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Population Health Management Principles and Practice
Where Results Begin
www.qfhc.com
Session Topics
Understand• Population Health Management Background and Overview• Risk StratificationNavigate• Care Coordination/Care Management: Principles and
PracticeActivate• Self-Management and Self Management Support, Self
Efficacy and Behavior Change• Medicare Chronic Care Model
Population Health Management Background and Overview
Where Results Begin
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Presenter:Candace Chitty, RN, MBA, CPHQ, PCMH CCE
Where Results Begin
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Learning Objectives
To develop a better understanding of:
• The key drivers, Why Population Health;
• The importance of redesigning population health to bridge clinical and non-medical services
Population Health ManagementTHEN:Population health has been defined as the health outcomes of a group of
individuals, including the distribution of such outcomes within the group. It is an approach to health that aims to proactively improve the health of an entire population.
From a population health perspective, health has been defined not simply as a state free from disease but as "the capacity of people to adapt to, respond to, or control life's challenges and changes".
Source: Kindig D, Stoddart G. What is population health? American Journal of Public Health 2003 Mar;93(3):380-3. Retrieved 2008-10-12.
NOW:Population health management includes collecting and analyzing data on segments of patient populations and managing those populations. It requires both analysis and action. It's a comprehensive approach to uncovering gaps in care, filling those gaps - for the benefits of your patients and your practice -improving outcomes, aligning physicians, coordinating care, and optimizing efficiency and revenue.
Why Do We Need Population Health?Escalating medical costs
The US health care system is the most costly in the world, accounting for 17% of the gross domestic product with estimates that percentage will grow to nearly 20% by 2020. Increasing medical costs can be traced to several root causes:
• A lack of integrated care systems (fragmented delivery)
• Compensation levels
• Quality and safety issues (overuse, underuse, misuse)
• Misalignment of payment incentives
• Personal population behavior resulting in poor health choices that increase the risk of an adverse health event.
Source: National Healthcare Expenditure Projections, 2010-2020. Centers for Medicare and Medicaid Services, Office of the Actuary
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Population Health Management Mastering Gaps and Hurdles
What does it take?Information, Analysis, and Activation Flow
AIMS of the Value-Based System
11
Effective Management of Populations Requires Change
Change is hard enough; transformation to a population health management model requires epic whole-practice re-imagination and redesign.
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You must understand and accept it is a transformation and not a series of incremental changes
PHM in Primary CareCan Be Challenging
• Primary Care practices handle such a wide array of patients it is difficult to routinize what happens each day.
• Tremendous diversity in primary care settings across the country• The central institution of primary care is the 15-minute physician
visit.• Too much work and too little time to do it. • Reimbursement is not well aligned with patient centered care.• Challenges of human relationships and personalities• Reliance on part-time providers• Team-based care is a huge paradigm shift for teams and for
patients. It requires change and that is hard.• Authoritative leadership style embedded vs. facilitative leadership• Misalignment of vision
Old Approach•Care is based on visits•Professional autonomy drives clinical variability•Professionals control care•Information is a record•Secrecy is necessary•The system reacts to needs
New Approach•Care is based on continuous healing relationships•Care is customized according to patient needs, values, preferences•Patient is source of control•Knowledge is shared and flows freely•Transparency is necessary•Needs are anticipated•Team care based on clinical staff optimization
Key Change Concept: Health Doesn’t Occur in a Health Care Setting Source: Peter B. Anderson, MD. The
Familiar Physician, 2014
Think Differently
Set the Foundation for an Effective and Sustainable PHM Program
Functional Efficiencies
The ability to:
• Generate robust data
• Integrate platforms
• Provide a comprehensive suite of tools
• Use clinical, operational and financial parameters
• Identify patients who would benefit most from the intervention
Operational effectiveness
The ability to:
• Align processes and systems
• Enhance the patient experience
• Establish wide-ranging business processes
• Cultivate a divers set of involved stakeholders
• Address client-specific needs
Strategic Alignment• Align changes in the PHM model with your organization long-term vision• Position the model to complement other strategic initiatives• Consider the far-reaching impact across your internal and external stakeholdersSource: Ernest & Young: Health Industry Post 2013
Key Considerations in Sustainable Change
Population Health management requires a commitment to system-wide transformation. Such transformation requires visible and sustained support and engagement from leadership, including the board of directors, executive management, and clinic leadership.
