Self-management support and
patient education for chronic
conditions at Group Health
Small steps to big changes
May 10, 2012 | Kim Wicklund, MPH
Randy’s story
Whether you think you
can do a thing or you can’t
do a thing, you’re right.
– Henry Ford
Chronic Conditions in U.S.
Among the American adult population:
 50% have at least one chronic condition
 25% have multiple chronic conditions
 75% of people age ≥65 have multiple chronic conditions
 ½ of those with hypertension, and over 60% of those
with diabetes and hyperlipidemia do not have
conditions well controlled
Vogeli, Shields, Lee 2007 JGIM
Medical Panel Expenditure Survey 2006
Schneider et al. 2009
Bodenheimer, Wagner, Grumbach 2002 JAMA
Chronic Care Model
Rationale for self-management support
 Through SMS people gain knowledge, skills, and
self-confidence
 Majority of care for chronic conditions is complex and
challenging self care
 SMS improves patient outcomes and controls costs
 Various SMS approaches: care managers, one-onone, group, telephonic coaching, online, peer
 Need effective models that are affordable and have
population level impact
Chronic Disease Self-Management Program

Developed at Stanford Patient Health Education Research
Center

6-week workshop (2.5 hrs/wk) based on self-efficacy theory

Designed for people with one or more chronic conditions

Leaders have personal experience with chronic conditions

Premise– people with chronic conditions share similar
challenges and need to master a generic set of selfmanagement skills

Contributes to improvements in psychological health status,
self-efficacy and select health behaviors. Modest effects can
have significance across large population. (CDC 5/2011)
CDSMP at Group Health
 Started in 1998
 18 medical centers
 65 volunteer leaders
 Average age: 65
 Most common conditions: diabetes, arthritis,
asthma/COPD, heart disease, depression
 Reach 2009-2011: 1,615 Group Health patients
 Recruitment: letters, care team, ghc.org, flyers,
word of mouth
Challenges of scaling CDSMP

Limited access for network members in eastern and
central Washington

Capacity determined by volunteer leader and room
availability

Schedule is sporadic

Chronic condition flare-ups can impact attendance

Difficult to commit to weekly 2 ½ hour sessions

Discomfort discussing sensitive topics face to face
Online CDSMP
Online CDSMP pilot
 Funded by GHF
 Partners: NCOA, Stanford, GHRI
 Target: 500 participants
 Timeline: June, 2009-June, 2011
 Eligibility:
• Adult Group Health member
• Any chronic condition
• Enhanced access to MGH
Intervention
 Follows structure of in-person program
6-week highly interactive online workshop
25 participants per workshop
Two peer moderators
New lessons posted each week
 Participants log on at their convenience 2-3 times/week
 Time commitment of 2-3 hours/week
Home page
Evaluation questions
1. Will the online program expand CDSMP’s reach to
Group Health members who are not reached by the
in-person workshops?
2. Will participants in the online program at Group
Health experience similar benefits to those reported
in Stanford’s evaluation?
3. What resources and expertise are needed to
administer the online program at Group Health?
4. Is the online format a viable strategy for bringing the
CDSMP intervention to scale at Group Health?
Participant flow
Stage in process
Total
Signed up as interested
1043
Enrolled
473 (45%)
Attended ≥1 session
91%
Completed ≥4 sessions
66%
Data for baseline and 6 months
50%
Evaluation
Health Status
Self-mgt
behaviors
Healthcare
Utilization
Self-efficacy
• Social/role
activity
limitations
• Exercise
• Visits to
physician
6 item selfefficacy scale
• Communication w/MD
• Visits to ED
• Depression
• Pain severity
• Shortness of
breath
• Cognitive
symptom
management
• Medication
management
• Self-rated
general health • Smoking status
• Health
distress
• Hospital stays
• Nights in
hospital
Demographics
Online
(n= 478)
Age:
18 – 39
40 – 64
>=65
Age range
Mean age
Gender
Female
Education
High school or less
College/Undergraduate
Race
White
African American
Asian/PI
Marital status
Single
Married/domestic ptnr
Separated/Divorced
Widowed
Health status
Excellent/very good
Good/fair
Poor
In-person
(n= 1615)
13%
66%
21%
20 – 89
54
2%
32%
66%
17 – 96
68
83%
69%
18.3%
57.8%
86.7%
4.7%
4.4%
15.8%
66.6%
15.2%
2.4%
20.2%
72.6%
7.2%
Conclusions
1. Online program expanded CDSMP’s reach
2. Benefits were similar to but not consistent with Stanford’s
3. Resources and expertise needed to administer the online
program are reasonable
 Mixed staffing model– GH Administrator; NCOA
mentor and facilitators
 Costs– per workshop: $4350; per participant: $174;
per completer: $255
4. Online format is a viable strategy for helping to bring the
CDSMP to scale at Group Health
Other strategies
Employer pilots
Testing 3 approaches:
1. Worksite-based workshops (King County)
 4 workshops- 56 employees
 Gold status for documented attendance of ≥4 sessions
2. Formal reporting of participation (SHWT)
 GH/SHWT reporting process for incentivizing employees
attending ≥4 sessions online or in person
3. Employee self report on participation (Group Health)

