Transcript Patient Self-Management

MSK Train the Trainer 1
Patient Self-Management
Connie Davis, MN, ARNP
[email protected]
www.pspbc.ca
Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
- Grants/Research Support: PharmaCorp ABC
- Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
- Consulting Fees: MedX Group Inc.
- Other: Employee of XYZ Hospital Group
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Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
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Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
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Certification
 Up to 21 Mainpro+ Certified credits for GPs awarded upon
completion of:
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› At least 1 Action Period
› The Post-Activity Reflective Questionnaire (2 months after LS3)
 Up to 10.5 Section 1 credits for Specialists
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› The Post-Activity Reflective Questionnaire (2 months after LS3)
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Update/revise
Action Plan
Report of AP1
experiences &
successes
Payment for:
PMV (optional)
LS1
Action Period 1
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Refine
implementation;
embed & sustain
improvements
attempted in
practice via
Action Plan +
AP2
requirements
Interactive
group learning
Finalize Action
Plan
Report of AP2
experiences &
successes
Payment for:
LS2
Action Period 2
LS3
Reflection
Interactive
group learning
Learning Session 3
Create Action
Plan (using
template)
Planning & initial
implementation
in practice;
review of Action
Plan &
improvements
attempted in
practice + AP1
requirements
Action Period 2
Interactive
group learning
Learning Session 2
Opportunity
for in-practice
visit to
introduce
applicable
EMR-enabled
tools &
templates prior
to LS1
Action Period 1
Learning Session 1
Pre-Module Visit
Learning Session & Action Period Workflow
Reinforce &
validate practice
improvements
GPs & Specialists
complete PostActivity
Reflective
Questionnaire
(PARQ) 2 months
after LS3 &
submit to PSP
Central
Payment Stream 1 (ideal)
Current Rates:
GPs
Specialists
MOAs
Hourly Rate
$125.73
$148.31
$20.00
Action Period 1
$880.10
$1,038.16
N/A
Action Period 2
$660.07
$778.62
N/A
Payment made after attending LS2
Payment made after attending LS3
GPs:
GPs:
PMV
= $125.73
LS2
= $440.05 ($125.73 x 3.5hrs max.)
LS1
= $440.05 ($125.73 x 3.5hrs max.)
AP2
= $660.08
AP1
= $880.10
LS3
= $440.05 ($125.73 x 3.5hrs max.)
TOTAL
$1,445.88
TOTAL
Specialists
Specialists
LS1
= $519.08 ($148.31 x 3.5hrs max.)
LS2
= $519.08 ($148.31 x 3.5hrs max.)
AP1
= $1,038.16
AP2
= $778.62
$1,557.24
LS3
= $519.08 ($148.31 x 3.5hrs max.)
TOTAL
TOTAL
MOAs
$1,816.78
MOAs
PMV
= $20.00
LS1
= $80.00 ($20.00 x 4hrs max.)
LS2
= $80.00 ($20.00 x 4hrs max.)
$100.00
LS3
= $80.00 ($20.00 x 4hrs max.)
TOTAL
TOTAL
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$1,540.18
$160.00
What do I hope to accomplish?
 Define self-management, self-management support, and selfefficacy
 Describe what is known about self-efficacy and its influence on
behavior and health
 Describe Brief Action Planning as an approach for improving
self-management of MSK conditions
 Link to resources for self-management
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Think about a time when you accomplished
something that challenged you…
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When you accomplished it, how did you feel?
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Did that success lead to anything else? If so, what?
Mt Outram, BC, photo by C Davis
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What is self-efficacy?
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Self-efficacy
 People’s beliefs about their
capabilities to perform specific
behaviors and their ability to
exercise influence over events that
affect their lives.
- Albert Bandura
Mt Frosty, BC, photo by C Davis
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What is self-management?
 Self-management relates to the tasks that an individual must
undertake to live well with one or more chronic conditions. These
tasks include gaining confidence to deal with medical
management, role management and emotional management.
- Adams, Greiner and Corrigan (2004)
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What is self-management support?
 The systematic provision of education and supportive
interventions by health care staff to increase patients’ skills and
confidence in managing their health problems, including regular
assessment of progress and problems, goal setting, and problemsolving support.
- Adams et al 2004
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Patient education and self-management support
 Patient education
 Information and skills are taught
 Usually disease-specific
 May assume that knowledge
creates behavior change
 Goal is often compliance
 Health care professionals are
the teachers
Bodenheimer et al JAMA 2002;288:2469
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 Self-management support
 Skills to solve pt. identified
problems are taught
 Skills are generalizable
 Assumes that confidence
yields better outcomes
 Goal is increased self-efficacy
 Teachers can be professionals
or peers
Stepped Care for Self-management Support
Healthy Communities and
Supportive Family, Friends, and
Caregivers
Expert
Methods
Advanced Approaches
(MI, Case/Care Mgmt, PST, Group, etc.)
