Patient Self-Management

Patrick McGowan, PhDUniversity of VictoriaCentre on Aging

Workshop OverviewWorkshop OverviewChronic conditionsComplexity of behaviourChronic vs. acute conditionsPatient needsRole of self-managementBC Expanded Chronic Care Model PracticeThe “Living a Healthy Life with Chronic Conditions” programProgram effectivenessOther BC Programs to encourage patient self-management

What’s the objective?What’s the objective?

Judy’s Story

Why does Judy eat this way?

Chicken Strips, fries, Caesar Salad and peach pie

Predisposing factors

Reinforcingfactors

Enablingfactors

Behaviourand

Lifestyle

Environment

HealthQuality

ofLife

PRECEDEPRECEDE--PROCEED PROCEED model of health promotion planning model of health promotion planning

Green & Green & KreuterKreuter, 1999, 1999

Predisposing Factors

KnowledgeBeliefsAttitudes ValuesMotivationConfidenceSelf-efficacy

Reinforcing Factors

FamilyPeersEmployersComfortingRelieves stress

Enabling Factors

Health-related skillsAccessibility to information Accessibility of health resources

Differences Between Acute and Chronic DiseaseDifferences Between Acute and Chronic Disease

ACUTE DISEASE CHRONIC DISEASE

BEGINNING Rapid Gradual

CAUSE Usually one Many

DURATION Short Indefinite

DIAGNOSIS Commonly accurate Often uncertain, especially early

DIAGNOSTIC TESTS Often decisive Often of limited value

TREATMENT Cure common Cure rare

ROLE OF PROFESSIONAL Select and conduct therapy Teacher and partner

ROLE OF PATIENT Follow orders Partner of health professionals, responsible for daily management

1. Recognizing and acting on their symptoms

2. Making most effective use of their medications and treatments

3. Dealing with acute attacks or exacerbations (managing emergencies)

4. Maintaining their nutrition and diet

5. Maintaining adequate exercise

6. Giving up smoking

7. Using stress reduction techniques

8. Interacting effectively with their health providers

9. Using community resources

10. Managing work and the resources of employment services (adapting to work)

11. Managing relations with significant others

12. Managing their psychological responses to illness.

New TasksNew Tasks

Traditional Patient EducationAsthma

Proper use of inhalerSelf-monitoringEnvironmental control measures

DiabetesInsulin injectionBlood-glucose monitoringHealthy eating (glucose levels)

Heart diseaseMedicationInformation on pacemakers, arrhythmias, chest pain, acute complicationshealthy eating (cholesterol)

Rheumatoid arthritisMedication Joint protection & use of adaptive equipment

Patient Contact with Health ProfessionalsPatient Contact with Health Professionals

Time managing at home over 1 yearTime managing at home over 1 year

GP visits per annum = 1 hourGP visits per annum = 1 hour

Visits to specialists = 1 hourVisits to specialists = 1 hour

PT, OT, Dietitian = 10 hoursPT, OT, Dietitian = 10 hours

Total = 12 hours with professionalsTotal = 12 hours with professionals

364.5 days managing on their own or 8748 hours364.5 days managing on their own or 8748 hours

Barlow, J. Interdisciplinary Research Centre in Health, School oBarlow, J. Interdisciplinary Research Centre in Health, School of f Health & Social Sciences, Coventry University, May 2003.Health & Social Sciences, Coventry University, May 2003.

Definition of SelfDefinition of Self--ManagementManagement

The tasks that individuals must undertake to live well with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management and emotional management of their conditions.

Report of a Summit. The 1st Annual Crossing the Quality Chasm Summit. September 2004

Self-management support is defined as the systematic provision of education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support.

SelfManagement /

Develop Personal Skills Decision

Support

InformationSystems

Delivery System Design /

Reorient Health Services

Build Healthy

Public Policy

CreateSupportive

Environments

StrengthenCommunity

Action

ActivatedCommunity

InformedActivatedPatient

ProductiveInteractions &Relationships

Population Health Outcomes / Functional and Clinical Outcomes

FIG. 1: THE EXPANDED CHRONIC CARE MODEL:INTEGRATING POPULATION HEALTH

PROMOTION

PreparedProactivePractice

Team

PreparedProactive

CommunityPartners

Traditional Definition of Traditional Definition of SelfSelf--ManagementManagement

“Self-management behaviours” for diabetes defined as:

- self injection of insulin- self-monitoring of glucose levels- eating properly- smoking cessation- exercising- taking medications properly

Practicing these “self-management behaviours” there is an expectation that intermediate goals will be achieved:- metabolic control- optimal blood glucose levels- blood lipid control- optimal weight

And, if these intermediate goals are achieved, there should be better diabetes outcomes:

- a reduction in morbidity (retinopathy, neuropathy, nephropathy)- fewer hospitalizations- a reduction in diabetes-related health care costs- reduced mortality

Education provides problem-solving skills relevant to the consequences of chronic conditions in general

Education is disease-specific and teaches information and technical skills related to the disease

What is the relation of education to the disease?

The patient identifies problems experienced that may or may not be related to the disease

Problems reflect inadequate control of the disease

How are problems formulated?

Skills on how to act on problems

Information & technical skills about the disease

What is taught?

Self-Management Education

TraditionalPatient Education

A health professional, peer leader, or other patients, often in group settings

A health professionalWho is the educator?

Increased self-efficacy to improve clinical outcomes

Compliance with behaviour changes taught to the patient to improve clinical outcomes

What is the goal?

Greater patient confidence in capacity to make life-improving changes (self-efficacy) yields better clinical outcomes

Disease-specific knowledge creates behaviour change, which in turn produces better clinical outcomes

What is the theory underlying the education?

Self-Management Education

TraditionalPatient Education

Facilitating Patient SelfFacilitating Patient Self--ManagementManagement

1. Using “Mastery Learning” strategies with patients.

2. Teaching and practicing “Problem-Solving” with patients.

3. Encouraging patients to participate in the community patient self-management program.

1. Mastery LearningMastery Learning

Goal → Action Plan → Follow-Up

Judy’s Goal

A Goal is something that you should be able to accomplish in 3 to 6 months from now. It’s too big to be able to accomplish all at once.

Judy replies: “I want to loose some weight”

An Action Plan is something that you can do between this visit and the next that contributes to achieving that goal.

1.1. Something YOU want to do Something YOU want to do

2.2. Reasonable Reasonable

3.3. BehaviourBehaviour--specific specific

4.4. Answer the questions:Answer the questions:

WhatWhat

How muchHow much

WhenWhen

How often How often

5.5. Confidence level that you will complete the Confidence level that you will complete the ENTIREENTIREaction planaction plan

Parts of an Action PlanParts of an Action Plan

Goal Goal –– Judy wants to lose Judy wants to lose some weightsome weight

This week I am not going to eat anything after 7 PM on at least 5 of the 7 days.

I am 8 confident that I will accomplish this.

The Action Plan must reflect contributions, preferences, and assessments of feasibility by the patient, not mere acquiescence to physician recommendations.

2. Problem2. Problem--Solving Steps Solving Steps

Identity the problemList ideasSelect oneAssess the resultsSubstitute another ideaUtilize other resourcesAccept that the problem may not be solvable now

Judy identifies her problem: Judy identifies her problem: ““I am not doing any exerciseI am not doing any exercise””

Possible reasons:Possible reasons:

I donI don’’t have the right clothest have the right clothes

I donI don’’t know what type of exercise I am supposed to dot know what type of exercise I am supposed to do

I have no one to exercise withI have no one to exercise with

Exercise is boringExercise is boring

ItIt’’s painful to exercises painful to exercise

I doesnI doesn’’t have the timet have the time

I am selfI am self--conscious about her body shapeconscious about her body shape

I canI can’’t get motivated to exerciset get motivated to exercise

It must be Judy who identifies the It must be Judy who identifies the mainmain reason why she reason why she isnisn’’t exercisingt exercising

Problem SolvingProblem Solving

1.1. Identify the problem Identify the problem –– I am not exercising because I just canI am not exercising because I just can’’t seem t seem to get motivated. to get motivated.

2.2. List ideasList ideas

•• I can join a club (pay the fee)I can join a club (pay the fee)

•• I can make a exercise schedule and reward herselfI can make a exercise schedule and reward herself

•• I can get a friend to go with me on scheduled walks I can get a friend to go with me on scheduled walks

•• I can persuade hubby to go for walks with me 3 times a week I can persuade hubby to go for walks with me 3 times a week

•• I can exercise at work (e.g., use the stairs, walk at lunch timI can exercise at work (e.g., use the stairs, walk at lunch time)e)

•• I can make an action plan and let all her friends and work I can make an action plan and let all her friends and work colleagues know about it colleagues know about it

3.3. Select one idea to try Select one idea to try –– I willI will gget my husband to go for a 45 minute et my husband to go for a 45 minute walk with me 3 times this week.walk with me 3 times this week.