≥4 sessions in person or online for 400 wellness points
 317 reported met goal
Disease-specific pilot
 Living Well with Diabetes (DSMP)
 GHF Partnership for Innovation grant to pilot 8-10
workshops
 To date offered 8 workshops to 128 people (14
scheduled)
 Evaluating impact on self-management behaviors,
blood sugar knowledge, medication management
“Today I received my latest blood and kidney test
results, and for the first time in my adult life they all
were within normal ranges. My A1c was 5.7….”
Integrating referrals into care

Point of care prompts in EMR

CMEs and nursing education

Clinical Pearls

Standard tools
 Health Profile
 After Visit Summaries
 Brochures
 MyGroupHealth
Reach 1999-2011
Online
Total members enrolled in LWCC
1999 to 2011
(Online program implemented June 2009)
Total
In person
900
800
700
600
500
400
300
200
100
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Patient education
resources
Myths about patient education

If patients have more information, they’ll have better
outcomes.

If I don’t share everything I know with my patients,
they won’t fully understand their condition and what
they need to do.

If my patients hear medical jargon, that’s ok. They’ll be
able to understand it from the context.

My patient is well educated, so s/he will understand
complex words and ideas.

My patient didn’t ask any questions so s/he must have
understood my instructions.
The reality for many patients

Most patients forget up to 80% of
what their clinician tells them as
soon as they leave the office

Nearly 50% of what patients do
remember they remember
incorrectly

Implications:
– Non-adherence and
disengagement
– Patient safety concerns
– Medication errors
– Missed surgeries and other
appointments
Strategies for providing information

Break the information into understandable chunks

Use plain language

Limit key points to 3 or fewer

Focus on action-oriented messages

Repeat key messages

Use analogies to help explain concepts

Use images and graphics

Tailor the message to the patient

Give consistent messages
Modular approach
Graphics clarify key concepts
Action planning
Action plan for diabetes management
Patient instructions provided in AVS
Lessons Learned
Lessons learned
 We have an ethical obligation to provide effective SMS
 Patients want and need different options for engaging in SMS
 People cycle through readiness and need to hear about SMS
from different sources at different times
 Clinical teams need ongoing reminders about the program
 Employers are an underutilized resource for promoting SMS
 Incorporating SMS concepts into patient education supports
awareness of care team and patients about SMS
Future directions
Next steps
 Continue exploring how to integrate referrals into standard work
 Continue to identify alternative ways to reach network members
 Update functionality and design of online program
 Further analyze evaluation data
 Explore more partnerships with employers (SU, Puyallup Tribe)
 Partner with community programs to address gap areas
 Create online community of LWCC alumni to provide ongoing support
 Considering SMS program for youth or young adults
Discussion