Patient Self-Management Support NCQA PCMH Standard 4

Presented by:

Medina Wilson, BS, CPC

Practice Support Coordinator

Wake Forest School of Medicine

NW AHEC

mewilson@wakehealth.edu

Objectives

Describe the key concepts and principles of self-management and self-management support

Identify specific strategies, tools and resources for engaging and activating patients and families in chronic illness care

Describe strategies for redesigning care to enhance the efficient delivery of self-management support

What is self-management?

“The individual’s ability to manage the symptoms, treatment, physical and social

consequences and lifestyle changes inherent in living with a chronic condition.”

Barlow et al, Patient Educ Couns 2002;48:177

Informed,

Activated

Patient

Productive

Interactions

Prepared,

Proactive

Practice Team

Delivery

System

Design

Decision

Support

Clinical

Information

Systems

Self-

Management

Support

Health System

Resources and

Policies

Community

Health Care Organization

Chronic Care Model

Improved Outcomes

What is Self-Management Support?

– “The systematic provision of education and

supportive interventions 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 patient’s central role in managing their illness

• Assess patient’s beliefs, behavior and knowledge.

• Advise patients by providing specific information about health risks and benefits of change.

Self-management support, cont.

• Assist patients with problem-solving by identifying personal barriers, strategies, and social/environmental support.

• Arrange a specific follow-up plan.

Self-Management Support

A collaborative process to help people to:

Understand/Choose treatments

Identify and set goals

Adopt and change behaviors

Cope and overcome barriers

Follow-through

Self-Management Support is NOT

• Didactic Patient Education

• Lecturing

• Inducing fear

• Finger-wagging

• “You should”

• Shaming

• Waiting for a patient to ask

What Works – Research Evidence?

Addressing knowledge is necessary but not sufficient to produce changes in chronic illness care outcomes

Key components that have been found to work well to support self-management include:

Involving patients in decision making

Assessment of patient-specific needs and barriers

Goal setting

Enhancing skills, problem-solving

Follow-up and support

Increasing access to resources

(Bodenheimer et al, 2002 ; Glasgow et al, 2003; Fisher et al, 2005)

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 providers

Why is self-management so important? What is different?

• Clinical outcomes are dependent on patient actions.

• Patient self-management is inevitable.

• The provider’s role is to be in partnership with the patient

• Professionals are experts about diseases, patients are experts about their own lives.

Emphasizing the patient role

Collaborative care

“If physicians view themselves as experts whose job is to get patients to behave in ways that

reflect that expertise, both will continue to be frustrated…Once physicians recognize patients

as experts on their own lives, they can add their medical expertise to what patients know

about themselves to create a plan that will help patients achieve their goals.”

Funnell & Anderson JAMA 2000;284:1709

How to emphasize the patient’s role

• Simple messages from the primary care provider: – “Diabetes is a serious condition. There are things you can do to live better

with diabetes and things the medical team can do to assist you. We are going to work together on this.”

• Consistent approach

• Culturally and linguistically appropriate

Self Management Support: Core Clinical Competencies

(New Health Partnerships, 2007)

• Relationship Building

• Exploring patients’ needs, expectations and values

• Information Sharing

• Collaborative Goal Setting

• Action Planning

• Skill Building & Problem Solving

• Follow-up on progress

Motivational Interviewing

“a skillful clinical style for eliciting from patients their own motivation for

making changes in the interest of their health.”

(Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

“Spirit of Motivational Interviewing”

(Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

• Collaborative

• Partnership, shared decision making

• Evocative

• Understand patient goals; evoke arguments for change

• Honoring patient autonomy

• Patients ultimately decide what to do

Motivational Interviewing

“Principles”

• Resist the Righting Reflex (Directing)

• Understand Patient Motivations

• Listen to Your Patient with Empathy

• Empower Your Patient

(Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

Explore: Agenda, Needs, Expectations

“What are you hoping to accomplish today?”

“What do you think is most important for us to talk about?”

What concerns do you have about your health?

What reasons do you have to change?

Where would you like to start?