4. 4. Assess the resultsAssess the results

4.4. Substitute another ideaSubstitute another idea

5.5. Utilize other resourcesUtilize other resources

6.6. Accept that the problem may not be solvable nowAccept that the problem may not be solvable now

Health Care Provider Health Care Provider Patient SelfPatient Self--Management EducationManagement EducationIndividuals and health care providers collaborate in problem solving, addressing issues and concerns to both parties.

Self-Management should be linked to the individual’s regular source of medical care.

Communication among the patient, the self-management delivery staff, and the patient’s usual provider is likely to improve results.

Practice: ProblemPractice: Problem--Solving with a Solving with a ColleagueColleague

1. Identify the problem (relating to either eating or exercise)

2. List ideas that may solve the problem

3. Select one idea to try

““What prevents you from What prevents you from exercising the way you think exercising the way you think

you should and want to?”you should and want to?”

““What prevents you What prevents you from eating the way from eating the way

you think you should you think you should or want to?or want to?””

Action Plan for this WeekAction Plan for this WeekSomething YOU want to do Something YOU want to do Reasonable Reasonable BehaviourBehaviour--specific specific Answer the questions:Answer the questions:

WhatWhatHow muchHow muchWhenWhenHow often How often

Confidence level that you will Confidence level that you will complete the complete the ENTIREENTIRE action planaction plan

The Chronic Disease SelfThe Chronic Disease Self--Management ProgramManagement Program

“Living a Healthy Life with Chronic Health Conditions”

Overview of the Chronic Disease Self-Management Program

Persons with any type of chronic health conditionsSelf-referralSpouses and significant others may participateLed by pairs of lay persons with chronic health conditionsLeaders receive a 4-day training workshop

Overview of the Chronic Disease Self-Management Program

Leaders follow a scripted Leader’s ManualCourse is given once a week for 2 ½ hours for 6 weeksIdeal class size is 10 to 12 personsParticipants receive “Living a Healthy Life with Chronic Conditions” workbookNo cost to participantsHistory of self-management in Canada

What do people learn in selfWhat do people learn in self--management programs?management programs?Information

From the programFrom other participants

Practical SkillsGetting started skills (e.g., exercise)Problem-solving skills Communication skillsWorking with health care professionalsDealing with anger/fear/frustration

Practical Skills (cont’d)Dealing with depressionDealing with fatigueDealing with shortness of breathEvaluating treatment options

Cognitive TechniquesSelf-talkRelaxation techniques

SelfSelf--efficacy Enhancing Strategiesefficacy Enhancing Strategies

Self-efficacy: Health outcomes

ModelingMastery learningVicarious learningPersuasion

Program ImplementationProgram Implementation

ReceptivenessDissemination

Integration

422840783577TOTAL

4474815415Vancouver Island

215021031528Vancouver Coastal

38131596Fraser

10669822319Interior

18420849Northern

ParticipantsCourses Delivered

Leaders Trained

Leader Training WorkshopsRegion

OVERALL TOTALS 2000 to 2004

Chronic Disease Self-Management Program

Program Effectiveness

http://bcauditor.com

Unusual Features of Audit Recommendations

Often, BC audits examine the processes used to implement a particular policy decision within a particular ministry or agency. In such a situation, what to address in recommendations, and who to address them to, is relatively straightforward.

But…

In essence, what we have found is not a program requiring relatively modest changes, but the absence of an organized program. Our recommendations, therefore, have to start from first principles:

Principles of Primary Prevention

Intervention choices must be evidence-based.

Effective interventions are likely to be those that provide the right treatment in sufficient dosage for sufficient time, and are targeted at multiple points of intervention.

Principles for Secondary Prevention

Effective interventions would likely use treatment plans similar to those in recent successful trials such as the Diabetes Prevention Program.

Principles in Tertiary Care

Effectiveness would likely result from care delivery organized using an integrated approach to management, as exemplified by the Chronic Care Model.

Effectiveness of CDSMP

Treatment subjects when compared with control subjects, demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations.

