Self Management Overview

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Self Management - Overview

• Co-facilitatorsFiona Manning, Frank Egan Ellen
  Anderson, Edwina Ingle, Esther Stevens

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Before we start

• Facilities, breaks
• Review/adapt ground rules
• Group/partner work format
• BCMA payment forms
• Evaluation forms

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• Shared responsibility
• Mutual respect and understanding
• Commitment
• Participation
• Full attention
• Time management
• Acronyms confuse
• Informality

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Agenda

• Introductions (name, where you work)
• Learning session format
• Assumptions and Approaches
• Plan for action

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Ongoing Support
Getting Started
Sep 13
Prework
Ongoing
AP1
Aug 16
AP2
Oct 11
AP3
Jul 19
Month 0
Month 9-12
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Meet Frank

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What we know

• Age 49
• T2DM for 11 years
• Divorced father 3 teens
• Lives alone
• Works as a truck driver
• Smokes 20/day
• Drinks 16 beer /wk

• BMI 35
• BPtru 148/88
• HbA1c 8.9
• TC/HDL ratio 4.8
• EGFR 67
• Last Blood work and visit 6 months ago
• Last 3 month Rx 6 months ago

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Purpose of todays learning session

• To create a safe space for doctors and MOAs to
  learn and experiment with new ways to help
  patients in better managing their health
• To focus on building lives, not just treating
  illnesses (Dr. Mark Ragins-Medical Director,
  MHA Village Integrated Service Agency, Los
  Angeles)

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SM Learning Objectives

• Reflect on our own self management strategies and
  challenges
• Learn and practice patient empowerment, education
  and support skills
• Develop an action plan to practice new skills in
  real time

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Whose agenda?

• DOCTOR
• Tests labwork, eyes
• Treatment compliance
• Thoroughness Complete flowsheet
• Time Busy office schedule
• Tracking Must remember to call Specialist

• PATIENT
• Fear Dad died at 63 after leg amputation
• Family Mom in nursing home, kids in hockey
• Finances child support, inadequate wage
• Fault guilt about wt, etc

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• Shifting our focus
• Doctors are highly trained to sniff out deficits
  We are great at figuring out What is wrong with
  you?
• In order for most people to change their
  attitudes/behaviours/lifestyle to better manage
  their health, they need to understand, identify
  and work with their strengths, what has worked
  well for them in the recent past.

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Its all about the patient

• Principle of freedom of choice, patient autonomy
• ?        Empathy
• ?        Asking permission
• ?        Patient directed care
• ?        Patient as consumer
• ?        Conveying respect
• ?        Active listening
• ?        Two way communication
• ?        Rolling with resistance

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Attitude is fundamental

• Our mind-set (attitude, beliefs, spirit) is more
  important than adoption of, or proficiency in,
  any particular communication strategy
• Extensive training in counselling is not
  necessary
• Our belief in a patients ability to make their
  own best choices is paramount

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Common Assumptions

• The patient OUGHT to change.
• This patient WANTS to change.
• This patient wants to change because of his/her
  health issue.
• If a patient rejects change, you are to blame.
• Patients are either motivated to change or not.
• The best time to change is NOW.
• Patients need confrontation to motivate change.
• My advice is expert, patients MUST follow it.
• A negotiation process (eg. like settling a labor
  dispute) is the best way to initiate change.

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The Why How To Get Started of Patient Self
Management

• ..and try it in the context of your current
  practice without always being late!

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Institute of Medicine New Rules for the 21st
Century

• THE OLD PARADIGM
• Care is based on patient initiated visits
• Professional autonomy drives variability
• Professionals control care
• Information is a record

• THE NEW PARADIGM
• Care is based on continuing relationships
• Care is customized according to pt needs and
  values
• The patient is the source of control
• Knowledge is shared and information flows freely

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IOM New Rules cont.

• Decision making is based on training and
  experience
• Do no harm is an individual responsibility
• Secrecy is necessary
• The system reacts to needs
• Cost reduction is sought
• Preference is given to professional roles over
  the system

• Decision making is evidence-based and informed
• Safety is a system property
• Transparency is necessary
• Needs are anticipated
• Waste is continuously decreased
• Co-operation among clinicians is a priority

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Key Messages

• Self management support can be embedded in every
  primary care visit
• The practitioners mind-set is more important
  than proficiency in a specific technique
• The clinicians belief that a patient can become
  an active self manager is itself a powerful force

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Where to start?

