Arthritis Self Management Program

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• Arthritis Self Management Program
• Focus on Training
• Mary Brachaniec BScPT
• The Arthritis Society
• New Brunswick Division
• November 2007

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Our Mission
To search for the underlying causes and
subsequent cures for arthritis, and to promote
the best possible care and treatment for people
with arthritis.
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Arthroscope - The Arthritis Society 2004

• Among Canadas top 3 most chronic conditions
• 36 of people with arthritis deal with severe to
  moderate pain compared to only 13 of people with
  non-arthritic conditions

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• More people with arthritis report significant
  reduction in activities than those with other
  chronic conditions
• 1998 arthritis related deaths exceeded deaths
  relating to melanoma, asthma or HIV/AIDs.

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Impact in Canada

• Cost exceeds 4.4 Billion/year
• 8.8 million physician visits/year
• Accounts for 9 all hospital admissions

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• 270 million in medication
• Significantly higher pain medication use than
  other chronic conditions

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What Constitutes Quality of Life?

• Health
• Family and friends
• Financial stability
• Ability to do things
• Environment
• Others?

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Patient Contact with Health Professionals
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New Tasks for people withChronic Disease

• Recognize and act on their symptoms
• Make most effective use of medications and
  treatments
• Deal with acute attacks or exacerbations (manage
  emergencies)
• Maintain good nutrition and diet
• Maintain adequate exercise
• Give up smoking

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New tasks contd

• Use stress reduction techniques
• Interact effectively with health providers
• Use community resources to maintain independence,
  health
• Manage work and the resources of employment
  services
• Manage relations with significant others
• Manage psychological responses to illness.

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Collaborative Care
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Collaborative Care contd
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Implications

• Patient education is effective with acute disease
• Chronic disease places new responsibilities on
  the individual
• People manage chronic disease by themselves
• Behavior is important
• Behavior is complex and multi-faceted
• Individuals need meaningful participation
• Outcomes best when patient and health care
  professional work together in collaborative
  fashion
• Patient education does not meet all the needs of
  people with chronic conditions

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Traditional Pt. Education vs.Self-Management
Education
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Traditional Patient Education vsSelf-Management
Education Contd
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Self-Management

• 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

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Self-Management Support 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.
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Arthritis Self-Management Program (ASMP) Overview

• Persons with any type of arthritis (or
  fibromyalgia)
• Self-referral
• Spouses and significant others may participate
• Led by pairs of leaders (1 or 2 of whom has
  arthritis) who have successfully completed 3 day
  training workshop
• Offered in Canada by Arthritis Society since 1992
  with more than 20,000 graduates

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ASMP contd

• Leaders follow a scripted Leaders Manual
• Six, weekly, 2 hour sessions
• Ideal class size is 10 to 12 persons
• Participants receive The Arthritis Helpbook
• 25.00 cost to participants and 40 per couple
• (covers cost of Helpbook)

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Pain Cycle Management

• Disease Pain

Tense Muscles
Fatigue
Mastery Learning
Psychological Stress
Depression
Anger, Fear Frustration
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Enhancing Self-efficacy

• Mastery Learning - goal setting (action plan),
  problem solving, follow up
• Modeling
• Reinterpreting Symptoms
• Persuasion
• Self-efficacy? Health outcomes

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Early research shows significant
improvements/increases in

• Health Behaviors (exercise, pain management,
  communication with health care team)
• Health Status (decreased fatigue, pain,
  depression, disability)
• Trends towards Changes in Health Care Utilization
  Patterns (i.e., decreased frequency emergency
  room visits)
• Improvements related to improved self-efficacy

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Lorig Colleagues, 1993 -ASMP Participants 4
year follow up

• 20 mean pain reductions
• 40 reduced physician visits
• Improved functional abilities
• Significant health care cost savings

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Effects of CDSMP on Patients with Chronic Disease
(Lorig Colleagues 2001)

• Peer led before-after cohort study (volunteers
  from Kaiser Permanente)
• Self Administered Questionnaire at one year post
  intervention
• Significant improvements in health behavior, self
  efficacy, health status and health care
  utilization
• Significantly less visits to ER trend to less
  hospital days
• Program cost at 200 per participant (estimate
  health care system cost saving 51).