They also had fewer hospitalizations and days in hospital. No differences were found in pain/physical discomfort, shortness of breath, or psychological well being.

Lorig, K., Sobel, D., Stewart, A., Brown, B., Bandura, A., Ritter, P., Gonzalez, V., Laurent, D. & Holman, H. (1999). Evidence suggesting that a Chronic Disease Self-Management Program can improve health status while reducing hospitalization. Medical Care, 37(1), 5 – 14.

2-Year Follow-up

Compared with baseline for each of the 2 years, Emergency Room and outpatient visits and health distress were reduced (P<0.05). Self-efficacy improved (P<0.05). There were no other significant changes.

Lorig, K., Ritter, P., Stewart, A., Sobel, D., Brown, B., Bandura, A., Gonzalez, V., Laurent, D. & Holman, H. (2001). Chronic Disease Self-Management Program: Two year health status and health care utilization outcomes. Medical Care, 39(11), 1217 – 1223.

Yukon ResultsAt six-months post-program, participants:

• were practicing more ways of coping with their symptoms;

• had higher levels of self-efficacy to manage their symptoms and to manage their disease;

• were less bothered by their illness;• were less depressed; • had more energy;• were less distressed about their health condition; • were experiencing less fatigue and shortness of

breath;• were experiencing less pain; • were less limited in their daily activities; and• had better communication with their doctor.

Vancouver/Richmond 2001At six-months post-program, participants:

• were practicing more ways of coping with their symptoms;

• had a higher level of self-efficacy to manage their symptoms;

• had a higher level of self-efficacy to control/manage depression;

• had a higher level of self-efficacy to manage their disease;

• believed they had better health;• were less limited in their daily activities; • were less bothered by their illness;• were less distressed about their health condition; • were experiencing less shortness of breath; and • were experiencing less pain.

Vancouver/Richmond 2003At six-months post-program, participants:

• had a higher level of self-efficacy to manage their symptoms;

• believed they had better health;• were less limited in their daily activities; • were less depressed;• had more energy;• were less distressed with their health condition; • were experiencing less shortness of breath; and • had spent less nights in hospital than they had in the

previous six-month period.

CDSMP Addresses the Determinants of Health

• Social Support Networks• Education• Social Environments• Personal Health Practices and Coping Skills• Health Services• Culture• Gender

Diabetes Self-ManagementLeader Training Workshops

Location LeadersVancouver 12Williams Lake 10Tofino 11Nanaimo 5, 9Victoria 19, 7Alkali Lake 5Prince George 10Parksville 13Sechelt 13Prince George 10, 8Campbell River 6Squamish 11Vernon 13

Kelowna 17Surrey 8Penticton 8Castlegar 7Fort Nelson 2Kamloops 14Chemainus 11Powell River 7

Total: 23 Workshops in 20 Communities226 trained leaders

Program Delivery - ParticipantsLocation ParticipantsVancouver 66Coquitlam 16Richmond 18Victoria 83Ladysmith 6Nanaimo 27Sechelt 20Valemount 18Campbell River 29Parksville 10Qualicum Beach 10Ladner 16Vernon 48Chase 17Powell River 7

Texada Island 7Prince George 65Cowichan 5Sorrento 13Falkland 22Kelowna 12Surrey 53Pemberton 9Penticton 40Castlegar 15Hixon 15Kamloops 86Chemainus 13

Total:66 courses in 26 Communities 746 participants

Diabetes Self-Management

had improved communication with their doctorhad a higher level of self-efficacy to manage disease symptomsbelieved they had better healthwere less distressed by their symptoms were experiencing less painhad increased the number days they ate breakfastwere eating yogurt more often at breakfast had fewer days where they missed taking medications as prescribed

.011.07896.0803256Pre HgA1c >.07

.640.06445.0649051Pre HgA1c >.06 ≤ .07

.003.05888.0560034Pre HgA1c ≤ .06

.161.06887.06995141All

P-valuePostPreNCases

Pre- and six-month post program Hemoglobin A1c levels of course

participants

BC Projects to encourage Patient Self-Management

BC NurseLine – Self-Management ModuleCollege of Family Physicians

Key Points

Knowing isn’t enough – it’s the behaviour!Judy must live her lifeFocus on the “ends”Programs must be “Best Practice”The integration of separate interventions

Toll-free line: 1-866-902-3767

Web site: www.coag.uvic.ca/cdsmp

www.newperspectivesconf.com

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