Behavior Change Support:
Goal Setting, Action Planning,
Problem solving, Follow-up
Culture
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Health
Literacy
Patients as Partners, British Columbia
Activation
How does self-efficacy impact health?
 High self-efficacy is associated with better
› recovery level after a heart attack or heart surgery
› coping with cancer or end-stage kidney disease
› adherence to medication
› lung function in chronic lung disease
› living with chronic fatigue syndrome
› pain management
› adherence to prescribed exercise routines
› control of alcohol or drug use
•
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- cited in Bandura, 1998
How can you increase self-efficacy?
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Ways to increase self-efficacy
 Skills mastery
 Modeling
 Reinterpreting symptoms
 Social persuasion
- Lorig & Holman, Ann Behav Med 2003
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Skills mastery
 Learning new skills and being successful
 What can work:
› Action plans to break big goals into smaller, more realistic
steps
› Education programs that teach skills
Joshua Bell
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Modeling
 Seeing and hearing from others like you who have been
successful
 What can work
› Group visits
› Peer supports
› Profiles, biographies of successful self-managers
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Reinterpreting Symptoms
Poor
sleep
Physical
limitations
Fatigue
 Symptoms are not just caused
by the disease, but can be due
to other factors.
 What can work:
› breathing techniques
Shortness
of breath
SYMPTOMS
a vicious
cycle
› relaxation
Pain
› healthy eating
Stress/
anxiety
Depression
› physical activity
› sleep hygiene
Difficult
emotions
Lorig et al, Living a Healthy Life with
Chronic Conditions, Bull Publishing, 2012
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Social Persuasion
Encouragement, expression of hope
 What can work
› structure for success (ex: small action
plans)
› group visits
› peer support
› affirmations (not praise)
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Can you really improve self-efficacy?
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Chronic Disease Self-Management Program
 Develop and studied by Kate Lorig and colleagues at Stanford
 Lay-leaders, 6 sessions, 2 1/2 hours each
 Addresses multiple conditions
 Includes planning and problem solving, skill acquisition
 “Everything you wish people knew”
 Outcomes: improved health behaviors and health status, fewer
hospitalizations some sustained for 2 years
Lorig, Med Care 1999;37:5, 2002;39:1217
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What was that?
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For the numbers people…
Treatment
Exercise in people with LBP
NNT
5-9
Time
3 months
Weight reduction OA
3
4 months
Non-tramadol opioids for OA
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12 weeks
(50% reduction in pain rating, median=51mg
morphine equivalent)
Froud et al, 2009; Tools for Practice, 19 Mar 2012, Zhang et al, OA & cartilage 2010
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NNT, cont
Tramadol for OA (for every 8 pts treated,
6
12 weeks
Topical NSAIDS for OA
4.6
14 weeks
Optimal tx comorbid MSK &
depression (optimized antidepressants
4.8
1 yr
1 stopped due to AE)
followed by 12 wks self-management education)
References: Tools for Practice, 19 Mar 2012; 24 Jan 2011; Kroenke et al JAMA, 2009
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Lunch
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What can we do to help people with MSK
conditions?
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What is Brief Action Planning?
 A self-management support tool based on the principles and
practice of Motivational Interviewing
 It is
› structured
› patient-centered
› evidence-informed
Reims et al, Brief Action Planning White Paper, 2013 available at
www.centreCMI.ca
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Spirit of Motivational Interviewing
 Compassion
 Acceptance
 Partnership
 Evocation
Miller W, Rollnick S. Motivational Interviewing: Preparing People for
Change, 3ed, 2013
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“Is there anything you would like to do for your health in the
next week or two?”
Behavioral Menu
Elicit a Commitment Statement
SMART Behavioral Plan
“How confident (on a scale from 0 to 10) do you feel about carrying out
your plan?”
If Confidence <7, Problem Solve Barriers
“Would you like to check in with me to review how you are
doing with your plan?”
Follow-up
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Time to Practice
 Work in pairs
 Each will help the other make an action plan (or not) for
something they really want to do (real play!)
 We will go one step at a time, so I will stop you after each step.
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Question 1
“Is there anything you would like to do for your health in the
next week or two?”
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Skill #1
Behavioral Menu
 Offer a behavioral menu when needed or requested.
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Behavioral Menu
 “Is it okay if I share some ideas from other people who are
working to improve their health? “
 If yes, share two or three ideas briefly in a group.
 “Maybe one of these would be of interest to you or maybe you
have thought of something else while we have been talking?”
Exercise
Weight
management
Resuming
Daily
Activities
Taking meds
Adapted from Stott et al, Family Practice 1995; Rollnick et al, 1999, 2010
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Skill #2
SMART Behavioral Plan
Action Planning is “SMART”: Specific, Measurable, Achievable,
Relevant and Timed
• What?
