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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
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Disclosure
• Presenters perceive no conflict of interest with this presentation.
• Slides will be available at: www.stonechurchclinic.ca
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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 non-adherence
• A1c 0.095• Progressing retinopathy, neuropathy• eGFR 15
A source of frustration to you and your team, what do you do?
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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!
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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.
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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.
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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 effortsefficiently in day-to-day practice.
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3 Terms to Know
• Self-Management
• Self-Efficacy
• Self-Management Support
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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
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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.
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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.
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Self-management Support (SMS)
• “requires a provider or health care team to perform a certain set of tasks to create the self-efficacy 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 thetwenty-first century. Queens University School of Policy; 2007.
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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
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“That’s great, does it work?”
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The Evidence• Literature supporting patient self-
management 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
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Outcome Measures Number of Studies Positive
Findings
Number of Studies
HCP Guideline Adherence 1 1
Patient Service Use 0 3
Patient Physiologic Measure of Disease
9 11
Patient Quality of Life 2 3
Patient Medication Adherence
2 3
Patient knowledge 5 5Zwar N et al. 2006. Available at:
http://www.anu.edu.au/aphcri/Domain/ChronicDiseaseMgmt/Approved_25_Zwar.pdf
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Goal Setting and Action Plans
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Let’s Share
• What are some of the goals you have for “your Susan’s”?
• What are “your Susan’s” goals for herself?
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SMART Goals
• Specific
• Measurable
• Action-Oriented
• Realistic & Relevant
• Time-Based
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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?
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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
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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 3 4 5 6 7 8 9 10Not At All
Confident A Little
ConfidentSomewhat confident
Very Confident Extremely Confident
http://www.newhealthpartnerships.org
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Pitfalls to Avoid
• Assumptions about patient’s knowledge
• Avoid setting goals for your patients– Remember motivation
and confidence
• If a patient is having a hard time setting a goal, it is OK to help by making suggestions as to what may improve their condition
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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
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Strategies for Bringing SMS To Your Practice
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Before the Visit
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Before the Visit
• Pre-visit contact by you or your staff (phone, email, mail)
• Waiting room assessment forms
• Patient education materials
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During the Visit
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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
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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 Self-
Management Program
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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/resourcesforregionalsupportteams/cdmresources/patientself-management
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Assessing Motivation
• Ask
• Assess
• Advise
• Assist
• Arrange
• Relevance
• Risks
• Rewards
• Roadblocks
• Repetition
From: Michael Valis 2009 Moving Mountains: Helping Patients with Lifestyle Change
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From: Lewis J. 2008. Diabetes Self Management Support Toolkit for Health
Professionals in Ontario
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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?
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After the Visit
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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
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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.
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Let’s Take It Home
SET A GOAL!
Over the next week, I will ___________ to support self-management in my practice.
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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
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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?
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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/SelfManagementSupport/
– Improving Chronic Illness Care http://www.improvingchroniccare.org
–
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Slides will be available at www.stonechurchclinic.ca
Contact Information