriate
• Focus groups conducted in
Spanish
• Health care professionals working
with persons with chronic
conditions
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP
Spanish Program Development
• Participants incorporate healthy habits into their
lives:
– Healthy eating habits
– Exercise (physical activity)
– Cognitive management of symptoms
– Better communication with health care providers
– Overall perception of better health
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP
Week One
Overview/
responsibilities
Acute/chronic
Using
mind/symptoms
Action plans
English
Overview/
Responsibilities
Acute/chronic
Proactive in
management,
Importance of food &
exercise
Healthy food
Spanish
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP
Week Two
Action plan
rpt/problem solve
Difficult emotions
Intro to physical
activity/exercise
Action plan
Share
diaries/problem solve
Formula for a healthy
menu
Action plans
Intro to physical
activity/exercise
English
Exercise practice
Spanish
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP
Week Three
Action plan
report/problem solve
Better breathing
Muscle relaxation
Pain/fatigue
management
Endurance activities
Action plan
Action plan
rpt/problem solve
Prepare a low fat
menu
Managing symptoms
Muscle relaxation
Better breathing
Action plan
English
Spanish
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP
Week Four
Action plan
report/problem solve
Future plans for health
care
Healthy eating
Communication skills
Problem solving
Action plan
English
Action plan rpt/problem
solve
Reading nutrition labels
Finding health care
Managing depression
Positive thinking
Action plan
Spanish
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP
Week Five
Action plan
report/problem solve
Medication usage
Informed treatment
decisions
Depression management
Positive thinking Guided
imagery
Action plan
Action plan
report/problem solve
Communication skills
Future plans for healthcare
Increasing physical activity
intensity
Medication usage
Working with healthcare
professional
Action plan
English
Spanish
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP
Week Six
Action plan rpt/problem
solve
Working with health
care Professional/health
care system
Looking back and plan
future
English
Action plan
rpt/problem solve
Evaluating home
remedies
Guided imagery
Sharing
successes/plan
future
Celebration
Spanish
Ideas for Linking CDSMP with
Diabetes Education
• The Utah Approach to CDSMP and Diabetes
Care: In no way is CDSMP to take the place of
Diabetes Self-Management Education (DSME)
• DSME comes first and foremost for a patient with
diabetes
• That said, we would like to encourage referrals
from Diabetes Programs into local CDSMP
classes for some of the following reasons….
Ideas for Linking CDSMP with
Diabetes Education
• Self-management support option for postDSME (National DSME Standard #7)
• Great option for follow up work with patients
with diabetes (National DSME Standard #8)
• Supports and complements self-management
efforts of diabetes educators/healthcare
providers
• Continuous quality improvement
opportunity??
Ideas for Linking CDSMP with
Diabetes Education
• Powerful evidence-based program for patients
with co-morbid conditions
– CDSMP is successful at addressing mental
health issues as well
• Excellent self-management option for
uninsured patients; if you have to turn away
uninsured patients, please send them to a free
CDSMP workshop
• Addresses income issues by offering classes
at no charge
Ideas for Linking CDSMP with
Diabetes Education
• Opportunity to connect to community
resources (perhaps as part of a planned care
model)
• Reinforces lifestyle behaviors so that patients
continue implementing healthy choices such
as regular physical activity and nutrition
• Other ideas?
Living Well with Chronic Conditions
Stanford Model of CDSMP
General Patient and Provider Benefits
• An evidence-based program such as Living
Well/CDSMP can capture many chronic
diseases through this one channel
• Self-management support option
• Can improve self-rated health and energy levels
• Reduced healthcare utilization (ED visits)
• As the New Jersey program puts it: Feel Better!
Living Well with Chronic Conditions
Stanford Model of CDSMP
Program Partnerships
• University of Utah Community Clinics
• Arthritis Foundation, Utah/Idaho Chapter
• Area Agencies on Aging/Senior Centers:
– Weber-Morgan
– Davis County
– Salt Lake County
– Mountainlands (Summit/Wasatch/Utah Counties)
– Five County (Southwest Utah)
– Tooele County
– San Juan County
Living Well with Chronic Conditions
Stanford Model of CDSMP
Program Partnerships
• Community-based Organizations:
– National Tongan American Society
– Alliance Community Services (Spanish)
• Local Health Departments:
– Bear River
– Central Utah
– Davis County
– Salt Lake Valley
– Southwest
– Tri County
– Utah County
– Weber-Morgan
Living Well with Chronic Conditions
Stanford Model of CDSMP
Program Partnerships
• Dixie Regional Medical Center in St. George
• Valley View Medical Center in Cedar City
• Salt Lake VA Medical Center
• Valley Mental Health
– SL County, Park City, Tooele
• Utah Partnership for Healthy Weight
– Healthy weight project in Magna
Living Well with Chronic Conditions
Stanford Model of CDSMP
Resources
– Stanford University’s site on CDSMP
http://patienteducation.stanford.edu
– Utah Arthritis Program (class schedules)
http://health.utah.gov/arthritis
– Administration on Aging: www.aoa.gov
– National Council on Aging:
http://healthyagingprograms.org
Living Well with Chronic Conditions
Stanford Model of CDSMP
Contact Information
• Utah Arthritis Program: www.health.utah.gov/arthritis
(for class schedules)
• Rebecca Castleton: [email protected];
801-538-9340
• Christine Weiss: [email protected];
801-538-9458
Help Your Clients
Quit Tobacco
Marci Nelson, B.S., CHES
Tobacco Prevention and Control Program
Utah Department of Health
[email protected]
http://www.tobaccofreeutah.org/healthcare.html
(801) 538-7002
Objectives
 Discuss the risks of tobacco use especially the
effects of smoking on diabetes
 Present a brief intervention to quit
 Discuss procedures for implementation
 Supply information on free tobacco cessation
services
Tobacco Use in Utah:
The Problem
 More
than 200,000 Utahns use tobacco
 More than 1,330 die annually from their
smoking
 Nearly 17,150 children exposed to secondhand
smoke in their homes
 $663 million each year in smoking-attributable
medical and lost productivity costs
Source: Tobacco Prevention and Control in Utah Tenth Annual Report - August 2010
Tobacco Health Effects

