SelfManagement Support: Some Practical Hints

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Self-Management SupportSome Practical Hints

• Thomas Bodenheimer MD
• UCSF Department of Family and Community Medicine

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What is self-management?

• Self-management is what people do every day
  decide what to eat, whether to exercise, if and
  when they will monitor their health or take
  medications.
• Everyone self-manages the question is whether or
  not people make decisions that improve their
  health-related behaviors and clinical outcomes.
• Bodenheimer et al. Helping Patients Manage their
  Chronic Conditions. California Healthcare
  Foundation, 2004. www.chcf.org

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What is self-management support?

• Self-management support is what health caregivers
  do to assist and encourage patients to become
  good self-managers.
• Institute of Medicine definition
• the systematic provision of education and
  supportive interventions to increase patients
  skills and confidence in managing their health
  problems, including regular assessment of
  progress and problems, goal setting, and
  problem-solving support.
• IOM. Priority Areas for National Action
  Transforming Health Care Quality. Washington DC
  National Academies Press, 2003, p 52.

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Chronic Care Model
Health System
Community
Resources and Policies
Health Care Organization
Self-Management Support
DeliverySystem Design
ClinicalInformationSystems
Decision Support
Informed, Activated Patient
Prepared, Proactive Practice Team
Productive Interactions
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The goal of self-management supportthe
informed, activated patient

• Requires
• Information-giving
• Collaborative decision-making

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Informed, activated patients

• Informed patient
• 50 of patients leave the physician office visit
  without understanding what the physician said.
  Roter and Hall. Ann Rev Public Health
  198910163
• However, studies in diabetes, hypertension,
  asthma, arthritis, and medication adherence show
  that providing information to patients is not
  sufficient to improve health-related behaviors
  and clinical outcomes. Something additional is
  needed.
• Norris et al. Diabetes Care 200124561. Fahey et
  al. Cochrane Review 2005(1)CD005182. Gibson et
  al. Cochrane Review 2002(1)CD001005. Riemsma et
  al. Cochrane Review 2003(2)CD003688. Haynes et
  al. Cochrane Review 2002(2)CD000011.

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Informed, activated patients

• Activated patient
• The additional factor needed is collaborative
  decision making, including goal-setting and
  teaching problem-solving skills.
• Patients engaged in collaborative decision-making
  and thereby becoming active participants in their
  care have better health-related behaviors and
  clinical outcomes compared with those who remain
  passive recipients of care. Heisler et al. J Gen
  Intern Med 200217243. Bodenheimer T, Lorig K,
  et al. JAMA 20022882469

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The goal of self-management supportthe
informed, activated patient

• What tools can we use to assist patients with
  chronic illness to become informed and activated?
• Informed Closing the loop
• Activated
• Collaborative agenda setting
• Shared decision-making
• Goal-setting, problem-solving with regular,
  sustained follow-up

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Providing information closing the loop

• Study of patients with diabetes in only 12 of
  patient visits, the clinician checked to see if
  the patient understood what the clinician had
  told the patient
• Asking patients if they understood what was said
  is called closing the loop
• In 47 of cases of closing the loop, the patient
  had not understood what the physician said
• When closing the loop took place, HbA1c levels
  were lower than when it did not take place
• Closing the loop should be an integral part of
  advising patients
• Schillinger et al. Arch Intern Med 200316383.