Considerations in assuring sustainability include:• Continuing staff awareness and ongoing training• Supportive Leadership• Resource Availability• Care Team Optimization• Engaged Providers and Patients• Sustainable Operational Workflows• Interoperable Systems
PHM Program Components
• Conceptual Framework
• Objectives
• Constructs
• Domains
• Measurement
Population Health Conceptual Framework
Source: Care Continuum Alliance (2012): http://www.exerciseismedicine.org/assets/page_documents/PHM%20Guide%20for%20Primary%20Care%20HL.pdf
Objectives:Population Health Management
• To proactively identify populations in need of care or services;
• To proactively identify populations who would benefit from care management;
• To coordinate and manage resources to support a defined populations;
• To build collaborative alliances and coalitions;
• To optimize the Quadruple Aim;
• To be a major contributor to the PCMH and other models (e.g. ACO).
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Population Health Constructs
Population Identification (Case Finding)Risk Assessment (Interview)Risk Stratification (Levels of Risk)Enrollment and Patient/Family EngagementCare Coordination Processes (care coordination, service
navigation, embedded primary care team members, transition management)
Care Management - chronic condition, high risk and complex care management, home visitation, patient-centered care plans, self-management education, motivational interviewing and patient engagement, health and wellness promotion
Data Analysis and Outcomes MeasurementPerformance Improvement (Quality)
Population Health Management-Tiers
Clinical Care Management
All patients in panel who are involved in referral or transition process
Logistical
High-risk, multi-morbid patients
Care Coordination
Clinical Follow-up Care
MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011
Patients with common chronic illnesses
Logistical
Logistical Clinical Monitoring
MedicationMgmt
Clinical Monitoring
Self Mgmt Support
Self Mgmt Support
Domain: Identification, Stratification, and Prioritization
Definition
Identification, stratification, and prioritization should be used to identify consumers at the highest risk who offer the greatest potential for improvements in health outcomes. Programs should incorporate clinical and non-clinical sources of information to identify patients who will most benefit from care management.
Tools and Resources
1. Health Risk Assessments
2. Predictive models
3. Surveys (e.g., Patient Health Questionnaire 9, Short Form 12)
• Case finding (e.g., reports, registries, chart reviews, etc.)
• Referrals (from member, provider, community)
Case Finding
Periodic and based on reportable case finding criteria such as:• Diagnoses (Newly diagnosed with Clinical
Depression) • Care Gaps• Clinical Outliers (A1c > 9, PHQ-9 > 10)• External Data (health plans, etc) • Utilization (ED visits, hospital readmissions,
pharmacy)• Social Determinants (homeless, no social
support, low income, etc)
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Page 6
Risk Assessment/Stratification
• Assessment Tool (biopsychosocial)
• Interviewing
• Objective Scoring
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Predictive Modeling
Domain Navigate: Intervention
Definition
Interventions must be tailored to meet individual patient/family/caregiver needs, respecting the role of the patient to be a decision maker in the care planning process, and considering their preferences. Interventions should be designed to best serve patients/families, be multi-faceted, improve quality and cost effectiveness, and ensure coordination of care.
Tools and Resources
1. Evidence-based practices
2. Interactive care plan, developed based on patient-set priorities
3. Multidisciplinary care teams
4. “Go to” person
5. Medical home care delivery
6. Physical/behavioral health integration
7. Specialized patient engagement (e.g., self-management training)
Domain: Evaluation
Definition
Evaluation should include systematic measurement, testing, and analysis to ensure that interventions improve quality, efficiency, and effectiveness. Careful and consistent evaluation will build the evidence base in terms of what works for complex and special need populations.
