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Demystifying Self-Management Support: A Practical Approach

Kathy Reims, MDCharting a Course for the FutureSeptember 24, 2011

Learn a five-step approach to implementing SMS in an ambulatory practiceExplore examples of how practices have implemented each step in the fieldDiscover tools for self-management support that can be adapted by the practice2

Session OverviewSelf-Management Support (SMS)Support for:

The individuals ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.1

Includes health care, community and social structuresMinimizes barriers to SM while supporting families and individuals to SMBuilds on the skills, resources and existing social networks people have in their daily livesCan be provided one-on-one, in groups, or electronically

1Barlow et al, Patient Educ Couns 2002;48:177

3What SMS do you currently provide in your practice?

Five Steps

Involve the Whole TeamEnlist Clinical LeadersProvide Additional SupportLook Beyond AssumptionsPartner Outside your Walls

1. Involve the Whole TeamProvide training: core for all, more for a fewDefine roles and responsibilities Support essential infrastructure: time and resourcesGuide the work but encourage autonomy to find approaches that work There is not a one-size fits all that works*See accompanying Resource List for recommended Training Materials.

6Train the TeamCore training for all staff:Context for SMSStages of ChangeBasic Motivational Interviewing strategiesHow to handle challengesAdvanced training for some:Personal action planning (self-management goals)Outreach and follow-upSpecialized skills health literacy, depression screening, cultural skills, other practice-based skills as needed

*See accompanying Resource List for recommended Training Materials.7EducationBegins with provider determination of needInformation and technical skills are taughtUsually disease-specificAssumes knowledge leads to behavior change (false)Goal is complianceTeachers are always professionals

SMSBegins with the patients self-identified problemsProblem-solving skills are taught Skills are generalizableAssumes self-efficacy leads to change (true)Goal is more self-efficacyTeachers can be professionals or peersBodenheimer et al JAMA 2002;288:2469Medical Professionals often Confuse SMS with Education8Both patient education and SMS are necessary.Some aspects of patient education work well, some do not. Information is necessary and skills must be taught.Knowledge does not create behavior change, and compliance is not a useful goal.Adapted from Bodenheimer, JAMA 2002;288:2469Norris et al. Effectiveness of self-management training in type 2 diabetes, Diabetes Care 2001;24:561-587.Take a medicineIncrease a healthy behaviorDecrease an unhealthy behavior

Status QuoChangeWe call it following a care planSM from the patient perspective is all about change.

Desire to see patients do wellExperience and knowledge to know what it takesReport card for outcomesMy patients are non-compliant..SM Tug of WarMy doctor does not listen to me..

Slide courtesy of IHINot going to be motivatedright nowMotivated by how we interact with them over time10 %10 %Miller & Rollnick, Motivational Interviewing, 200280 %Motivated by InformationCan we impact an individuals behavior? Additional references about information alone being insufficient:Wolf et al. Educational interventions for asthma in children. (Cochrane Review)Valk et al. Patient education for preventing diabetic foot ulceration. (Cochrane Review)Lancaster et al. Self-help interventions for smoking cessation. (Cochrane Review) Stages of Change

Basic Motivational InterviewingActive listeningExpress empathyDevelop discrepancy Roll with resistanceAmbivalence is normalImportance of a personal action plans (self-management goals) Support self-efficacy Operationalize with StaffProcess map strategy for self- management goal setting and follow upRemember to consider documentation of the goal who and whereChoose tools to support the processConsider Group Visit options

Tips and Tools Clear roles and responsibilities for SMSPrompts: work flow, VS, flow sheetUse picturesAsk for patients story Process for unexpected challengesContinued emphasis of team supporting a panel of patients

Blood glucose monitoringTaking medications to help control blood sugarLosing weightDaily foot careDepressionSmokingSkin care

Taking insulinDiet

BUBBLE DIAGRAM Diabetes Here are some things other people have decided to do for their health. Would you like to set goals concerning any of them?17