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Encouraging patients to be activated agenda
setting

• A study of 1000 physician visits found that the
  patient did not participate in decisions 91 of
  the time. Braddock et al. JAMA 19992822313
• In a study of 264 visits with family physicians,
  patients making an initial statement of their
  problem were interrupted after an average of 23
  seconds. In 25 of visits the physician never
  asked the patient for his/her concerns at all.
  Marvel et al. JAMA 1999281283
• Collaboratively setting the visit agenda is the
  first step in activating the patient

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Encouraging patients to be activated shared
decision making

• The combination of good patient-clinician
  communication and shared decision making
• Increases patient satisfaction
• Higher self-reported health status
• More adherence to treatment plans
• Improved health outcomes (especially diabetes)
• Heisler et al. JGIM 200217243

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Chronic care improvement project 1

• One chronic care improvement project would be to
  have training sessions for the entire clinic
  staff on closing the loop, collaborative agenda
  setting and shared decision making
• Then have patients complete simple anonymous
  questionnaires about whether they noticed these
  changes taking place

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Encouraging patients to be activated
Goal-setting and action plans

• An important part of activating patients is
  goal-setting assisting patients to set goals and
  make realistic and specific action plans
• Patient chooses goal to lose weight
• Unrealistic action plan I will lose 20 pounds
  in the next month. I will walk 5 miles a day.
• Realistic and specific action plan I will eat
  one candy bar each day rather than the 5 per day
  I eat now. I will walk for 15 minutes each day
  after lunch.
• Success in achieving an action plan increases
  self-efficacy (confidence that one can improve
  ones life)

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Setting a goal

• Kate Lorigs question Is there anything you
  would like to do this week to improve your
  health?

Other things?
Physical activity
Taking medications
Reducing stress?
Healthy diet
Checking sugars
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Self management support

• If people dont want to do something,
• they wont do it
• Kate Lorig RN, Dr. PH
• Stanford Medical School

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Goal-setting

• Goal-setting theory from studies in industry
• A specific goal leads to higher performance than
  does no goal or a vague goal such as do your
  best
• Self-efficacy theory
• Success increases self-efficacy (confidence in
  ones ability to achieve a goal), which in turn
  breeds more success and the setting of higher
  goals.
• Failure reduces self-efficacy leading to goal
  abandonment
• Self-efficacy in health care
• A number of studies related to health behavior
  change demonstrate that increased self-efficacy
  which can be measured using validated
  questionnaires is associated with improved
  health-related behaviors and better clinical
  outcomes
• Bandura A. Self-efficacy The Exercise of
  Control. New York, NY WH Freeman Co 1997
  Strecher et al. Health Educ Q. 199522190 Marks
  et al. Health Promotion Practice 2005637,148.

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Goal-setting

• Goal-setting theorists Locke and Latham support
  the action plan concept with their empirical
  observation that proximal goals (short-term and
  specific) are more effective than distal
  (long-term and general) goals. Action plans are
  proximal goals.
• Locke and Latham, American Psychologist
  200257705.

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Goal-setting

• Ammerman et al. reviewed 92 studies involving
  behavioral interventions to improve diet.
• Goal setting was associated with a greater
  likelihood of obtaining a significant
  intervention effect for all 3 outcomes (less
  total fat, less saturated fat, and more
  fruits/vegetables).
• Ammerman et al. Preventive Medicine 20023525.

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Goal-setting

• Cullen reviewed 13 studies utilizing goal-setting
  in adult nutrition education.
• Persons engaged in goal setting to improve diet
  did better in terms of self-reported dietary
  change, weight loss and improved serum
  cholesterol than control groups.
• Goal setting was most successful if it included
  follow-up, problem-solving, and adjusting
  activities if goals were not being achieved.
• Cullen et al. J Am Diet Assoc 2001101562.

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There is no improvement, Henry. Are you sure
youve given up everything you enjoy?
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Goal-setting

• Shilts reviewed 28 studies of goal-setting for
  dietary and physical activity behavior change.
• 32 of the studies were evaluated as fully
  supporting the use of goal-setting.
• The review concluded that goal-setting has shown
  some promise in promoting dietary and physical
  activity behavior change among adults and that
• The literature for adolescents and children is
  limited.
• Shilts et al. Am J Health Promotion 20041981.

