Self-management: A Practical Primer for Family Practitioners

Lisa McCarthy RPh BScPhm PharmD

Michele MacDonald-Werstuck RD MSc CDE

Inge Schabort MB ChB CCFP

October 29, 2009

Disclosure

• Presenters perceive no conflict of interest with this presentation.

• Slides will be available at: www.stonechurchclinic.ca

Introducing Susan...

• 41 year old female, Type 1 diabetes– Attended all diabetes education in the area,

sent back to you by the specialist due to non-adherence

• A1c 0.095• Progressing retinopathy, neuropathy• eGFR 15

A source of frustration to you and your team, what do you do?

Today’s Goal

• Discuss some strategies that you can try with your Susan’s when you get home...– And your not-so-challenging folks too!

Burden of Chronic Illness in Canada

• 2/3 deaths in Canada due to chronic disease – cancer, CVD, type 2 diabetes, chronic

obstructive lung disorders

• Significant impact on health care system, economy, quality of life

Improving the Health of Canadians. Chronic Disease Prevention

Alliance of Canada, 2007.

Burden Cont’d

• Through healthier diet, regular activity and avoidance of tobacco– Estimates 80% premature heart disease,

stroke, diabetes and 40% cancers could be prevented

• This is not news to health care providers or patients, yet there is still a gap

Improving the Health of Canadians. Chronic Disease Prevention Alliance of Canada, 2007.

Objectives

• At the end of the session, participants will be able to:1) Define self-management.

2) Describe the rationale for its gaining momentum as means for empowering patients.

3) Explain how family physicians can support patient self-management effortsefficiently in day-to-day practice.

3 Terms to Know

• Self-Management

• Self-Efficacy

• Self-Management Support

Self-Management Defined

• “The tasks that an individual must undertake to live well with one or more chronic conditions. – These tasks include having confidence to deal with:

• 1) medical management (tasks associated with the condition)

• 2) role management (tasks required for everyday living) • 3) emotional management (coping with anger, fear,

frustration and sadness).”

Institute of Medicine, Report of a Summit, Sept 2004

Self-Efficacy• Confidence that one

can carry out a behaviour necessary to reach a desired goal (Bandura 1986)

• **Successful achievement of a goal is more important than the goal itself**

Bodenheimer, T et al. JAMA 2002;288(19):2469-2475.

WAIT! Not all of my patients want to be self-managers...

• Patient self-management is inevitable– Patients decide what they eat, to exercise or

not and whether to take prescribed medications

• “The question is not whether patients with chronic conditions can manage their illness, but how they manage (Bodenheimer et al 2002)”

Bodenheimer, T et al. JAMA 2002;288(19):2469-2475.

Self-management Support (SMS)

• “requires a provider or health care team to perform a certain set of tasks to create the self-efficacy necessary for a patient to deal confidently with their own range of emotional, physical, + physiological symptoms of their chronic disease”

McGowan P. In: Dorland J, McColl MA, editors. Emerging Approaches to Chronic

Disease Management in Primary Health Care: Managing chronic disease in thetwenty-first century. Queens University School of Policy; 2007.

SMS Cont’d

• SMS is not the same as patient education.

• Helps patients to adopt healthy behaviours and problem solve.

• Overall goal of SMS– Increase patients’ confidence in their ability to

change their own health behaviours

Supporting Patient Self-Management Module, www.practicesupport.bc.ca

“That’s great, does it work?”

The Evidence• Literature supporting patient self-

management has many limitations– Differing definitions of SMS + multifactor

interventions

• 2006 systematic review of systematic reviews– Compiled 11 systematic reviews

• Diabetes (6)• Asthma, COPD, Hypertension, Arthritis (2 each)

Zwar N et al. 2006. Available at: http://www.anu.edu.au/aphcri/Domain/ChronicDisea

seMgmt/Approved_25_Zwar.pdf

Outcome Measures Number of Studies Positive

Findings

Number of Studies

HCP Guideline Adherence 1 1

Patient Service Use 0 3

Patient Physiologic Measure of Disease

9 11

Patient Quality of Life 2 3

Patient Medication Adherence

2 3

Patient knowledge 5 5Zwar N et al. 2006. Available at:

http://www.anu.edu.au/aphcri/Domain/ChronicDiseaseMgmt/Approved_25_Zwar.pdf

Goal Setting and Action Plans

Let’s Share

• What are some of the goals you have for “your Susan’s”?

