Change the ConversationChange the Outcome

Self Management SupportSelf Management Support

Christopher Bolling, MD FAAPAdjunct Associate Professor of Pediatrics

Disclosure Statement

I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME

activity.

1. Discuss concepts and importance of self-management in improving outcomes in chronic care.

2. Identify some tools and processes that assist in providing effective self-management support.

3. Describe ways to incorporate self-management into clinical practice.

U.S. Determinants of Health (%)Source: Centers for Disease Control and Prevention

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Access to Care Genetics Environment Behavior

Modifying Behavior - the “50%”

• One of the most significant challenges we face as health care professionals

• We spend energy and time on how to change the patient’s or family’s behavior

• There is good evidence that we also need to change ours

• Are we helping people to change…or are we promoting resistance?

• If we change our behavior, will the patient and family follow?

Definition of Self-ManagementGruman and Von Korff, 1996

“Self-management involves [the individual experiencing chronic illness] engaging in activities that protect and promote health, monitoring and managing of symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes”*

*Based on a literature review of over 400 articles

Why Self-Management?

• Recognizes that patient/parent has wisdom about the situation; respects their competence

• Family-centered: acknowledges and supports the patient’s/family’s right to make autonomous choices

• Non-judgmental support can increase the patient’s/family’s self-acceptance and internal locus of control

• Small successes can increase self-efficacy and generalize to other areas of the person’s life into the future

Self-Management Skills

• Five core self-management skills are:problem solving decision makingaccessing appropriate resourcesforming a partnership with healthcare

providerstaking action toward health goals(Lorig 2003 [S])

Self-Management Tasks

• Incorporating medical management of the chronic illness into one’s life

• Adjusting one’s life behaviors to accommodate the chronic illness role management

• Dealing with the emotional consequences of having a chronic illness emotional management

Lorig, K. R., and Holman, H.: Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med, 26(1): 1-7, 2003

Does Self-Management Support Make a Difference?

Self-management education & support: – improves effective home management – reduces symptoms– reduces exacerbations– decreases school absenteeism – decreases number of hospitalizations

and emergency room visits Fireman, et. al. Teaching self-management skills to asthmatic children and their parents in an

ambulatory care setting. Pediatrics, 68(3): 341-8, 1981, [C] Gibson, et. al. Self-management education and regular practitioner review for adults with

asthma. Cochrane Database Syst Rev, (1) 2004, [M]

Strong evidence for…

• Comprehensive care delivery to include:– Self-management support– Care management and disease management

• Patient education combined with written action plans; neither alone is enough

• Collaborative communication (i.e. motivational interviewing; shared decision-making) is more effective than advice-giving in promoting adherence and choice

• Regular assessment and review (follow-up) to identify families at risk for sub-optimal outcomes

Model of 5 A’s Cycle to Integrate Self-Management Into Care Delivery

Created from concepts originally identified by (Manley 1991 [E] )

Strategies for Clinical Practice

• Establishing an Agenda• Using Collaborative Communication/Motivational

Interviewing– May actually shorten office visits

• Assessing Readiness and Self-Management Capability

• Goal Setting and Action Planning• Closing the Loop

Clark N, et al. Pediatrics 1998; 101:831

Important considerations

• Level of Motivation (Readiness to Change)

• Level of Importance (Priority)

• Level of Confidence (Self-Efficacy)

Readiness to change is determined by:

Importance – personal values related to the change “Why should I change?”

Confidence – self-efficacy “Can I do it?”, “How will I do it?” “Who will help me?”

Importance

Readiness

Confidence

Stages of Change

Pre-contem

plation

Contem

plation

Preparation

Action

Maintenance

Relapse

Don’t see problem

Recognize problem but ambivalent about change

Planning solutions or thinking of solutions to problem

Actively trying to make changes or modify behavior

Holding the change

Not really a stage, but anticipated risk

ProvidersPatients/families

We call this disconnect“denial” and non-compliance

Possible Disconnect

• Most healthcare professionals are at the action stage and use advice-giving - “righting reflex”

• Only about 20% of patients and families who present to care are ready for action

• If we proceed as if they are at action (or ready), we increase risk of resistance to change or adoption of a recommended plan of care

Matching Interventions to Goals

• Goals related to lack of knowledge/skill deficits addressed by – didactic methods such as information-giving – or return demonstration

Matching Interventions to Goals

• Goals related to lack of readiness or motivation are addressed by – collaborative communication/motivational

techniques until patient identifies and endorses something they want to change/manage

Matching Interventions to Goals

• Goals related to lack of self-efficacy or confidence are addressed by – problem-solving techniques– incremental successes – and support

Key MI Skills to promote change

Help navigate ambivalence and promote change talk by patient/parent by using OARS:

O: Ask open-ended questions (“Can you tell me how…”)

A: Affirming to enhance self-efficacy

R: Reflective listening (acknowledge content and feelings “you seem frustrated about…”)

S: Summarizing (“it sounds like your plan is…”)

Goal: Eliciting self-motivational statements (change talk – getting to “well, maybe I will…”)

Closing the Loop

• Arrange a plan for follow-up• Research shows that as many as half of patients

leave office not understanding what the provider told them

• Make a note to begin next visit with a check-in on goal that was set this visit

• Put a copy of action plan in the chart; give a copy to the patient/family

Self-Management Tools

Assessment

completed by patient/family immediately prior to visit

Or

if time permits during the visit with a provider

Progress Tool

• Provider documents the provider’s assessed level of patient readiness and coaching focus from the visit

Self-Management Tools

Action Plan:Completed when

Patient is in “Action” stage of readiness

Patient creates his “own" action plan– Writes it himself– Uses his own words

Assessment Progress Tool

Self-ManagementGuideline

Self-Management Tools

Case Presentation

• 13 yo girl with history of asthma, chronic cough, GERD,and poor adherence.– Frequent night-time awakenings– Exercise limitation– GERD symptoms– ACT <19– Complex social situation (parents divorced, sibs

with CF, anxiety, limited resources)

Case Presentation

• Self-management assessment was revealing!– Fears about dying from asthma, etc– Engaged quickly and intensely

• Child and mother developed excellent plans• Enthusiastic and energized• Use medication calendar, cut pills

– Desired phone follow up at 2 weeks

Case Presentation

• “Chance meeting” at ~ 2 weeks – Eager to share progress– Reported adherence to treatment plan

• Using calendar, amassing stickers, eager to celebrate• Feeling better!• Follow up call ???

Case Presentation

• Telephone follow up– Reported taking meds most days (stickers on

calendar)• Some trouble remembering pm doses

– Able to work through other solutions to further improve adherence

• Self-management process was excellent mechanism to engage this patient

Best Lessons

• Team approach works best; but ownership of process must be made clear– Obtaining action plan requires separate individual and/or time– Team approach valuable to set process in motion and for follow

up• Consider scheduling separate self-management visits

– Group visit item• One person cannot do it all

– Will not work well if MD alone is responsible for getting plans– Will not work well if MD is not active in process

THANK

YOU!