SMART

Specific, Measurable, Achievable, Realistic, and Timed

2. Clinical LeadershipEncourages supportive cultureRecognizes that SMS is an essential part of careUnderstands SMS takes a teamOpinion leader and can lead by example

Engaging ApproachPersuasion or Sales ApproachCollaborationHonors patients experience and perspective. Reflects on related experience and successes. Respects concerns and perceived barriers to care.ConfrontationImposes reality that the care plan is the right thing to do but the patient just cant see that. Assumes if you say it forcefully enough, you will convert their thinking.EvocationThe motivation for change is presumed to exist. The goal is to get the patient to articulate their reasons to follow a care plan.EducationThe patient is presumed to lack the knowledge for change and education is provided to enlighten so to address this deficit in knowledge. The expectation is that with sufficient knowledge, the patient will follow the plan. AutonomyAffirms that patients own the change and facilitates informed choice regarding care options.AuthorityTells the patient this is what they must do to follow the care plan. Clinical Leaders for SMS are Engaging21Encourage all Providers to:Incorporate SM goal into every visitConsider setting a visit agendaUse MI techniquesLeverage the whole teamEncourage all Staff to:Expect patients to engageBe creative to meet heterogeneous needs of patientsCelebrate SMS successes!

High needs and complicated patientsProgress check or coaching callIncreasingly technology used: text, email, mAppsFocus on removing barriers and improving SMS successOutreach, information, re-assess confidence3. Provide Additional Support: SMS after the Visit

4. Look Beyond Assumptions

Tendency to jump to conclusionsInstead, view SM failure as a challenge:

Health literacy issue? Undiagnosed mental health issue?Cultural issues?Other undisclosed barriers?Goal too ambitious? Ambivalence? Prefer a more anonymous approach?

Tools to Uncover ChallengesNewest Vital SignPHQ-9Confidence RulerDirect but open-ended questionsAdvanced MI skillsExplore alternatives: web sites, apps

5. Partner Outside your WallsCommunity OrganizationsPublic HealthSchoolsWorkplaceSocial SupportsPeer Supports

Take Home PointsSelf-management is essentialSelf-management requires change and patients need support to make changesA step-wise, methodical approach can build on the SMS already in placePlease contact me with questions or to share your success!

Kathy Reims, MDkreims@spreadinnovation.com

SMS Resources: Core TrainingSchaefer J, Miller D, Goldstein M, Simmons L. Partnering in Self-Management Support: A Toolkit for Clinicians. Cambridge, MA: Institute for Healthcare Improvement; 2009. Available at: www.IHI.org Physician Tip Sheet for Self-Management Support. Chicago, IL: American Medical Association; 2008. AMA.orgProchaska, JO; Norcross, JC; DiClemente, CC. Changing for good: the revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits. New York: W. Morrow; 1994. ISBN 0688112633.

SMS Resources: Advanced Training Cole S. Ultra-Brief Personal Action Planning. Rochester, NY: Stony Brook University Medical Center; 2008.http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162California HealthCare foundation Website: http://www.chcf.org/publications/2005/06/helping-patients-manage-their-chronic-conditions Weiss, Barry D., Mays, Mary Z., Martz, William, Castro, Kelley Merriam, DeWalt, Darren A., Pignone, Michael P., Mockbee, Joy, Hale, Frank A.Quick Assessment of Literacy in Primary Care: The Newest Vital SignAnn Fam Med 2005 3: 514-522

SMS Resources: Advanced TrainingThe Newest Vital Sign: A New Health Literacy Assessment Tool for Health Care Providers http://www.pfizerhealthliteracy.com/physicians-providers/newest-vital-sign.html

The Macarthur Initiative on Depression and Primary Care http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/

Motivational Interviewing http://www.motivationalinterview.org/

Motivational Interviewing in Health Care: Helping Patients Change Behavior (Applications of Motivational Interviewing) Stephen P Rollnick PhD, William R. Miller Phd, Christopher C. Butler MD, Guilford Press, New York, 2008.