Clinical Tools and Strategies for
Supporting Self-Management
IBHP Webinar
March 18, 2009
Michael G. Goldstein, MD
Chief, Mental Health and Behavioral Sciences Service
Providence VA Medical Center
Professor, Psychiatry and Human Behavior,
Alpert Medical School of Brown University
Objectives
By the end of the session, participants will be able to:
• Describe the key concepts and principles of selfmanagement 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
Outline
• Self-Management
• Self-Management Support (SMS)
• Key Components of SMS
• Core Clinical Competencies/Tools &
Resources
• Health Care System Redesign
• Community Linkages
• Questions and Discussion
Self-Management Tasks
• To take care of the illness
(medical management)
• To carry out normal activities
(role management)
• To manage emotional changes
(emotional management)
(Corbin & Strauss, 1998 Bodenheimer et al, 2002;
Lorig et al, 2003)
Self-Management Tasks for Diabetes
• Blood glucose monitoring
• Managing high/low blood sugars
• Diet
•
•
•
•
•
•
•
Physical activity/exercise
Medication taking
Medical monitoring/visits
Coping with emotions
Foot care
Eye care
Dental care
What is Self-Management Support?
Institute of Medicine Definition:
• “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 problemsolving support.”
(IOM, 2003)
What Works – Research Evidence?
• Addressing knowledge is necessary but not
sufficient to produce changes in chronic illness
care outcomes
• Key strategies for improving outcomes of
educational and behavior change interventions:
• 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
What is Self-Management Support?
A collaborative process to
help people to:
• Understand
• Choose among 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
Self-Management Support
A Fundamental Shift in the Process of Care
Traditional Care
Collaborative Care
Assumes knowledge drives
change
Assumes knowledge +
confidence drives change
Clinician sets agenda
Patient sets agenda
Goal is compliance
Goal is enhanced confidence
Decisions made by caregiver
Decisions made
collaboratively
(Bodenheimer et al, CA Health Care Foundation, 2005)
SMS: Key Components
•
Core Clinical Competencies and Tools and
Resources for Teams, Patients & Families
•
System redesign to efficiently deliver SMS
within the context and flow of clinical care
•
Meaningful links to community resources
and community-based programs and
campaigns
(New Health Partnerships: www.newhealthpartnerships.org)
SMS: Key Components
•
Core Clinical Competencies and Tools and
Resources for Teams, Patients & Families
•
System redesign to efficiently deliver SMS
within the context and flow of clinical care
•
Meaningful links to community resources
and community-based programs and
campaigns
(New Health Partnerships: www.newhealthpartnerships.org)
SMS: Core Clinical Competencies
•
Relationship Building
•
Exploring patients’ needs,
expectations and values
•
Information Sharing
•
Collaborative Goal Setting
•
Action Planning
•
Skill Building & Problem
Solving
•
Follow-up on progress
(New Health Partnerships, 2007)
SMS: Core Clinical Competencies
•
Relationship Building
•
Exploring patients’ needs,
expectations and values
•
Information Sharing
•
Collaborative Goal Setting
•
Action Planning
•
Skill Building & Problem
Solving
•
Follow-up on progress
(New Health Partnerships, 2007)
Motivational Interviewing
“Definition”
“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)
The “Spirit of MI”
• Collaborative
• Partnership, shared decision making
• Evocative
• Understand patient goals; evoke arguments
for change
• Honoring patient autonomy
• Patients ultimately decide what to do
(Rollnick, Miller and Butler, Motivational Interviewing in
Health Care, 2008)
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)
MI Style
A refined form of guiding, rather
than directing or following……
helping the patient make his or
her own decision about behavior
change
(Rollnick, Miller and Butler, Motivational Interviewing in
Health Care, 2008)
Motivational Interviewing
• Asking
• Listening
• Informing
Guiding balancing skills,
flexibly applied
(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?
If you have DIABETES, here are some things you can talk about
with your health care provider
Choose to talk about changing any of these and add other concerns in
the blank circles.
Blood glucose
monitoring
Taking medications
to help control
blood sugar
Skin care
Taking insulin
Diet
Depression

Losing weight
Daily foot care
Smoking
(RI Dept of Health Chronic Care Collaborative)
Explore Conviction/Importance
“How convinced are you that it is important to monitor your
blood sugars?”
