Patient Engagement
and Self-Management
Jeanie Knox Houtsinger
University of Pittsburgh School of Medicine
Department of Psychiatry
Robert Wood Johnson Foundation
Depression in Primary Care National Program
Presentation Overview
Key concepts related to patient
engagement and self-management
Why is self-management and patient
education so critical to good chronic illness
care?
Strategies for engaging patients,
developing wellness toolkits and working
through symptom relapse
PCASG Recognition Awards
PCASG quality program is based on
NCQA PPC – PCMH system



Creates baseline (floor) quality requirements
Creates pay for performance requirements
Allows organizational selection of participation
/ priorities
National Committee on Quality Assurance
(NCQA) Physician Practice Connections®
Patient-Centered Medical Home Survey
PPC-PCMH Content and Scoring
Standard 1: Access and Communication
A.
Has written standards for patient access and patient
communication**
B.
Uses data to show it meets its standards for patient
access and communication**
Pt
4
5
9
Standard 2: Patient Tracking and Registry Functions
A. Uses data system for basic patient information
(mostly non-clinical data)
B. Has clinical data system with clinical data in
searchable data fields
C. Uses the clinical data system
D. Uses paper or electronic-based charting tools to organize
clinical information**
E.
Uses data to identify important diagnoses and conditions
in practice**
F.
Generates lists of patients and reminds patients and
clinicians of services needed (population
management)
Pt
Standard 3: Care Management
A.
Adopts and implements evidence-based guidelines for
three conditions **
B. Generates reminders about preventive services for
clinicians
C. Uses non-physician staff to manage patient care
D. Conducts care management, including care plans,
assessing progress, addressing barriers
E.
Coordinates care//follow-up for patients who receive
care in inpatient and outpatient facilities
Pt
2
Standard 5: Electronic Prescribing
s A. Uses electronic system to write prescriptions
B. Has electronic prescription writer with safety
checks
C. Has electronic prescription writer with cost
checks
Pts
3
3
Standard 6: Test Tracking
Tracks tests and identifies abnormal results
s A.
systematically**
B. Uses electronic systems to order and retrieve
tests and flag duplicate tests
Pts
7
Standard 7: Referral Tracking
A.
Tracks referrals using paper-based or electronic
system**
PT
4
3
3
6
4
3
21
3
4
3
5
Standard 8: Performance Reporting and Improvement
A.
Measures clinical and/or service performance by
physician or across the practice**
B. Survey of patients’ care experience
C. Reports performance across the practice or by
s
physician **
D. Sets goals and takes action to improve
performance
E.
Produces reports using standardized measures
F.
Transmits reports with standardized measures
electronically to external entities
Standard 9: Advanced Electronic Communications
A. Availability of Interactive Website
B. Electronic Patient Identification
C. Electronic Care Management Support
Pt
s
2
4
6
8
6
13
4
Pts
3
3
3
3
2
1
15
5
20
Standard 4: Patient Self-Management Support
A.
Assesses language preference and other communication
barriers
B.
Actively supports patient self-management**
2
Pts
1
2
1
4
National Committee on Quality Assurance
Physician Practice Connections®
Patient-Centered Medical Home Survey Tool
PPC9C
Electronic Care Management Support:
For patients with the three clinically important
conditions, the practice care management team uses
electronic communication for the following:
Factor
PPC9C_fct1
PPC9C_fct2
Description
To communicate with disease or case
managers about patient needs
Web-based educational modules
for patient self-management.
NCQA PPC/PCMH Home Survey Tool
PPC4: Patient Self-Management Support - Practice works to improve
patients' ability to self-manage health by providing educational
resources and ongoing assistance and encouragement.
Intent: The practice collaborates with patients and families to pursue
their goals for optimal achievable health.
Description: The practice assesses patient/family-specific barriers
to communication using a systematic process to:
Factor
PPC4A_fct1
PPC4A_fct2
Description
Identify and display in the record the language preference
of the patient and family.
Assess both hearing and vision barriers to communication.
NCQA PPC-PCMH Home Survey Tool
PPC4B: Self-Management Support
Description: The practice conducts the following activities to support
patient/family self-management, for the three important conditions:
1.
2.
3.
4.
5.
6.
7.
Assesses patient/family preferences, readiness to change and selfmanagement abilities
Provides educational resources language or medium that the patient and
family understands
Provides self-monitoring tools or personal health record, or works with
patients' self-monitoring tools or health record, for patients/families to
record results home setting where applicable
Provides or connects patients/families to self-management support
programs
Provides or connects patients/families to classes taught by qualified
instructors
Provides or connects patients/families to other self-management
resources where needed
Provides written care plan to the patient/family.
NCQA PPC-PCMH Home Survey Tool
PPC4B:
Self-Management Support
Description: The practice conducts the following activities to support
patient/family self-management, for the three important
conditions:
Factor
Answers (based on patients see in the past 3 months)
PPC4B_fct1
10% or less have at least 3 activities documented;
11%-24% have at least 3 activities documented
25%-49% have at least 3 activities documented
50%-74% have at least 3 activities documented
75%-100% have at least 3 activities documented
NCQA PPC-PCMH Home Survey Tool
PPC8B:
Patient Experience Data
Description: The practice collects data on patient
experience with care in the following areas:
Factor
PPC8B_fct1
PPC8B_fct2
PPC8B_fct3
PPC8B_fct4
Description
Patient access to care
Quality of physician communication
Patient/family confidence in self care
Patient/family satisfaction with care
Definitions
Engagement – Strategies that providers can use
to help educate and motivate patients to access
and use services and tools to manage their
illness.
Self Management – Strategies that patients can
use to look at their health behaviors and then
make choices to improve their health based on
their knowledge, skills and attitudes.
Strategies for Addressing Barriers to
Patient Engagement
Systems Barriers
Cultural - Reform curriculum for health care providers so
that it incorporates determining patient expectations of
care and education/management strategies.
Infrastructure - Modify systems so that personal health
information includes goal-setting and
achievement/compliance with self-management plans
Financial – Incentivize use of patient education and selfmanagement techniques by rewarding
providers/practices that actively incorporate them into
day-to-day practice.
Strategies for Addressing Barriers to
Patient Engagement
Patient Barriers
Language – Determine language preference early
Literacy – Determine what reading level and technical
abilities they are to determine which tools are the most
appropriate
Support system – Find out who will be their partner in
helping them to better manage their illness
Financial challenges – Be prepared to offer suggestions
for low cost/no cost activities the patient can use when
developing self-management plans.
Engagement Interventions
Focus on 2 phases of treatment