Tools and Resources
1. Program evaluations
2. Rapid-cycle (PDSA) micro experiments (e.g., continuous quality improvement, testing, and program adjustments)
3. Measures of quality (e.g., HEDIS, CAHPS)
4. Measures of cost (e.g., ROI calculations)
SMART Goals
Measure What Matters• Enrollment
• Engagement
• Clinical Performance
• Satisfaction
• Utilization
• Health Care Costs
Page 10
Domain: Payment
Definition
Payment/financing should be aligned to support improvements in care management by rewarding patients and providers for participating in
interventions/evaluations and establishing accountability for quality and cost
Tools and Resources
1. Pay for performance at multiple levels (e.g., health plan, provider, and patient level)
2. Share in program savings (gainsharing)
3. Case management/medical home payments (CMS CCM, MACRA)
How Does HIT Best Fit into PHM?“The Top Ten”
• Electronic Health Record• Patient Registry• Health Information Exchange• Risk Stratification• Automated Outreach• Referral Tracking• Patient Portal• Telehealth/telemedicine• Remote Patient Monitoring• Advanced Population Analytics
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Care Coordination: Principles and Practice
Where Results Begin
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Learning ObjectivesTo develop a better understanding of:• The definition, principles, and aims of care
coordination in transitions;• The value of investing in care coordination;• Steps to consider in assessing your care coordination
activities and making improvements;• Critical success factors to consider when implementing
a care coordinating model;• Care Coordination models and resources.
• Performance Measurement/management
Population Health Management-Tiers
Clinical Care Management
All patients in panel who are involved in referral or transition process
Logistical
High-risk, multi-morbid patients
Care Coordination
Clinical Follow-up Care
MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011
Patients with common chronic illnesses
Logistical
Logistical Clinical Monitoring
MedicationMgmt
Clinical Monitoring
Self Mgmt Support
Self Mgmt Support
Care Coordination-Defined
“The deliberate integration of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of healthcare services”. Source: McDonald, KM;
Sundaram, V, et al. 2007. “Closing the quality gap: A critical analysis of quality management strategies. (Vol 7. Care Coordination), Rockville, MD: Agency for Healthcare Research and Quality. Report No.: 04(07)-0051-7.
It is an essential component of primary care. It is not a new concept. Care coordination can occur without care
management.
Primary care as conceptualized by the Institute of Medicine is, “The provision of accessible, comprehensive, longitudinal and coordinated care in the context of families and community.” Primary Care: America’s Health in a New Era: Washington, DC. National Academy of Sciences. 1996.
36
Key Principles and Concepts
Principles:The transfer and exchange of information
Accountability
Central Activities:Assess Patient Needs (Health and Social Determinants)
Develop and update proactive care plan
Emphasize communication
Facilitate transitions
Connect with community resources
Align resources with population needsSource: Fisher, E; Grumbach, K, et al. September 8, 2010 Consensus Meeting
Briefing Materials on Care Coordination: Issues for PCMHs and ACOs
37
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Success Factors for Care Coordination
Provider CollaborationInterdisciplinary ApproachBlended Model Based on RiskEffective Communication
Success Factor: Provider Collaboration
Clinicians are known for having a more autocratic leadership style. Care coordination is most successful when incorporating a more collaborative style of leadership and team concepts. Clinicians, You don’t have to do it all!
40
Critical Success Factor: Interdisciplinary Approach
• Providers (PCPs)
• Care Team Members (RN, LPN, MA, etc)
• Co-Managed (SCPs, Pharmacy, Nutrition, BH, HH, LTC, etc)
• Community Resources
41
Success Factor: Blended Model
Condition Management blended with Care Coordination to ensure patient has one contact person, when appropriate and based on risk level.
This model is most commonly utilized for patients with needs beyond basic care coordination. The risk assessment and risk segmentation tools are two important tools to identify when a blended model should be used.
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Success Factor: Communication
Communicating and Sharing Knowledge – Working Together
44
Communication Aims• Improve the quality of care transitions and communications across
care settings.
• Improve continuity of care and close care gaps by communicatingeffectively information across the care team spectrum
• Improve the quality of life for patients by communicating and following an integrated current care plan that anticipates and addresses symptom management, psychosocial needs, and functional status.
• Establish shared accountability and integration of communities and healthcare systems through flexible and ongoing communicationchannels to improve quality of care and reduce health disparities.
How can we achieve these aims?
45
Good Team communicationSkills• Communicate with team members
adapting own style of communication to needs of team and situation
• Demonstrate/communicate commitment to care coordination plan
• Learn communication techniques such as teach-back, motivational interviewing, etc.
