SELF MANAGEMENT SUPPORT

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SELF MANAGEMENT SUPPORT

• Jeanne Harmon RD, MBA, CDE
• Washington State Department of Health
• Diabetes Prevention and Control Program

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Session Overview

• 1. Definitions and rationale for self-management
  support
• 2. Key steps in a self-management support program
• 3. Implementing a self-management support program
  
• 4. Summary and conclusions tools and reminders

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What Is Self-management Support?

• Helps people understand their health behaviors
  and develop strategies to live as fully and
  productively as they can

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Characteristics

• Goal and emphasis on behavior change, not
  increasing knowledge
• Patients are actively involved, not passive
  recipients
• Ongoing active process that provides support and
  feedback

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What Self-Management Support Isnt...

• Didactic patient education
• Sage on the stage
• You should
• Finger wagging
• Lecturing
• Waiting for patients to ask for help

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General Definition OfSelf-Management

• Activities that patients need to perform on a
  regular, often daily, basis to
• Take care of their illness(es)
• Carry out normal activities
• Cope with the impact of illness and itstreatment
  on themselves and others

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7 Self-Care BehaviorsAmerican Association of
Diabetes Educators

• Healthy eating
• Being active
• Monitoring
• Taking medication
• Problem solving
• Healthy coping
• Reducing risks

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Self-Management Behaviors

• Symptom monitoring
• Collaborative goal setting
• Healthy eating
• Regular physical activity
• Smoking cessation
• Medication taking

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Self-Management Behaviors

• Ongoing problem-solving to overcome barriers
• Medical guidelines adherence
• Communicating with health care team, family, and
  others

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Collaborative Self Management Goal

• Specific, rather than general goals (e.g., eat 5
  servings of fruit/veggies a day is much better
  than eat better).
• Goal needs to be achievable based on what the
  patient is currently doing.
• Specify the time frame for achieving the goal
  (generally something that they can achieve
  between now and the next visit).

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Key Conclusions From Research on Chronic Illness
Self-Management

• "Adherence" or Self-Management is not an all or
  none personality trait--it varies across regimen
  areas and over time
• Patients need to be active, key team members in
  planning care They are the expert on what is
  feasible to carry out
• Knowledge is not enough Your mother's
  classroom-based patient education does not
  produce behavior change (Mullen et al, 1997)
• The social environment is critically
  importantespecially for maintenance. (Glasgow,
  Wagner et al, 1999)

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Key Conclusions..

• We don't so much change the patient as, address
  barriers, and provide planned strategies to help
  individuals cope with and change their
  environment
• It is critically important to tailor intervention
  to individuals-- one size does not fit all
  (Skinner et al, 1999)
• Tailoring must be done in a collaborative
  empowering manner and involve patient choice,
  preferences and values (Anderson et al, 1995)
• More is NOT necessarily better--all of the above
  can be done efficiently and cost-effectively--if
  planned and coordinated

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Key Conclusions.

• If you provide it, they wont necessarily come.
• There are now well-controlled, randomized trials
  documenting the effectiveness of modern,
  self-management training (Lorig et al, 1999
  Clark, et al 1992 Glasgow et al, 1997)
• Self-management needs to be integrated with other
  care activitiesit is not something done to a
  patient via referral on a one-time basis
• Small successes are good and can be built
  upondont need to change everything at one visit
  (ala PDSA cycles)
• Follow-up support is critical

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Examples

• Chronic Disease Self-Management Program
• Office Practice (Glasgow)
• Patient Empowerment (Anderson)

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Chronic Disease Self-Management Program

• Developed and studied by Kate Lorig and
  colleagues at Stanford
• Lay-leaders, 6 sessions, 2 1/2 hours each
• Addresses multiple conditions
• Includes planning and problem solving, skill
  acquisition
• Everything you wish patients knew
• Outcomes improved health behaviors and health
  status, fewer hospitalizations (Lorig, Med Care
  1999375-14)

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Individual Office Practice

• Developed by Glasgow and colleagues
• Prior to visit mailed reminder of
  self-monitoring
• Waiting room self-care form
• Exam room feedback on changes, check on goal,
  elicit current self-care concern
• Physical exam message
• Follow-up negotiate goals, develop plan,
  anticipate barriers, plan for support
• Outcomes decr. serum cholesterol, alt. dietary
  habits, impr. satisfaction (Glasgow, Pt Ed
  Couns 199732175-184)

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Patient Empowerment

• Developed by Anderson and colleagues at
  University of Michigan
• Emphasis on whole patient
• Patient generates options
• Build on patient strengths
• Failures are learning experiences
• Diabetes outcomes reduced HbA1c, improved
  self-efficacy (Anderson, Diabetes Care
  199518943-949)

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Why is Self-Management Support So Important?

• The patient does the majority of the work of
  health care and the regimen plan is theirs
  whether we like it or not
• It is the place where the practice team interacts
  and collaborates with the patient and caregivers
• Your patients (and all of youthe staff) will
  like itincreased patient satisfaction

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What works in chronic disease self-management
support programs?

• Assessment of self-management behavior, beliefs
  and knowledge
• Collaborative goal setting
• Identification of barriers and support
• Personalized problem-solving
• Follow-up support

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Assessment

• Adapt instruments to your setting (PDSA cycles
• Assess knowledge, skills, behavior, confidence,
  supports, and barriers
• If can only do one thing, assess behavior
• Use results/feedback to inform other steps

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Sample Quick Assessment

• What are your concerns about your diabetes
  management?
• How is diabetes affecting your life?
• What would you like to know more about?
• What would you like to work on in managing your
  diabetes?
• How can we help you with your management of
  diabetes?