Initial attendance
Ongoing retention
Can be implemented in all areas of
Chronic Care Model
Engagement Interventions and the
Chronic Care Model
Delivery system


Redesign system to assure effective and efficient clinical care and promote
self-management
Create culture, organization and mechanisms that promote effective
interaction, workflow improvement, and self-management.
Clinical information systems

Use patient registry to track assessment scores, appointment attendance,
patient action plan.
Decision support


Promote self-management strategies consistent with scientific evidence and
patient preferences
Telephone engagement and use of patient action plan
Self-management

Use evidence-based guidelines to help patient address barriers to achieving
self-management goals
Community services

Information and linkages with community services (e.g. childcare,
transportation, activities) to reduce no-shows and help patients achieve selfmanagement goals
Empowering the Patient
Effective Self-Management Tools:
Don’t require an “expert”
Rely on “natural supports” (friends, family,
neighbors, etc.) rather than “programs”
Can be applied across a range of
conditions (not just a single disorder)
Meet people “where they are” through the
course of their illness and recovery
Can fit on a refrigerator door
Self–Management Supports:
What to Avoid
Gender bias
Cultural bias
Literacy assumptions – including
“computer literacy”
Excessive focus on medication
management
Overuse of the word ”Compliance”
Examples of
Self-Management
Action Plans
Wellness Action Recovery Plan (WRAP)
www.mentalhealthrecovery.com
Wellness Toolbox: Used to develop WRAP Plan