• What are “your Susan’s” goals for herself?

SMART Goals

• Specific

• Measurable

• Action-Oriented

• Realistic & Relevant

• Time-Based

Goal Setting Steps

• 1) What are you going to do?

• 2) How much are you going to do?

• 3) When are you going to do it?

• 4) How often are you going to do it?

Let’s Practice

1. Choose one behaviour change you would like to embrace in your own life.

2. How could you make this into a SMART goal?

Pick something you are comfortable sharing with a partner

The Confidence Ruler

• On a scale of 0 to 10, with 0 being not at all confident and 10 being as confident as you can be, how confident are you that you can achieve your goal?

0 1 2 3 4 5 6 7 8 9 10Not At All

Confident A Little

ConfidentSomewhat confident

Very Confident Extremely Confident

http://www.newhealthpartnerships.org

Pitfalls to Avoid

• Assumptions about patient’s knowledge

• Avoid setting goals for your patients– Remember motivation

and confidence

• If a patient is having a hard time setting a goal, it is OK to help by making suggestions as to what may improve their condition

The Challenging Patient

• Any step toward a potential positive behaviour change is something

• The goal could be to come up with a list of pros and cons to the recommended behaviour change

Strategies for Bringing SMS To Your Practice

Before the Visit

Before the Visit

• Pre-visit contact by you or your staff (phone, email, mail)

• Waiting room assessment forms

• Patient education materials

During the Visit

During the Visit

• Review waiting room assessments

• Goal setting and action planning– If follow up visit, make sure to give feedback

on achievements and goals

• Referral for more SMS

• 5 A’s or 3 questions

Referrals for SMS

• You don’t need to be the expert!

• There are many out there, your job is to find them– e.g., Stanford Chronic Disease Self-

Management Program

Starting SMS in a Visit

• 1) What worries you most about your health? 

• 2) How do you feel about it?

• 3) What do you think you may be able to do about it?

http://www.impactbc.ca/practicesupportprogram/resourcesforregionalsupportteams/cdmresources/patientself-management

Assessing Motivation

• Ask

• Assess

• Advise

• Assist

• Arrange

• Relevance

• Risks

• Rewards

• Roadblocks

• Repetition

From: Michael Valis 2009 Moving Mountains: Helping Patients with Lifestyle Change

From: Lewis J. 2008. Diabetes Self Management Support Toolkit for Health

Professionals in Ontario

Tips

• Don’t rush into thinking it’s your job to solve the problem

• Assess the situation and determine:– Is this a problem of motivation?– Is this a problem of behaviour?– Is this a problem of stress or emotion?

After the Visit

After the Visit

• Referrals to other supports

• Further 5 A’s counseling

• Phone call follow-up• Mailed patient

education

• Peer support• Newsletters• Follow up visits• Email/web sites

Take Home Messages

• You don’t have to be an expert to support self-management in your practice.

• If you set goals with your patients, critical (and time saving!) to revisit at the next follow-up.

Let’s Take It Home

SET A GOAL!

Over the next week, I will ___________ to support self-management in my practice.

Examples...

• Ask patients their view of the challenges they face (3 questions)

• Waiting room assessment form• Help patients to generate simple and achievable

action plans• Identify local resources for self-management

education

Goal Setting

• 1) What are you going to do?

• 2) How much are you going to do?

• 3) When are you going to do it?

• 4) How often are you going to do it?

Resources• Review Articles

– Bodenheimer T et al. Patient Self-management of Chronic Disease in Primary Care. JAMA 2002;288:2469-75.

– Coleman MT, Newton KS. Supporting Self-management in Patients with Chronic Illness. Am Fam Physician 2005;72:1503-10.

• Tools– Stanford Self-Management Programs. Stanford School of Medicine.

http://patienteducation.stanford.edu/programs/– Institute for Healthcare Improvement.

http://www.ihi.org/IHI/Topics/PatientCenteredCare/SelfManagementSupport/

– Improving Chronic Illness Care http://www.improvingchroniccare.org

–

Slides will be available at www.stonechurchclinic.ca

Contact Information

ischabo@mcmaster.ca

lmccart@mcmaster.ca

macdonmic@hhsc.ca