• Solicit input from other team members to improve individual, team performance and communication
• Listen actively and encourage ideas
• Contribute to resolution of conflict and disagreement
• Clear and concise collaborative agreements that include communication expectations
Attitudes• Value collaborative teamwork and the
relationships upon which it is based
• Value different styles of communication used by patients, families, and others involved in care coordination activities
• Value the influence of system solutions as communication tools in achieving care coordination success
47
It’s not Easy
Teams Must Overcome:
• low level of confidence
• dominant figures
• preconceived ideas
• territorialism
• lack of knowledge of each other’s strengths
• training background
48
Building Blocks: Creating EffectiveCare Coordination
• Engage an improvement team
• Develop a plan
• Set goals
• Gain provider consensus on goals and objectives
• Develop efficient mechanisms for sharing information
• Evaluate office workflows
• Implement the plan
• Reach outside your health center to communicate and negotiate your needs
• Facilitate agreements with collaborating partners
• Engage and empower your patients
• Follow-up
49
Care Coordination Barriers to Consider
• No (or few) financial incentives or requirements for care coordination
• Lack of staff and time for investment in coordination (at the practice and broader community level)
• Lack of right staff composition• Limited primary care clinician involvement
in inpatient care• Fragmented, diverse services, rather than
an integrated delivery system
50
Care Coordination Barriers to Consider
• Limited financial integration across most providers
• Limited Health IT infrastructure and interoperability
• Practice norms that encourage clinicians to act in silos rather than coordinate with each other
• Complexity of care coordination for patients with high levels of need an/or frequent self-referrals
• Patient self-referrals
• Misperception regarding HIPAA provisions and limits to information exchange
51
Goals of Care Coordinator Role
• Reduce fragmentation in care delivery by organizing care across healthcare providers and settings;
• Better manage care transitions as patients move through the network;
• Close gaps in care;• Decrease hospital readmissions by identifying
problems before they require an inpatient stay;• Manage referrals to help keep patients within the
network;• Keep patients out of the emergency room.
52
EXAMPLE: PHM Program Structure and Functional Components
Steering/Governing Board/Other
Program Lead/PCP
Care Transitions
ED IP
Care Management Care Coordination/Health Pro.
Key Components/Work Flows:Resource ManagementAdvocacyManaging Care GapsCoordination Processes and Protocols for :--Specialist Referral Tracking and Follow-Up--Community Resource Tracking and Follow-Up,--Lab Tracking and Follow-Up--Imaging Tracking and Follow-Up--Pre-Operative CoordinationDocumentation ToolsPerf. Measurement
Key Components/Work Flows:Eligibility CriteriaCase Finding MethodsIntake and Enrollment (Opt-In Program)Risk Assessment and StratificationIndividualized Care Planning Documentation ToolsPatient/Family SupportMonitoring Progress/Follow-UpDischarge CriteriaMaintenance ProgramPerf. Measurement
Key Components/Work Flows:Finding/Receiving NoticeRisk Assessment (LACE)Pharmacy Coord.Patient/Family SupportSocial ServicesDocumentation ToolsMonitoring Progress Tracking and Follow-UpDischarge CriteriaPerf. Measurement
Page 2
Other activities that may be integrated in the above core functions include patient/family support, Referral to Community and Social Support Services, and Use of HIT
54
Models
• IHI Care Coordination Model www.IHI.org
• CareOregon Care Support www.careoregon.org
• Guided Care Nurse www.guidedcare.org
• Geisinger ProvenHealth™ Navigator www.geisinger.org
• BOOST Care Transitions www.hospitalmedicine.org
55
Models
• Eric Coleman’s Care Transitions ™ www.caretransitions.org
• Patient-Centered Medical Home Model www.pcpccnet
• Wagner’s Chronic Care Model www.ihi.org
• Population Health Model www.carecontinuum.org/
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Resources• Innovative Staffing for the Medical Practice: Deborah Walker
Keenan; www.mgma.com
• Coordinating Care in the Medical Neighborhood: Clinical Components and Available Mechanisms: ARHQ, June 2011.