List of activities that patients have done in the past - or could do
in the future - to help them stay well
List of activities that patients can do to help them feel better
when they are not doing well
Elements of written WRAP plan





Daily Maintenance List
Triggers
Early Warning Signs
Things are Breaking Down
Crisis Planning
Developed by Mary Ellen Copeland, MA
Wellness Toolbox:
Examples of Wellness Tools
Talk to a friend
Talk to a health care professional
Peer counseling or exchange listening
Focusing exercises
Relaxation and stress reduction exercises
Guided imagery
Journaling (writing in a notebook)
Creative affirming activities
Exercise
Diet considerations
Elements of WRAP Plan
Daily Maintenance List



Describe how you feel when you are feeling well.
List the things you need to do for yourself every day to stay well.
List reminders that you might need to do based on how you are
feeling.
Triggers


List those things that, if they happen, might cause an increase in
your symptoms or things that may have triggered your symptoms
in the past.
Write an action plan that you can use if triggers come up.
Elements of WRAP Plan
When Things Are Breaking Down


List early warning signs that you have noticed in the past when your
condition worsened.
Write an action plan to use if early warning signs come up.
Crisis Planning



Develop crisis plan slowly when you are feeling well.
Use crisis plan to instruct others about how to help you when you are
not feeling well and need help.
Crisis plan keeps you in control even when it seems like things are
out of control.
Insures your needs are met because others will know what to do
Saves time and frustration
Depression Self-Care Action Plan
DEPRESSION IS TREATABLE!
STAY PHYSICALLY ACTIVE.
Make sure you make time to address your basic physical needs, for example,
walking for a certain amount of time each day.
Every day during the next week, I will spend at least _________ minutes
(make it easy and reasonable) doing ____________________________.
MAKE TIME FOR PLEASURABLE ACTIVITIES.
Even though you may not feel as motivated, or get the same amount of
pleasure as you used to, commit to schedule some fun activity each day, for
example, doing a hobby, listening to music or watching a video.
Every day during the next week, I will spend at least _________ minutes
(make it easy and reasonable) doing ____________________________.
Depression Self-Care Action Plan
DEPRESSION IS TREATABLE!
SPEND TIME WITH PEOPLE WHO CAN SUPPORT YOU.
It’s easy to avoid contact with people when you’re depressed, but you need the
support of friends and loved ones. Explain to them how you fell, if you can. If you
can’t talk about it, that’s okay – just ask them to be with you, maybe accompanying
you on one of your activities.
During the next week, I will make contact for at least ________ minutes
(make it easy and reasonable) with:
____________ (name) doing/talking about _______________________.
____________ (name) doing/talking about _______________________.
____________ (name) doing/talking about _______________________.
Depression Self-Care Action Plan
DEPRESSION IS TREATABLE!
PRACTICE RELAXING.
For many people, the change that comes with depression – no longer keeping
up with our usual activities and responsibilities, feeling increasingly sad and
hopeless – leads to anxiety. Since physical relaxation can lead to mental
relaxation, practicing relaxing is another way to help yourself. Try deep
breathing, or a warm bath, or just a quiet, comfortable, peaceful place and
saying comforting things to yourself (like “It’s okay.”)
Every day during the next week, I will practice physical relaxation at least
________ times, for at least __________ minutes each time (make it easy
and reasonable).
Depression Self-Care Action Plan
DEPRESSION IS TREATABLE!
SIMPLE GOALS AND SMALL STEPS.
It’s easy to feel overwhelmed when you’re depressed. Some problems and
decisions can be delayed, but others cannot. It can be hard to deal with them when
you’re feeling sad, have little energy, and not thinking clearly. Try breaking things
down into small steps. Give yourself credit for each step that you accomplish.
The problem is _________________________________________
_____________________________________________________
My goal is to ___________________________________________
______________________________________________________
How Likely Are You To Follow Through With These Activities
Prior to Your Next Visit?
Not Likely
1
2
3
4
5
6
7
8
9
10
Very Likely
Depression Self-Care Action Plan
DEPRESSION IS TREATABLE!
Things to Know About Your Antidepressant Medication
Your antidepressant medication is NOT ADDICTIVE OR HABIT
FORMING. They are NOT uppers or downers. It is safe for you to take
your medication according to your provider’s orders. If you are using
alcohol or other drugs, please discuss this with your provider.
Target symptoms for antidepressant medications are: Sleep, Appetite,
Concentration, Mood and Energy.
It takes time for your medication to work. Most people begin to feel
better in 1-4 weeks. Don’t give up if you don’t feel better right away.
Important things for you to do:
Keep all of your appointments.
Take the medicine exactly as your provider prescribes – even if you
feel better.
If you forget a dose DO NOT DOUBLE DOSE – Take your next dose at
the regular time.
What Are You Using…
To educate patients about their illness
(e.g. one-pagers, brochures, web-sites)
To engage patients in taking a more active
role in managing their illness (e.g. goalsetting, reward system for achieving goals)
To give patients the tools they need when
they go home to better manage their
disease
Where Can I Learn More?
Self-Management Tools on the Web
New Health Partnerships (http://www.collaborativeselfmanagement.org/)

