Engaging Patients in Their Care Theory into Action

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Engaging Patients in Their CareTheory into Action

• Alan Glaseroff MD
• CMO, Humboldt Del Norte IPA
• Wisconsin Dalles
• Oct 6, 2009

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A National Crisis?

• Those With Multiple Conditions Cause Bulk Of
  Medicare Spending Growth
• Sunday Health Policy UpDate (Health Affairs Web
  Exclusive) August 27, 2006
• Virtually all of the growth in Medicare spending
  over the past 15 years can be traced to patients
  who were treated for five or more medical
  conditions during the year, according to a new
  study by economists Kenneth Thorpe and David
  Howard released today as a Web Exclusive on the
  Web site of the journal Health Affairs. These
  beneficiaries alone accounted for 76 percent of
  total Medicare spending in 2002, up from 52.2
  percent in 1987.

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Determinants of Health and Their Contribution to
Premature Death
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Social
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Environmental
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Medical
Behavioral
Genetic
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Schroeder, NEJM 357 12
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We are less important than we think
Hospital Services
Specialists
Primary Care Medical Home
Friends and Family
Workplace
Patients Home
Internet
Community
Place of Worship
The empowered patients medical home ?
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Core of Care
Primary care is about building the productive
relationship
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Aligning Forces for Quality

• Chronic Care Model elements IPA-led community
  wide improvement effort
• Health IT Chronic Disease registry
• Decision Support E-referrals, disease specific
  guidelines at the point of care
• Self-Management Support Health Education
  Alliance
• Delivery System Design Care Support
• Primary Care Renewal IPA-led build your own
  medical home collaborative
• Our Pathways to Health peer-led SMS
• Care Transitions RN-led hospital program for ED
  and post-admit patients
• Comparative Performance Reporting Triple Aim
• Population Health HMO and PPO Measures (HEDIS)
• Patient Experience CAHPS (PAS in CA)
• Efficiency Measures Total Cost of Care, ED
  visits, bed days, generics, imaging for LBP,
  30-day readmits, evidence-based cervical cancer
  screening

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Primary Care Renewal The only way to know is
to try

• Build Your Own Medical Home
• Defining key principles allows each to create
  the medical home ideas and practices that work
  for them and might be useful to others

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New Actions in Practice
PDSAs
Population Management
A process
Proactively engaging patients
Examining Data
Team meetings
A way of seeing
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Self-Management SupportOur Pathways to Health

• Patient Education
• Information and skills are taught
• Usually disease-specific
• Assumes that knowledge creates behavior change
• Goal is compliance
• Teachers are health care professionals
• Didactic

• Self-Management
• Skills to solve patient-identified problems are
  taught
• Skills are generalizable to all chronic
  conditions
• Assumes that confidence yields better outcomes
• Goal is to increase self-efficacy
• Teachers can be professionals or peers
• Interactive

adapted from Bodenheimer, Lorig, et al JAMA
20022882469.
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Care Transitions in the Chronic Care Model

• The intervention focuses on four conceptual
  pillars to empower patients
• Medication self-management Patient is
  knowledgeable about medications and has a
  medication management system.
• Use of a dynamic patient-centered record Patient
  understands and utilizes the Personal Health
  Record (PHR) to facilitate communication and
  ensure continuity of care plan across providers
  and settings. The patient or informal caregiver
  manages the PHR.
• Primary Care and Specialist Follow-Up Patient
  schedules and completes follow-up visit with the
  primary care physician or specialist physician
  and is empowered to be an active participant in
  these interactions.
• Knowledge of Red Flags Patient is knowledgeable
  about indications that their condition is
  worsening and how to respond.

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CareSupport Key Principles (5 Domains)
Community
Resources and Policy
Health System
Organization of Health Care
Self-Management Support
Delivery System Design
Decision Support
Clinical Information Systems
Medical/ Social Health System Access
Individual Social Support System


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Putting It All Together
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Why wouldnt a person with a chronic condition
do everything in their power to live long and
feel well?
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Why Do Our Patients Struggle?
(strong endorsements by physicians) poor
self-discipline 53.2 poor will-power 50.0
not scared enough 36.9 not intelligent
enough 16.3
Polonsky, Boswell and Edelman, 1996
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Do As I Say, Not As I Do

• Attributional Bias
• Im too busy
• My patients come first
• Ill start exercising when I retire
• Character defects in patients, situational
  stressors in ourselves
• Life gets in the way

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What Else Gets in the Way?
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Why Do Our Patients Struggle?

• Almost no one is unmotivated to live a long and
  healthy life.
• The rewards for good diabetes care are
• relatively subtle
• mostly long-term
• If you do everything perfectly, you can expect
  to feelnothing! What a concept to motivate a
  person to strive hard on a daily basis!

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Unachievable Self-Care Plans

• Unclear
• Im supposed to start exercising.
• Unrealistic
• My doctor told me to lose 10 lbs before the next
  visit.
• Taking care of my diabetes means Im supposed to
  eat perfectly and never cheat.