• Health Team Works www.healthteamworks.com
• National Association for Quality Assurance – www.ncqa.org
• Institute for Health Improvement – PCMH Assessment, www.ihi.org
• Agency for Healthcare Research and Quality, www.ahrq.org
• National Transitions of Care Coalition - www.ntocc.org
57
Resources• Patient Centered Primary Care Collaborative www.pcpcc.net
• Safety Net Medical Home Initiative http://www.safetynetmedicalhome.org/change-concepts
• Institute for Healthcare Improvement – www.ihi.org
• Tools for Team Building Effective Teams in the Workplace – Leigh Thompson, Eileen Aranda, et al.
• Health Resources and Services Administration – www.hrsa.gov
• Cambridge Health Alliance Care Team Tool-kit. http://www.integration.samhsa.gov/workforce/team-members/Cambridge_health_alliance_team-based_care_toolkit.pdf
• Managing Populations; Maximizing Technology. http://www.integration.samhsa.gov/news/PCPCC_Population_Health_FINAL_e-version.pdf
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Risk Stratification
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Care Management: Principles and Practice
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Population Health Management-Tiers
Clinical Care Management
All patients in panel who are involved in referral or transition process
Logistical
High-risk, multi-morbid patients
Care Coordination
Clinical Follow-up Care
MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011
Patients with common chronic illnesses-low or rising risk
Logistical
Logistical Clinical Monitoring
MedicationMgmt
Clinical Monitoring
Self Mgmt Support
Self Mgmt Support
Considerations• Assessing determinants of health is a critical assessment domain in effective
chronic care management. Some determinants may be assessed and found in the medical record. Others will be assessed during CM intake and enrollment.
• Executive Leadership and Management support is critical to the success of any care management program.
• Clearly defined roles and responsibilities of staff and program structural development is critical.
• Close working relationship with IT resources is recommended so workflows, documentation, and reporting business requirements are identified and addressed.
• Comprehensive assessments that assess a wide array of domains is critical to identifying risks and needs of the population.
• Use of validated tools for measuring improved confidence and ability to care for self
Page 9
EXAMPLE: PHM Program Structure and Functional Components
Steering/Governing Board/Other
Program Lead/PCP
Care Transitions
ED IP
Care Management Care Coordination/Health Pro.
Key Components/Work Flows:Resource ManagementAdvocacyManaging Care GapsCoordination Processes and Protocols for :--Specialist Referral Tracking and Follow-Up--Community Resource Tracking and Follow-Up,--Lab Tracking and Follow-Up--Imaging Tracking and Follow-Up--Pre-Operative CoordinationDocumentation ToolsPerf. Measurement
Key Components/Work Flows:Eligibility CriteriaCase Finding MethodsIntake and Enrollment (Opt-In Program)Risk Assessment and StratificationIndividualized Care Planning Documentation ToolsPatient/Family SupportMonitoring Progress/Follow-UpDischarge CriteriaMaintenance ProgramPerf. Measurement
Key Components/Work Flows:Finding/Receiving NoticeRisk Assessment (LACE)Pharmacy Coord.Patient/Family SupportSocial ServicesDocumentation ToolsMonitoring Progress Tracking and Follow-UpDischarge CriteriaPerf. Measurement
Page 2
Other activities that may be integrated in the above core functions include patient/family support, Referral to Community and Social Support Services, and Use of HIT
Care Management Process
• Case Finding• Gather information from the patient on health status and
determinants of health• Risk Stratification• Engage• Develop a self-management plan (goals setting and prioritization)• Facilitate self-management: Provide education, remind the
patient/family to perform certain tasks and provide self-management tools, connect with resources
• Assess progress and address barriers• Facilitate communication between the patient/family, primary care
physician, and the care team
Referral to Care TeamCase Finding Criteria
Specialist
Pt/Family
Health PlanCare Transitions
Primary Care
Meets Initial Criteria?
Yes
No
Document reason and notify source criteria not met
Contact Pt to schedule enrollment and intake assessment
Intake completed?