Long-term

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Heart disease
Stroke
Lung function
Cancers
Ulcer
Infertility

Short-term

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Respiratory illness
Decreased lung capacity
High blood pressure &
cholesterol
Nervousness
Mouth problems
Reduced taste & smell
Responsible for more than 400,000 premature deaths each year in the U.S.
Health Effects of Secondhand Smoke
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Stillbirth; miscarriage
Premature Birth
Cleft palates and lips
Sudden Infant Death
Infertility
Tooth Decay
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Cancer
Bronchitis;
pneumonia
Asthma
Upper Respiratory
Tract Disease
Ear Infections
Coughs
Secondhand smoke affects loved ones & is a powerful
motivator to quit!
Effect of Smoking on Diabetes
 Tobacco raises
blood sugar levels
 Tobacco use increases the risk of heart attack
or stroke
 Increased chance of getting gum disease and
may suffer tooth loss
 Tobacco use can make foot ulcers, foot
infections, and blood vessel disease in the legs
worse
WHY SHOULD CLINICIANS
ADDRESS TOBACCO?
 Tobacco users
expect to be encouraged to quit by
health professionals.
• 72% of Utahns saw a healthcare provider in the last year
 Screening for
tobacco use and providing tobacco
cessation counseling are positively associated with
patient satisfaction (Barzilai et al., 2001).
 Advice from a healthcare provider can double the
chances of successful quitting.
Clinical Practice Guideline for Treating
Tobacco Use and Dependence