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• WHAT DOESNT WORK
• Labeling patient as unmotivated, unwilling to
  change, or non-compliant
• Taking sides in the patients ambivalence
• Giving advice
• Transmitting unwanted/unneeded information
• Threatening bad outcomes
• What part do you think will fall off first?
• Urging more willpower
• If you would just try harder
• Caring more than the patient

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Key Competency Motivational Interviewing

• Patient-centered, goal-oriented method for
  enhancing intrinsic motivation to change by
  exploring and resolving ambivalence
• MI is collaborative, evocative, and supports
  autonomy
• Express empathy, develop discrepancy, support
  self-efficacy, and roll with resistance
• Helping the patient build their own will,
  discover the change ideas that work for them, and
  execute a individualized plan of action
• Dancing vs Wrestling

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The Overarching Approach

• GOALS BELIEVE SELF-MANAGEMENT IS WORTHWHILE
  The patient must feel there is hope and benefit
  in doing a good job.

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FACTS AND FICTIONS

• Diabetes is the leading cause of adult blindness,
  amputations and kidney failure. True or false?

________________________________________ A.
False. Poorly controlled diabetes is the leading
cause of adult blindness, amputations and kidney
failure.
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Feelings Can Fuel Change

• What are your own feelings about diabetes?
• Judgments (of those who are obese of smokers
  etc) are commonand dangerous
• Be honest!!!
• Put it on a shelf and focus on the patients
  reality

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Feelings Can Fuel Change

• What are the patients feelings?
• Think of a patient youve seen recently
• Have you ever asked how he/she feels about
  his/her diabetes?
• What bugs that person the most about his/her
  diabetes???
• What is working for that person in their current
  lifestyle? (what is the function in the
  dysfunction)
• ASK! (then listen)

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The Overarching Approach

• GOALS BELIEVE SELF-MANAGEMENT IS WORTHWHILE The
  patient must feel there is hope and benefit in
  doing a good job.
• ACTION PLANS KNOW WHAT TO DO The patient must
  have a clear and achievable plan for
  self-management

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Behavior Change Strategies

• Begin with your patients interests
• Agenda must be personally meaningful for the
  patient
• Start with questions, not information
• What questions should we make sure to address
  today?
• Whats been driving you crazy about diabetes?

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Behavior Change Strategies

• Begin with your patients interests
• Believe that your patient is motivated to live a
  long, healthy life
• You are both on the same side

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Behavior Change Strategies

• Begin with your patients interests
• Believe that your patient is motivated to live a
  long, healthy life
• Help your patient determine exactly what they
  might want to change
• Identify and respect patient ambivalence
• Empathize with their dilemma

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Listen Well and Summarize
It sounds like youre inclined in two different
directions. On the one hand, youre somewhat
worried about the possible long-term effects of
your diabetes if you dont manage it well
blindness, amputations, things like that. Those
are distressing to think about. On the other
hand, youre young and you feel fairly healthy
most of the time. You enjoy eating what you
like, and the long-term consequences seem far
away. Youre concerned, and at the same time
youre not concerned.
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Behavior Change Strategies

• Begin with your patients interests
• Believe that your patient is motivated to live a
  long, healthy life
• Help your patient determine exactly what they
  might want to change
• Identify and respect ambivalence
• Present the bouquet
• Develop a reasonable, detailed action plan

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The Action Plan Intervention
1. Dont tell patients what to do 2. Negotiate
what changes to focus on blending your expertise
and patients desires 3. Focus on 1 2 concrete
actions to start Not attitudes, numbers, or
actions to stop Not lose 5 pounds in 2 weeks
InsteadWalk briskly 20 minutes 3 x/ week,
Monday, Wednesday and Friday after lunch
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The Action Plan Intervention

• 4. Start with changes that are achievable
• even if physiologically silly
• 5. Selected actions must be personally meaningful
• 6. Do the first step right away
• What does this mean youll do tomorrow AM?

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The Action Plan Intervention

• Identify area for behavior change
• Importance and confidence should be elevated
• Determine a specific action plan
• Meaningful, action-oriented, measurable,
  behavioral
• Make certain that goals are practical/achievable
• Break down, specify, and limit steps as needed
• Ask about obstacles, and problem solve
• Feed back your understanding of the plan
• Offer support/sincere encouragement, BUT
• OFFER AS LITTLE ADVICE AS POSSIBLE!

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Behavior Change Strategies

• Begin with your patients interests
• Believe that your patient is motivated to live a
  long, healthy life
• Help your patient determine exactly what they
  might want to change
• Develop a reasonable, detailed action plan
• Stay alert for common obstacles

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Patient Self-Management Barriers

• Social devastation (poverty, homelessness, lack
  of access to health care services, etc)
• Lack of information
• Cultural disconnect
• Low functional health literacy
• Relative lack of life skills
• Anxiety/disease-specific distress/depression

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Creating Meaning

• Meaning is a human need. It strengthens us, not
  by numbing our pain or distracting us from our
  problems, or even by comforting us. It heals us
  by reminding us of our integrity, who we are, and
  what we stand for. It offers a place from which
  to meet the challenges of life. Part of our
  responsibility as professionals is to fight for
  our sense of meaningagainst fatigue and
  numbness, overwork, and unreasonable
  expectationsto find ways to strengthen it in
  ourselves and each other.
• Rachel Naomi Remen, Recapturing the soul of
  medicine, West J Med 2001 1744-5.

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