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How confident are you that you can control any
symptoms or health problems you have so that they
dont interfere with the things you want to do?
Totally confident
Not at all confident
1 2 3 4 5 6 7 8 9 10
Lorig et al Outcome Measures for Health Education
and other Health Care Interventions, SAGE
Publications, 1996
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Collaborative Goal Setting

• The patients goal (not yours)
• Specific realistic
• Focus on only 1-2 goals at a time
• Address patient values, beliefs, and environment

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Formulating a Collaborative Self-Management Goal

• What would be easiest for the patient to do first
  (most likelihood of success)?
• The goal is something enjoyable that fits their
  lifestyle.
• Bottom line What does the patient see as
  priority and is willing to work on?

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Collaborative Self-Management Goal

• Specific, rather than general goals (e.g., eat 5
  servings of fruit/veggies a day is much better
  than eat better).
• Goal needs to be achievable based on what the
  patient is currently doing.
• Specify the time frame for achieving the goal
  (generally something that they can achieve
  between now and the next visit).

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Identification of Barriers and Support

• Anticipate likely obstacles
• Breakdown seemingly overwhelmingchallenges
• May need to adjust goals based on barriers

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Personalized Problem-Solving

• Identify the problem.
• List all possible solutions.
• Pick one.
• Try it for 2 weeks.
• If it doesnt work, try another.
• If that doesnt work, find a resource for ideas.
• If that doesnt work, accept that the problem
  may not be solvable now.

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Action Plan

• Something you WANT to do
• Describe
• How Where
• What Frequency
• When
• Barriers
• Plans to overcome barriers
• Confidence rating (1-10)
• Follow-Up plan

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Follow-Up Support

• Can actually reduce demand
• Variety of modalities (phone, mail, community
  resources, etc.)

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Follow-up Modalities

• Group-based education sessions - Professional or
  lay led
• Mail - Tailored Print Materials
• Face to face during primary care, hospitalization
  or other visits
• Phone calls - live or automated voice messaging
• Computer-assisted, multimedia, touchscreen kiosks
• Worksite and community-based approaches
• Internet, intranet and related-distance approaches

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PDSA CYCLE
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Self Management Support
Collaborative Goal Setting
Patient, Health Care Team, Health Care System
Follow-Up Support
ID Barriers
Personalized Problem-Solving
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Self-Management Interview Guide

• 1. Set Collaborative Goal
• (Specific Patient-driven, achievable within the
  patients lifestyle realistically given latest
  self-management assessment)
• _________________________________________________
  ___________________________
• 2. Identify Barriers to Achieving the Goal
• (Whats going to get in the way of achieving the
  goal?)
• _________________________________________________
  ___________________________

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Self-Management Interview Guide

• 3. Problem Solve Barriers
• (How can you get around the barrier? Have
  multiple coping strategies)
• _________________________________________________
  _____________________________
• 4. Arrange for Follow-up Support
• (Help the patient identify specific sources of
  support. Follow-up phone call, repeat visit,
  friends/family, community resources.) Schedule
  these.
• _________________________________________________
  _____________________________

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Integrating Self-Management into Office Visits
Prior to Visit
Waiting Room
Exam Room Vital Signs
Physician Exam
Nurse, Counselor or Health Educator Follow-up
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Prior to Visit

• Mailed reminder re
• Self-monitoring logs
• (e.g., symptoms, goals,diet, exercise)

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Waiting Room

• Patient completes Self-Care Form
• Surrounded by information on self-management and
  resources (pamphlets, posters, notices)

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Exam Room and Vital Signs

• Nurse gives patient feedback on changes since
  last visit (weight, blood pressure, lipids, blood
  glucose)
• Inquires about self-management goal since last
  visit
• Nurse checks Self-Care Form and asks which area
  is currently of most concern (circles area for
  physician reinforces patient interest educates
  on importance of
• selfcare)

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During Physician Exam (1 minute)

• Check Self-Care Form and discuss area of most
  concern to patient
• Message I see you would most like to
  discussHow can I help you withthis?
• Reinforce patients willingness to change
  behavior, importance of Self-Care Goals, and
  refer to nurse or educator for specific plan

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Nurse or Counselor Follow-up

• Negotiate goals for behavior change in 1-2
  area(s) of self-care
• Develop specific, realistic, measurable plan
• Have patient identify barriers to plan and assist
  in his/her problem-solving
• Plan for continued support refer to patient
  education or support group community resources
  phone calls between visits
• Record goal in a place where all staff can see
  (with copy for patient) and plan for follow-up at
  subsequent visits

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Examples of PDSA Cycles for Self Management
Support

• Testing or Adapting Self-Management Assessments,
  Surveys or Feedback
• Group Self-Management or Cluster Visits
• Patient Goal-Setting Forms
• Development of Localized Self-Management
  Materials
• Follow-up Calls or Support Letters to Patients
• Staff Education, Training, or Workshops
• Patients Versions of or Wallet Cards on Diabetes
  Guidelines

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Checklist to Enhance Your Self-Management
SystemDoes Your Improvement Plan Address Each of
These Issues?
Yes No
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Yes No
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Key Characteristics of Successful Teams

• Shifted world views from provider-centric to
  patient-centered (Glasgow Anderson article)
• Changed educational approach from classes
  teaching standardized material to individualized
  goal setting and problem-solving
• Integrated self-management with other Planned
  Care model components
• Provided follow-up support
• Able to grasp population-based approach and
  importance of outreach

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Who can do this?

• Natural helpers
• Trained peers
• Health educators
• Nurses
• Physicians
• Any caring person...

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A philosophical shift

• Professional -
  patient
• Professional -
  Patient
• Patient -
  Professional
• Patient -
  professional
• Person -
  professional
• Person-Person

Adapted from Tom Janisse, Kaiser NW
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