Update released May 2008
Sponsored by the Agency for
Healthcare Research and Quality of the
U.S. Public Heath Service with
 Centers for Disease Control and
Prevention
 National Cancer Institute
 National Institute for Drug Addiction
 National Heart, Lung, & Blood
Institute
 Robert Wood Johnson Foundation
Brief Counseling:
ASK, ADVISE, REFER
ASK
about tobacco USE
ADVISE
tobacco users to QUIT
REFER
to other resources
Patient receives assistance, with
follow-up counseling arranged,
from other resources such as
the Utah Tobacco Quit Line
ASSIST
ARRANGE
Step 1: ASK
1 min
Ask EVERY patient about tobacco use status at
EVERY visit.
•
•
•
Current
Former
Never
This occurs most consistently when there are systems
in place, such as question on intake form, chart
stickers, or electronic prompts on electronic medical
records. Chart stickers are available.
Step 2: Advise
1 min
Clinicians should urge all tobacco users to quit.
Even brief advice to quit by a clinician results in greater
quit rates. Smokers cite a clinician's advice to quit as an
important motivator for attempting to stop smoking.
Advice should be:
• clear
• strong
• personalized
Specific to the individual 's own situation
(e.g. oral health condition, family status, costs of tobacco).
What if they are not willing?
Offer a motivational
intervention, the “5 R's”
Relevance
Risks
Rewards
Roadblocks
Repetition
The “5 R’s”
Relevance: Why is quitting important to their own
personal situation?
Risks: Outline the risks of continued tobacco use.
Rewards: Outline the benefits of quitting.
Roadblocks: What are the barriers preventing this
person from quitting? What are some solutions to
these barriers?
Repetition: Repeat this discussion frequently, until
the person is ready to quit.
Step 3: Refer
1 min
Referral options:
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A doctor, nurse, pharmacist, or other clinician, for
additional counseling
The Utah Tobacco Quit Line
Utah QuitNet
Text to Quit
Local Services
- Ending Nicotine Dependence (youth)
- First Step (pregnant women)
Utah Tobacco Quit Line
free: 1.800.QUIT.NOW
- Spanish: 1.877.629.1585
- TTY: 1-877-777-6534
 Monday-Sunday, 6:00 am to 11:00 pm
 FREE
 For adults and youth
 Services available in English, Spanish and
translation in 140 other languages
 Toll
Utah Tobacco Quit Line
• Professional counseling sessions by
telephone – up to five 40-minute sessions
• Individualized Quit Plan
• NRT upon qualification (patch, gum or
lozenge)
• Tailored resources for Utah residents
1.800.QUIT.NOW
Fax Referral System
“Would you like
the Utah Tobacco
Quit Line to help
you quit?”
3 Simple Steps
1. Personalize your forms
online at:
www.tobaccofreeutah.org
/utqlprofax.html
2. 2 A’s and R with client.
For those ready to quit
give them the form to fill
out. Verify signature!
3. Fax form in to the Utah
Tobacco Quit Line:
1-800-483-3076
*The Quit Line will fax you to inform
you of services your patient received.
http://utahquitnet.com
 Quitting guide
 Personalized quit plan
 Medication guide  24 hour community support
 Expert counseling  Online NRT purchase
Lifetime membership!

Text messaging service that offers Utahns daily
quit tips to help them get through the quitting
process

Users text READY to 53535 to receive two quit tips
per day via cell phone for 21 days.
• Users will be asked to answer simple questions regarding
age, gender and zip code.

New research suggests that motivational text
messages more than double the odds that
smokers will be able to kick the habit.
Source: The Lancet, news release, June 29, 2011
Tobacco Dependence:
a 2-Part Problem
Tobacco Dependence
Physiological
Behavioral
The addiction to nicotine
The habit of using tobacco
Treatment
Medications for cessation
Treatment
Behavior change program
Treatment should address the physiological and
the behavioral aspects of dependence.
Smoking Cessation Medications
Nicotine polacrilex gum
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Nicorette (OTC)
Generic nicotine gum (OTC)
Nicotine nasal spray
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Nicotrol NS (Rx)
Nicotine inhaler
Nicotine lozenge
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Commit (OTC)
Generic nicotine lozenge (OTC)
Nicotine transdermal patch

Nicoderm CQ (OTC)
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Nicotrol (OTC)
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Nicotrol (Rx)
Bupropion SR (Zyban)
Varenicline (Chantix)
Generic nicotine patches (OTC, Rx)
These are the only medications that are
FDA-approved for smoking cessation.
What About A Relapse?
Viewed as a learning experience
Not a sign of personal or clinician failure
Continue to provide encouragement
It takes an average of 7 quit attempts to
successfully quit using tobacco!
Make a Commitment
Address tobacco use
with all patients.
At a minimum,
make a commitment to incorporate brief tobacco
interventions as part of routine patient care.
Ask, Advise, and Refer.
For more information, contact:
Tobacco Free Resource Line: 1-877-220-3466 or
http://www.tobaccofreeutah.org/healthcare1.html