Yes
No
Attempt to complete x3
Unsuccessful document and notify referral sourceOpts Out?Yes
Provide program info and contact number; document and notify referral source
NOTE: Purple = Document
Page 3
Depression/Anxiety plus one or more:HDCOPDHTNDMAsthma
Health Action Plan created. Includes;DX. Level of Patient Engagement, Barriers/Areas of Concern, Planned Actions and must align with MI-Care Team Required Services
No
Using results of intake assessment and Clinical Info Stratify and Document Stratification
Rising Risk High Risk
Engage patient/family is goal setting related to health action plan
Establish short and long term goals and frequency of contacts (at leas 1x per month or rising risk and at least 2x month for high risk for a period of 1-2 months before reducing contact frequency)
Give pt plan and welcome info and team contacts
RN assign interventions to appropriate team members (Coordinator, Social Worker, etc)
Implement Individualized Care Plan
Page 4
Pt actively participating and
progressing toward goals?
NoYes
Address barriers with patient and
team
Continue care mgmt
Goals Met?
YesNo
Able to maintain
contact with Pt.?
Yes
Disenroll patient and document. Notify patient.
Discuss with team
OK to Disenroll?
No Yes
Continue care coordination
No
Graduate from active status to maintenance program. Telephone contacts monthly for 3-6 months.
Page 5
Primary Concept of Care Planning
It is not one for all and all for One!
Collaborative Care Planning
70
Care Manager Role
• The care manager in the clinic setting is typically a RN assigned to the at risk, complex and/or chronic condition patient populations to conduct not only care coordination activities but assessments, care/self management planning, care transitions, and preventive health activities that occur beyond the primary care physician office and into the medical neighborhood.
Care ManagementOperating Tools/Documentation
• Policies and Procedures • Staff Job Descriptions or CM Team Roles and Responsibilities • Staff Training Outline and Materials• Staff Competency Assessment Tools• Chronic Care Management – Patient Materials (program information, welcome
letter, self-management resources and education materials, etc)• Evidence-based Guideline (s)• Referral Form • Intake Assessment Tool(s)• Self-Management Plan (ability to give copy to patient and provider)• Care Management Workflow (goals, assignments, follow-up, etc)• Patient Discharge Summary/Letter of Achievement• Patient Satisfaction Survey Instrument and Data Collection System• Staff Satisfaction Survey Instrument and Data Collection System• Reports (Process and Outcome Measures)
Page 12
Job Description
73
Core Competency Assessment
https://bphc.hrsa.gov/archive/technicalassistance/resourcecenter/clinicalservices/casemanagercompetencytool.pdf
74
Proposed Performance MetricsEnrollment
• # referred by referral source
• % enrolled
Engagement
• % actively participating
• # goals met
• % transitioned to maintenance
• % dis-enrolled by reason code
• # of referrals made by type
• % of referrals completed by type
Clinical Performance:
• % with A1c testing at least every 6 months
• % with A1c < 9%
• % with BP controlled (<130/80)
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Proposed Performance MetricsClinical Performance (continued):
• % with LDL < 100 mg/dl
• % with BMI < 30
Satisfaction:
• # completing satisfaction survey
• Survey summary results
Utilization:
• # ED visits
• # Hospitalizations
• # of PCP visits
• Predicted Reduction in Future Medical Expenditures
Health Care Costs:
• Change in ED costs of care
• Change in hospital costs of care
• Change in health center medical cost of care per patient enrolled
Page 11
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BREAK 15 Minutes
78
Action Planning -Self-Management, Self-Efficacy, and
Behavior Change
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Learning Objectives
• Distinguish between key concepts of self-management and self- management support;
• Define self-efficacy;• Identify strategies, tools (action planning), and
resources for engaging and activating patients and families in chronic illness care.
What is self-management?
“The individuals ability to manage the symptoms, treatment ,physical, and social
consequences and lifestyle changes inherent in living with a chronic condition.”
(Barlow etal, Patient Educ Couns 2008;48:177)
Self- Management Core Concepts
• Dignity and Respect
• Information Sharing
• Participation
• Collaborative Goal setting
• Action Planning
• Follow-up on progress
(New Health Partnerships,2007)
What is 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.
(IOM, 2003)
Self-Management Support
• Emphasize the patients central role in managing their illness.
• Assess patients beliefs, behavior and knowledge
• Advise patients by providing specific information about health risks and benefits of change.
Self-Management Support is NOT
• Didactic patient education
• Lecturing
• Inducing fear
• Finger-wagging
• “You should”
• Shaming
• Waiting for a patient to ask
Distinction
• Self-Management – refers to the behaviors that patients engage in outside the health care context.