Designed to facilitate collaborative self-management engaging patients,
family members, and health care providers who want to work together as
partners in care.
Institute for Healthcare Improvement
(http://www.ihi.org/IHI/Topics/PatientCenteredCare/SelfManagementSup
port/Resources/)

Features links to websites and publications focusing on self-management
and patient-centered care.
Massachusetts Consortium on Depression in Primary Care
(www.mcdpc.org/ConsumerInfo):

Includes consumer information in English and Spanish on medications used
to treat depression and suggestions for managing their illness.
MacArthur Foundation Initiative on Depression (www.depressionprimarycare.org/clinicians/toolkits/materials/patient_edu/self_mgmt_2/.

Provides downloadable self-management tools in English and Spanish.
Hope to Healing (http://www.hopetohealing.com):

Forum for patients to share personal stories about challenges they face, how
they sought help and ongoing efforts to manage their disease.
Suggested Reading: Engagement
Wang et al. (2008) Disruption of Existing Mental Health Treatments
and Failure to Initiate new Treatment after Hurricane Katrina, The
American Journal of Psychiatry, 165(1):34-42.
Cavaleri et al. (2007) The Sustainability of a Learning Collaborative
to Improve Mental Health Service Use among Low-Income Urban
Youth and Families, Best Practices in Mental Health, 3(2):52-61.
McKay et al. Integrating Evidence-Based Engagement Interventions
into “Real World” Child Mental health Settings (2004) Brief
Treatment and Crisis Intervention, 4:177-186.
Wagner et al. (1998) Chronic Disease Management: What Will It
Take to Improve Care for Chronic Illness? Effective Clinical Practice,
93:239-243.
Suggested Reading: Self-Management
Brownson et al. (2007) A Quality Improvement Tool to Assess SelfManagement Support in Primary Care. The Joint Commission Journal on
Quality and Patient Safety, 33(7):408-416.
Bachman et al. (2006) Patient self-management in the primary care
treatment of depression. Administration Policy and Mental Health,
33(1):76-85.
Pincus HA et al. (2005) Depression in primary care: Bringing behavioral
health safely into the main stream. Health Affairs, 24:271-276.
Battersby MW. (2004) Community models of mental care warrant more
governmental support. British Medical Journal, 329:1140-1141.
Bodenheimer et al. (2002). Patient self-management of chronic disease in
primary care. Journal of the American Medical Association, 288:24692475.
Wagner et al. (2001). Improving chronic illness care: Translating evidence
into action. Health Affairs, 20, 64-78.
Copeland ME. (2001). The Depression Workbook: A Guide to Living With
Depression and Manic Depression. Oakland, CA: New Harbinger
Publications.