Not at all
convinced
0 1 2 3 4 5 6 7 8 9 10
Totally
convinced
“What makes you say 4?”
“What leads you to say 4 and not zero?”
“What would it take (or have to happen) to move it to a 6?”
(From Keller and White, 1997; Rollnick, Mason and Butler, 1999)
Share Information
Ask Permission
Ask Understanding
Tell (Personalize)
Ask Understanding
Collaboratively Set Goals
• Share clinician priorities
• Offer options
• Agree on something to work on
• Negotiate a specific action plan
SMS: Core Clinical Competencies
•
Relationship Building
•
Exploring patients’ needs,
expectations and values
•
Information Sharing
•
Collaborative Goal Setting
•
Action Planning
•
Skill Building & Problem
Solving
•
Follow-up on progress
(New Health Partnerships, 2007)
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
Action Planning:
Assess and Enhance Confidence
“How confident are you that you can meet your goal of
exercising 5 days a week?
Not at all
confident
0 1 2 3 4 5 6 7 8 9 10 Totally
confident
“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
EXPLORE :
Needs, Expectations, Values,
Behavior, Progress
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
BUILD SKILLS :
Identify personal
barriers, strategies, problem-solving
techniques and
social/environmental
support
SHARE :
Provide specific
Information about
health risks,
benefits of
change, and
strategies to selfmanage
SET GOALS:
Collaboratively set
goals based on patient’s
conviction and
confidence
in their ability to change
Adapted from: Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87
SMS: Key Components
•
Core Clinical Competencies and Tools and
Resources for Teams, Patients & Families
•
System redesign to efficiently deliver SMS
within the context and flow of clinical care
•
Meaningful links to community resources
and community-based programs and
campaigns
(New Health Partnerships: www.newhealthpartnerships.org)
A Model for Planned Care*
Community
Health System
Resources and Policies
Organization of Health Care
SelfManagement
Support
Informed,
Activated
Patient
Decision
Support
Productive
Interactions
Delivery
System
Design
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
*E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound
Delivery System Redesign
• Determine process and define roles for
delivering SMS among members of the care
team
• Planned Care visits
• Medical Group visits
• Chronic Disease Self-Management groups
• Planned peer interactions
• Provide support and coordination according
to level of need
Opportunities for SMS:
When, Where and By Whom
• Before the Encounter
• During the Encounter
• After the Encounter
Chronic Disease SelfManagement Program
• Developed and studied by Kate Lorig and colleagues
at Stanford
• Lay-leaders, 6 sessions, 2 1/2 hours each
• Single or multiple conditions
• Focus on collaborative goal-setting, personalized
problem solving, skill acquisition
• Outcomes: improved health behaviors and health
status, fewer hospitalizations
• Limitations: limited population
(Lorig et al, Med Care 1999, 37:5-14; Lorig, et al., Med Care,
2001, 39: 1217-1223)
Clinical Information Systems
• Provide access to educational materials
and tools
• Create capacity to identify and contact
relevant subpopulations for proactive care
• Monitor and share SMS performance
data.
Community Linkages
• Identity community programs and
resources
• Partner with community organizations
• Partner with employers
• Raise community awareness: community
campaigns
Implementing Health System Changes
to Support Self-Management
• Quality Improvement Collaboratives:
with focus on SMS (e.g., New Health
Partnerships) and Patient Activation (MN)
• Educational Outreach – QIOs, DOQ-IT,
Voluntary Agencies
• Provider education and training - Core
Competencies, Motivational Interviewing
• Incentives, rewards for provider delivery of
SMS, system change
SMS: Key Components
•
Core Clinical Competencies and Tools and
Resources for Teams, Patients & Families
•
System redesign to efficiently deliver SMS
within the context and flow of clinical care
•
Meaningful links to community resources
and community-based programs and
campaigns
(New Health Partnerships: www.newhealthpartnerships.org)
SMS: Core Clinical Competencies
•
Relationship Building
•
Exploring patients’ needs,
expectations and values
•
Information Sharing
•
Collaborative Goal Setting
•
Action Planning
•
Skill Building & Problem
Solving
•
Follow-up on progress
(New Health Partnerships, 2007)