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PATIENT- AND FAMILY-CENTERED CARE: Partnerships for Safety & Quality Staff Physician & Resident Physician Toolkit Self-Management Support The VA and Transformation of Organizational Culture Redesign of Primary Care and the Management of Chronic Conditions Patient- and FamilyCentered Care The Recovery Model Self- Management Support Patient-Centered Medical Home Self-Management Support is . . . a way of providing health care that "aids and inspires patients to become informed about their conditions and take an active role in their treatment." Bodenheimer, Helping Patients Manage Their Chronic Conditions, 2005, http://www.chcf.org/topics/patient-self-management Self-Management Support is . . . ▼ The assistance caregivers across all disciplines give to patients with chronic disease in order to encourage and support patient’s daily decisions that improve healthrelated behaviors and clinical outcomes. ▼ A portfolio of techniques and tools that help patients choose healthy behaviors. ▼ A fundamental transformation of the patient-caregiver relationship into a collaborative partnership. Bodenheimer, 2005, http://www.chcf.org/topics/patient-self-management Self-Management Support ▼ Describes and promotes the patient as the expert in managing his or her chronic condition. ▼ Emphasizes the patient's central role in managing his/her health. ▼ Shares information and communication in a way that meets patients’and families’ needs and preferences. Explores and creates the plan based on the patient’s values, preferences, cultural, and personal beliefs. ▼ Collaboratively sets goal(s) and develops action plans; uses skill building and problem-solving strategies that help patients and families identify and overcome barriers to reaching goals. ▼ Provides follow-up on action plans and connects patients with community programs to sustain healthy behaviors. Self-Management Support Essential Activities ▼ Information Sharing ▼ Goal Setting ▼ Action Plans ▼ Follow-Up Support Family-Focused Care Chief Nurse of Mental Health Tuscaloosa VAMC Scenario—Redesigning the Clinic Visit Ralph Jackson is a helicopter pilot who served in Vietnam. He is now 72 years, and he has Type 2 Diabetes. He is married and his wife does the grocery shopping and all the cooking. His Hgb A1c is 11.4. He is taking 2,000 mg of Metformin daily. He finds it challenging to maintain a regular exercise program. Developing Tools for Staff and Physicians to Use . . . \ If you have DIABETES, here are some things you can talk about with your health care provider Choose to talk about changing any of these and add other concerns in the blank circles. Blood glucose monitoring Taking medications to help control blood sugar Taking insulin Physical Activity Diet Depression Losing weight Daily foot care Smoking Adapted from Stott et al, Fam Practice, 1995 by Barbara Kondilis of the RI Chronic Care Collaborative Shared Care Plan Pilot Project Whatcom County Physicians and St. Joseph’s Hospital, Bellingham, WA Transition Planning with the patient and family and hospital, clinic, and other community providers http://www.ihi.org/IHI/Topics/MedicalSurgicalCare/MedicalSurgicalCare General/Tools/TCABHowToGuideTransitionHomeforHF.htm Self-Management Patient Education Programs ▼ K. Lorig, Arthritis Rheumatology, 1985 Arthritis Self- Management Program Knowledge Pain Self-efficacy Medical Office visits (43% below baseline) Cost ($200 to $650 over four years) ▼ Lorig, K., et al. Medical Care, 1999. In 1999, a randomized trial suggests that a chronic disease self-management program with education programs taught by patients (lay leaders) with chronic illness can improve health status while reducing hospitalization ▼ Marks, R., Allegrante, J. P., & Lorig, K., Health Promotion Practice, 2005. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: Implications for health education practice (Part I) A Patient-Centered Approach to Primary Care: The Benefits ▼ Selected aspects of health resource utilization (numbers of visits to specialty care clinics, hospitalizations, and laboratory and diagnostic tests) were lower for patients whose physicians showed higher averages of patientcentered behaviors (or interactions) during the time period of the study. ▼ In addition, a statistically significant association between patient-centered care and total charges for health service utilization during one year of care was demonstrated. Bertakis, K. D. & Azari, R. (2011). Patient-centered care is associated with healthcare utilization, Journal of the American Board of Family Medicine, 24(3), 229-239. A patient advisor who teaches classes in the Healthier Living Series, participates on a QI team, and helps train peer support group facilitators. The Use of Group Visits or Shared Medical Appointments ▼ Group visits or shared medical appointments are another way to enhance the information and support provided people living with chronic conditions and to apply SelfManagement Support concepts. ▼ Group Visits create an important and valuable form of peer support and problem solving. They also provide clinicians the opportunity to share more in-depth information tailored to the interests and priorities of patients and families. ▼ Veteran and family advisors bring important perspectives about management of chronic conditions and it is recommended that several of these advisors be prepared and supported in participating on a QI team to plan, implement, and evaluate group visits. Partnering in Self-Management Support: A Toolkit for Clinicians New Health Partnerships: Improving Care by Engaging Patients May 2009 http://www.teamupforhealth.org/ Team Up For Health Results ▼ Demonstrated positive trends in patient perceptions of patient- provider communication (nine of nine total sites); patient- and family-centered care (six of nine total sites); and self care (six of nine total sites); ▼ Improved provider perception that self-management supports had a positive impact on patient treatment and the patientprovider relationship; cross-site improvements in organizational measures of chronic illness care, with significant improvements in organization of health care delivery and clinical information systems (measured with the ACIC survey); and ▼ Demonstrated positive trends in clinical and process outcomes including A1C screening (eight of nine total sites); A1C levels (six of nine total sites); LDL levels (six of nine total sites); and blood pressure (five of nine total sites). Ways patient and family advisors can help VA clinics. . . FOR VETERANS AND FAMILIES AT THE VISIT ▼ Improve first impressions. ▼ Make waiting rooms become places of learning. ▼ Share tips with other patients and families for how to get the most out of a clinic visit. ▼ Serve as greeters. Ways patient and family advisors can help VA clinics. . . FOR VETERANS AND FAMILIES AFTER THE VISIT ▼ Help design the After Visit Summary. ▼ Help design the clinic's website and find other useful websites. ▼ Update the lists and connections with community resources. ▼ Partner in developing peer support and patient/family education programs. Additional ways patient and family advisors can help VA clinics. . . ▼ Share stories at meetings, in orientation for new staff, and in educational programs for provider. ▼ Participate in mapping the care experience and improving workflow. ▼ Develop tools and information materials for patients and families. ▼ Develop tools for staff and clinicians to use. Team Up for Health: Humboldt Open Door Clinic—The Story of Two Patient Advisors In Summary: Self-Management Support is Encouraging Engagement ▼ This means inviting patients and their families clearly, explicitly, and probably over and over again to: Ask questions until they get answers they understand. Participate in their care to the extent they want. Provide you with information only they have. Share their observations and concerns. Become a valued member of the health care team. ▼ This means inviting patients and their families to serve as advisors in advancing the practice of selfmanagement support.