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Goal-setting

• A review of the evidence on improving diet,
  published by the Agency for Healthcare Research
  and Quality, included goal-setting in a list of a
  few intervention components shown to be
  associated with improved behavioral outcomes.
  Systematic Evidence Review Number 18. Counseling
  to Promote a Healthy Diet. AHRQ April 2002
• Pignone et al. reviewed dietary counseling for
  the USPSTF. Goal-setting was one activity thought
  to be associated with healthier behaviors Am J
  Prev Med 20032475

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Goal-setting

• In a study of action planning in 4 private
  practices and 4 safety net clinics, the majority
  of patients reported a behavior change based on
  making an action plan, and low-income patients
  had equal success as higher-income patients
• Handley et al. JABFM 2006 (in press)

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Goal-setting in groups

• Kate Lorig created the Chronic Disease
  Self-Management Program. People with a variety of
  chronic illnesses come together for 7 weekly
  classes learning coping and problem-solving
  skills, goal-setting and action plans.
• The classes are led by a peer leader, usually a
  person with a chronic condition, who is trained
  through Kate Lorigs train the trainer program.
  Patients buddy-up to check on each others action
  plans
• 2 years after the classes were completed, there
  were still improvements in quality of life scores
  and reduced physician and ED visits Lorig et al.
  Medical Care 2001391217
• Lorig, Holman, et al. Living a Healthy Life with
  Chronic Conditions. Palo Alto, CA Bull
  Publishing, 2006. http//patienteducation.stanfor
  d.edu

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Goal setting

• Regular and sustained follow-up is crucial for
  the success of goal-setting and action-planning
• Follow-up includes problem-solving of barriers to
  goal achievement
• Follow-up can be done in person, by phone, by
  medical assistants, promotoras, or other patients

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Chronic care improvement project 2

• Train everyone in the clinic to do goal setting
  and action-planning
• Choose a few people (medical assistants, health
  educators, promotoras) to engage patients in
  goal-setting and action-planning, including
  regular follow-up
• Action plans need to be entered into registries
  or charts and need regular and sustained
  telephone follow-up with problem-solving

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2 Chronic care improvement projects

• Training sessions for the entire clinic staff on
  closing the loop, collaborative agenda setting
  and shared decision making
• 2. Train everyone in the clinic to do goal
  setting and action-planning. Choose a few people
  (medical assistants, health educators,
  promotoras) to engage patients in goal-setting
  and action-planning, including regular follow-up
• Not possible in many primary care settings

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Self-management support and primary care

• To do self-management support
• Closing the loop,
• Collaborative agenda setting
• Shared decision making
• Goal-setting and action-planning
• Regular follow-up
• Requires planned visits

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Planned chronic care visits

• Planned visits are visits in which the only
  agenda topic is the patients chronic
  condition(s)
• Planned visits are essential to assist people to
  adopt healthy behaviors
• Planned visit is antidote to tyranny of the
  urgent -- acute issues crowding out chronic care
  management
• Visits can be with nurses, pharmacists, health
  educators, nutritionists, promotoras, or trained
  patients
• Group or individual visits

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Planned visits

• There is a large body of evidence that planned
  visits improve outcomes for patients with chronic
  conditions
• Sadur et al. Diabetes Care 1999222011. Wagner
  EH et al. Diabetes Care 200125695. Peters,
  Davidson. Diab Care 1998211037. Anderson,
  Funnell et al. Diab Care 199518943. Renders
  et al. Interventions to improve the management
  of diabetes mellitus in primary care, outpatient
  and community settings. Cochrane Review. In
  Cochrane Library Issue 3, 2001.

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Summary

• Two chronic care improvement projects
• Training sessions for the entire clinic staff on
  closing the loop, collaborative agenda setting
  and shared decision making
• Train everyone in the clinic to do goal setting
  and action-planning. Choose a few people (medical
  assistants, health educators, promotoras) to
  engage patients in goal-setting and
  action-planning, including regular follow-up
• Needs a team (clinicians, medical assistants,
  health educators, promotaras, trained patients)
• Needs planned visits by one or more team members

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Self-management support including patients in
their own care.