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Bodenheimer Colleagues 2002

• Review of Arthritis Self-Management Studies(1993
  2001)
• 8 ASMP studies demonstrated 20 mean reduction in
  pain symptoms after 4 years
• Improvement associated with increased
  self-efficacy
• Studies of arthritis education programs (without
  self-management elements) were much less
  effective

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ASMP in the UK RCT (Barlow colleagues 2000)

• Short term improvements in self-efficacy, greater
  use of health behaviours, less depression/improved
  mood.
• No change in physical functioning, pain and GP
  visits
• Similar pattern seen at 12 month f/u ASMP
  participation

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BMJ 2006 RCT for OA Patients in Primary Care in
the U.K.

• Significant improvements in psychological well
  being, anxiety and self efficacy
• Small but non-significant improvements in other
  areas (such as pain physical functioning)
• No significant change GP visits
• MB Comment Issues with study relating to
  readiness of participants and high attrition in
  intervention group (30 didnt attend any
  classes)

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Lay Led CDSMP in UK (Kennedy 2007) RCT

• Improved Self Efficacy and Energy Levels
• Increased health related quality of life
• Small reductions in costs

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Very recent studies

• RCT in Hong Kong with ASMP and exercises for OA
  Knee with significant findings -pain, fatigue,
  function, health care utilization (Yip et. Al.,
  Patient Ed. And Counsel 2007)
• Questionable Outcomes in UK National Health
  Expert Patient (Lay Led) Self Management Programs
  (Analysis Griffiths et. al., BMJ 2007)

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Future Self Management Programs

• NB holding CDSMP Master Training Session this
  Fall (planning within DOH and Health NGOs)
• Variable approaches (i.e., ASMP versus CDSMP)
  across Canada
• ASMP Programming in Atlantic Canada contact the
  Arthritis Society for schedules.

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Chronic Pain Management Workshop

• Two hour group workshop available in English or
  French
• Based on information presented in ASMP
• Includes the structure of the joint, pain
  management/relaxation techniques, coping with
  depression, exercise and a brief introduction to
  role of medications in arthritis

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Self Management SupportWhat can health
professionals and significant others do?

• Spread the word about/refer to Self Management
  Programs in your community
• Ask patient to identify their problems goals
  (action plan)
• Follow up on progress

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Action Planning

• Something YOU want to do
• Reasonable
• Behavior-specific
• Answer the questions
• What?
• How much?
• When?
• How often?
• Confidence level of 7 or more

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Problem-Solving Steps

• Identify the problem
• List ideas that could solve the problem
• Select one to try
• Assess the results
• Substitute another idea
• Utilize other resources
• Accept that the problem may not be solvable now

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Leader Training (Stanford)

• Evidence Based Program - 3 full day training
• Skill set differs from traditional health
  professional role
• Good self managers ideal leaders/co-leaders
• (modelling)
• Mastery Learning (not provision of information)
  is key to success
• Not all trainees are certified as leaders
• Leaders/Master Trainers/T-Trainers ensures
  quality
• How to start programs in communities - discussion

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Additonal Programs

• Chronic Pain Management Seminars
• Healthy Living Presentation for Health
  Professionals
• Active Living and Wellness Presentations -
  community groups, workplaces, wellness fairs
• Learning About Arthritis Grade 5 program
• ASMP is supported by Pfizer
• Our local programs and services also supported by
  United Way Centraide

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Our Services

• The Arthritis Information Line 1-800-321-1433
• The Arthritis Registry 1-800-321-1433 or
  www.arthritis.ca
• Educational printed materials
• A lending library of books and videos
• Speakers and Public Forums
• Support groups located throughout the Province.

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• There is hope for people living with arthritis
• The Arthritis Society
• 1.800.321.1433
• info_at_arthritis.nb.ca
• www.arthritis.ca