• How much?
• When?
• Where?
• How often?
Based on the work of Locke
(1968) and Locke & Latham
.
(1990, 2002); Bodenheimer, 2009
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Skill #3
Elicit a Commitment
Statement
 After the plan has been formulated, the clinician/coach elicits a
final “commitment statement.”
 Strength of the commitment statement predicts success on action
plan.
Aharonovich, 2008; Amrhein, 2003
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Question 2
“How confident (on a scale from 0 to 10) do you
feel about carrying out your plan?”
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Skill #4
Problem Solving
 Problem-solving is used for confidence levels less than 7.
Bandura, 1983; Lorig et al, Med Care 2001; Bodenheimer review,
CHCF 2005; Bodenheimer, Pt Ed Couns 2009.
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Problem Solving
“A ___ (the number they chose) is higher than a zero.
That’s good.”
“Is there something you could do to
raise your confidence?”
Yes
No
Behavioral Menu
Revise plan, restate plan and
repeat confidence measure
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Question 3
“Would you like to check in with me to review how you are
doing with your plan?”
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Skill #5
Follow-up
Follow-up builds confidence



Follow-up often with early action plans and decrease
frequency as behavior is more secure.
Regular contact over time is better than 1x intervention.
Follow-up builds a trusting relationship
Resnicow, 2002; Artinian et al, Circulation,2010
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Follow-up
“How did it go with your
plan?”
Success
Partial
success
Recognize
success
Recognize partial
success
Did not try or no
success
Reassure that this is
common occurrence
“What would you like to do
next?”
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“Is there anything you would like to do for your health in the next
week or two?”
Have an
idea?
Specific
Measureable
Achievable
Relevant
Timely
Not sure?
Behavioral Menu
SMART Behavioral Plan
Elicit a Commitment Statement
Not at
this time
Permission to
check next time
1) Ask permission to
share ideas.
2) Share 2-3 ideas.
3) Ask if any of these
ideas or something else
might work.
“How confident (on a scale from 0 to 10) do you feel about carrying
out your plan?”
Confidence <7,
Problem Solving
Confidence ≥7
“Would you like to set a specific time to check back in with me so we can
review how things have been going with the plan?”
Follow-up
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Tips for Giving Information and Advice
 When?
› They ask for information or advice
› You ask permission to give it
› You have a professional obligation to inform your client of
something they don’t know
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Tips for Giving Information and Advice
How? ASK-TELL-ASK and respect their autonomy
› ASK
 Ask what they already know
› TELL
 Fill in any gaps or gently correct misunderstandings
 Concentrate on key messages
› ASK
 Use Teach-Back
 Ask what they think about your information or advice
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What do we know about Brief Action Planning in
practice?
 Family practice
› team sport
› Question 1 asked in about half the visits
› half of those make an action plan
› 2/3 will do at least part of their plan
 Specialty practice
› in rheumatology, Question 1 asked routinely will result in ¾ of
patients making action plans
- unpublished data, CCMI and Handley, 2006
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What resources are there to support people with
MSK conditions?
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Tools in MSK Toolkit
 Arthritis education programs resource list
 Resources for acute and chronic low back pain
 CHARD
 Local arthritis resources
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Purpose of the Personal Health Record
 Compile health information – share with new providers or foster
communication between providers
 Track symptom changes
 Prepare for medical visit
 Set action plan and monitor outcomes of those actions
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Current Personal Health Record
 10 Sections
› Personal and health care team information
› My health care appointments
› Allergies
› Medical conditions/surgeries
› Medications/supplements
› Test results
› Pain diary / General health diary
› Notes for next health care visit
› Reminder for future medical tests
› My action plan
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Arthritis Society Programs
 Arthritis answers line
 www.Arthritis.Ca
 Arthritis self-management program
 Chronic pain management workshop
 Lifestyle makeover challenge
 Take charge! Early intervention for OA
 Joint works and water works
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Talk to Your Doctor and other Health Care
Professionals
 Trained peer leaders
 Started in Prince George, Victoria and the Lower Mainland
 Workshop focused on
› Informed shared decision-making
› Communication skills for patients (prepare, ask, clarify,
express concerns)
 Partnering with many organizations as workshop providers
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Additional Information
 Arthritis Society
 Programs & Personal Health Records
› Mary Pack Arthritis Program
 OASIS
› education workshops, resources
 More about motivational approaches
› www.centreCMI.ca
› www.motivationalinterviewing.org
› Motivational Interviewing in Health Care by Rollnick, Miller and
Butler, 2007, Guildford Press
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Thank you!
Coquihalla Highway from Mt Henning, photo by C Davis
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