• There is no Recipe
• We are going to present you a Menu of options
  and a chance to try them out
• Spontaneity often rules our personal encounters
• Effective Spontaneity requires some background
  structure and rules
• Respect for the person in front of us is key to
  our success

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Dr. Kathy Reims

• A 3 minute audio clip

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Establishing concordance

• A shared understanding of the problem
• Agreement on direction and purpose of their
  office visit
• Empowering explanations
• A way to come to agreement on and support patient
  chosen goals for behavior change

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There are many paths to the same place

• What framework do you prefer?
• What fits best with your clinical style?
• What works best for different kinds of patients?
• and for different kinds of problems?
• It helps if you have a chance to try out new ways
  of doing things.
• See one, do one, teach one

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What if the patient doesnt want to change
anything?

• Arguing creates resistance
• Change happens when it is internally motivated
• Just because you think something needs to change
  doesnt mean the patient sees it the same way
• It takes time to develop discrepancy
• Real change may be made up of many very small
  steps and may take a long time

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What about patient education?

• Educating a patient is NOT the same as nurturing
  self management
• But it may be a necessary first step to..
• A shared understanding of a problem
• The patient is the expert on what it is like to
  be them
• The doc usually knows more about the medical
  problem or the condition

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Back to Frank..
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Back to Frank..

• What if we try and understand Franks priorities?
• What if we work with his strengths?
• What if we encourage and support his own chosen
  specific realistic and scheduled goals? (with
  some coaching of course)

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Small group discussion

• 20 minute activity
• 10 minute summaries from each group

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Break 20 minutes
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4 Key words for our shift in approach

• Humility
• Graciousness
• Hope
• Partnership

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Primary care can be humbling

• Sincere advice on self care is usually met with
  superficial agreement
• Repeated advice that someone doesnt follow can
  make the doc feel frustrated and the patient
  embarassedguiltyashamedavoidant
• Patients are more likely to engage in self
  management if they sense that their practitioner
  is already engaged in their own self management

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Patient centered practice is gracious

• If we are truly patient centered in our
  approach, patients are more likely to engage in
  self management
• We respect patient autonomy
• We ask permission
• We listen actively
• We allow two-way communication
• We are non-judgmental

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Hope is essential for change

• Patients who have a strong sense of self efficacy
  are more likely to try new things
• Self efficacy is different than will-power
• Some folks know their own strengths others need
  us to help them remember and engage their
  strengths
• Ambivalence about trying new things is normal
• An effective coach believes in their clients
  capacity

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Patients need partners to support their change

• The entire health care team including MOAs can
  support patients in new behaviors
• We can share our important knowledge effectively
  without advice giving and persuasion
• Empowering explanations exchange necessary
  information between practitioner and patient

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A Menu of models

• The 3 questions approach
• Kate Lorig Model
• BCCFP Self management program
• The 5 As
• Stage of change trans theoretical approach
• Motivational interviewing
• Strength-based counseling strategies
• Health literacy sensitivity/knowledge

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THE 3 Questions

• What worries you most about your condition?
• How do you feel about this?
• What would you most like to change and how do you
  think you might do that?

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A word about the 3 x10 minute role plays

• There are no non-participants
• Take turns in each role clinician/MOA, patient,
  observer
• Have some fun with it
• Dont try to be the worlds MOST difficult
  patient (but dont be too easy either)
• 5 minutes in each role, 5 minutes for observation
  supportive discussion (no advice!) then switch
• Notice your own feelings about doing this

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Office Action Plan

•  20 minutes to make an office plan for self
  management changes you will try in the next month
• Next Learning Session is Thursday, August 16,
  same time and place.

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List of Tools and Resources

• Self Management Document Chris Rauscher
• Connie Sixta Manual
• Prochaska, James O. Norcross, John C. (2001)
  Stages of Change.
• www.practicesupport.bc.ca
• Please share what you have found helpful

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Payment for session
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Patient Self Management LS Billing
Action Periods x 3
Potential Total 3,586.65
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CME Info

• Please Confirm (applied for both MAINPRO- M1 and
  C level accreditation )

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Evaluation Forms
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Summary
Breathe deekg