• Self-Management Support- refers to how patients are supported in their self-management goals and activities by the health care team.
What is Self-Efficacy?
“One’s belief that one can perform a specific behavior or task in the future.”
Dr. Albert Bandura
What are the desired outcomes of self-management support?
• People with Chronic Conditions (and their families) are more:
Aware and informed
Engaged
Activated
Empowered Confident they can self-manage
Partners with health care team
Opportunistic Self-Management Support Examples
• Use effective and empathetic communication techniques
• Use motivational interviewing techniques to enhance client motivation and self-efficacy
• Provide patients with tailored information in a simple format and in appropriate amounts
• Document and share information relevant to patients ability to self-manage, ensuring that care team members are updated
Opportunistic Self-Management Support Examples cont.
• Inviting family members and caregivers to be involved in care to ensure key supports are empowered in their roles.
• Facilitate patients access to local health and community resources that support self-management efforts.
(Incorporating self-management support into Primary Care, A Victorian Government Initiative)
Institute for HealthcareImprovement Partnering in
Self-Management Support:A Toolkit for Clinicians
Delivery System Redesign to Support Self-Management
• Determine process and define roles for delivering self-management support among members of the care team
• Consider Planned Care visits
• Consider Medical Group visits
• Provide support and coordination according to level of need
Behavior Change
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Tools to Promote Behavior Change
Action Planning
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“How confident are you that you can meet your goal of
exercising 5 days a week?
Not at all
confident
Totally
confident0 1 2 3 4 5 6 7 8 9 10
Action Planning:Assess and Enhance Confidence
“What makes you say 6?
“What might help you to get to a 7 or 8?”
“What could I do to help you to feel more confident?”
(From Keller and White, 1997; Rollnick, Mason and Butler, 1999)
Enhancing ConfidenceIdentifying Barriers & Problem Solving
• What will get in the way?
• Anything Else?
• What might help you to overcome that barrier?
• Anything help in the past?
• Here is what others have done?
• Ok. Now what is your plan?
• Reassess confidence
Action Planning- Starts with SMART Goals
Specific and behavioral
Measureable
Attractive
Realistic
Timely
Active Action Plan
1. Goals: Something you WANT to do
2. Describe
How Where
What Frequency
When
3. Barriers
4. Plans to overcome barriers
5. Conviction and Confidence ratings (0-10)
6. Follow-Up
Sample Action Plan
http://familydocs.org/diabetes-resources
Collaboratively Set Goals
Action Planning Video
https://cepc.ucsf.edu/action-plans-video
Putting it all together
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References• Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med. 2007 Sep-
Oct;5(5):457-461. The 15-minute visit does not allow the physician sufficient time to provide the variety of services expected of primary care. A teamlet (little team) model of care is proposed to extend the 15-minute physician visit.
• Corbin J.M. & Strauss A. (1988). Unending work and care: Managing chronic illness at home. Jossey-Bass; San Francisco, CA.
• Department of Health (2012). Long-term conditions compendium of Information: 3rd edition. Department of Health.
• Foster, G., Taylor, S. J. C., Eldridge, S., Ramsay, J., Griffiths, C. J. (2009). Self-management education programmes by lay leaders for people with chronic conditions (review). The Cochrane Library.
• Hamilton-West, K.E. and Katona, C. and King, A. and Rowe, J and Coulton, S. and Milne, A.J. and Alaszewski, A.M. and Pinnock, H (2010) Improving Concordance in Older People with Type 2 Diabetes (ICOPE-D). Final Report to the National Institute for Health Research. Annex A. Concordance Therapy Manual [PB-PG-0906-10182]. Available at: http://kar.kent.ac.uk/34279
• Hamilton-West, K.E., Rowe, J.A., Katona, C., King, A.M., Coulton, A., Milne, A.J., Alaszewski, A., Ellis, K. & Pinnock, H. (2013). A concordance therapy to help older people self-manage type 2 diabetes. Diabetes & Primary Care 15: 240–8
References• Hamilton-West, K.E., Smith, K., Grice, K., Smith, J., Vaughan, A., Kolubinski,
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