Self-management skills for patients

Five areas of self-care – some ideas to get started

Information

Skills and knowledge training

Tools and self-monitoring devices

Healthy lifestyles choices

Support networks

Action Planning – Starts with SMART Goals

• Specific and behavioral

• Measurable

• Attractive

• Realistic

• Timely

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:

Action Plan

1. Goals: Something you WANT to do Begin Exercise

2. Describe

How Walking Where Neighborhood

What 20 min Frequency 3x/week

When After dinner

3. Barriers - Dishes, safety (no sidewalks)

4. Plans to overcome barriers - get kids to clean up, ask neighbor

or husband to join me, wear reflective vest

5. Conviction and Confidence ratings (0-10) - 9/8

6. Follow-Up: Will keep log and bring to next visit in 1

month

Action Planning

• Review past experience -

especially successes

• Define small steps that

are likely to lead to

success

“How confident are you that you can meet your goal of exercising 5 days a week?

Not at all confident

Totally confident

0 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 Confidence

• Provide tools, strategies, resources, skills

• Address barriers

• Attend to progress and to perceive slips as occasions for problem solving rather than as failure

Enhancing Confidence: Identifying 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

Self-Management Support

Cycle

Adapted from: Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87

EXPLORE : Needs, Expectations, Values,

Behavior, Progress SHARE : Provide specific

Information about health risks,

benefits of change, and strategies to self-

manage

SET GOALS: Collaboratively set

goals based on patient’s conviction and confidence

in their ability to change

BUILD SKILLS : Identify personal

barriers, strategies, problem-solving techniques and

social/environmental support

ARRANGE : Specify plan for

follow-up (e.g., visits, phone calls, mailed

reminders Personal Action Plan

1. List specific goals

in behavioral terms

2. List barriers and strategies

to address barriers

3. Specify follow-up plan

4. Share plan with practice

team and patient’s social

support

Opportunities for Self Management Support: When, Where and By Whom

Before the Encounter

During the Encounter

After the Encounter

Opportunities for SMS

Before the Encounter

• Pre-visit contact (phone, mail or e-mail)

• Waiting room assessment

• Patient education material

• Posters

• Pamphlets on “Talking to Your Provider”

• Community outreach

Opportunities for SMS

During the Encounter

• Review assessments

•

• Feedback on achievements vs. goals

• Identifies priorities for visit

• 5 “A”s Counseling

• Targeted patient education materials

• Referral for more SMS

Opportunities for SMS

After the Encounter

• Referrals (Health Education, etc)

• Further 5 “A”s counseling

• Phone calls follow-up

• Mailed patient education

• Peer support

• Newsletters

• Follow-up visits

• e-mail/Internet sites

Implementing Health System Changes to Support Self-Management

• Quality Improvement Collaboratives: IPIP/PCMH Collaborative

• Educational Outreach – QIOs (CCME), AHEC, CCNC

• Provider education and training - Core Competencies, Motivational Interviewing

• Incentives, rewards for provider delivery of SMS, system change

SELF MANAGEMENT AND HOW IT RELATES TO PCMH STANDARD 4

PCMH Standard 4 Provide Self-Care Support and Community Resources

Element A : Support Self-Care Process

Element B : Provide Referrals to Community

Resources

PCMH Standard 4 Element A: Support Self-Care Process

• Provides education resources or refers at least 50% of patients to educational resources to assist in self-management

• Uses an EHR to identify patient-specific education resources

• Develops and documents self-management plans and goals

• Documents self-management abilities for al least 50% patients

• Provides self- management tools to record self-care results for at least 50%

• Counsels at least 50% of patients/families to adopt healthy behaviors

The practice conducts activities to support patients/families in self-management.

PCMH Standard 4 Element B: Provide Referrals to Community Resources

• Maintains a current resource list on five topics

• Tracks referrals provided to patients/families

• Arranges or provides treatment for mental health and substance abuse disorders

• Offers opportunities for health education programs (such as group classes and peer support)

The practice supports patients/families that need access to community resources:

Resources for Implementing Self-Management

Self-Management Support: A Toolkit for Clinicians

http://www.improvingchroniccare.org/downloads/partnering_in_selfmanagement_sup

port__a_toolkit_for_clinicians.doc

Primary Care Resources and Support for Chronic Disease and Self-Management

http://improveselfmanagement.org/index.aspx

Improving Your Practice Manual - Improving Chronic Care, 2005

www.improvingchroniccare.org/index.php?p=Steps_for_Improvement&s=37

Primary Care Resources and Support for Chronic Disease and Self-Management

http://improveselfmanagement.org/index.aspx

Improving Your Practice Manual - Improving Chronic Care, 2005

www.improvingchroniccare.org/index.php?p=Steps_for_Improvement&s=37

Questions??