Engaging and Sustaining Healthcare Providers in Chronic Disease
Self-Management Support What, Why, and How Healthcare Professionals
Can Do Durhane Wong-Rieger, President Institute for Optimizing
Health Outcomes March 2012 Institute for Optimizing Health Outcomes
1 Slide 2 Disclosure of Potential for Conflict of Interest Durhane
Wong-Rieger, President & CEO, Institute for Optimizing Health
Outcomes FINANCIAL DISCLOSURE: Grants / Research Support: No
Conflict Speaker bureau/Honoraria: Champlain Living Healthy
Consulting Fees: None Other: None March 2012 Institute for
Optimizing Health Outcomes 2 Slide 3 Learning objectives March 2012
3 After this program, the participant will be able to: 1. Define
the importance of an engaged patient for treatment adherence and
health behaviour change 2. Identify the knowledge and skills of
engaged self-managing patients 3. Know the five-step model of
patient engagement and concepts of self-management support 4. Know
role of motivational interviewing/decisional balance to increase
patient readiness to engage 5. Implement roles of patients and
healthcare professionals as partners in chronic disease
self-management Institute for Optimizing Health Outcomes Slide 4
Case 1: What health problem? Greg: 54-year old finance manager for
small municipality; high stress, long hours, two teenage children
Diagnosed: moderate hypertension (150/90); weight (210 lbs.)/height
(511) = BMI 29.2 Lifestyle: sedentary and overweight as child; as
young adult active runner and biker; now mostly sedentary Diet:
prefers meat and potatoes; tries to include fish and vegetables;
often fast food because of work schedule Family history of heart
disease (father died of heart attack at age 54); cancer (both
uncles); grandmother died at age 90 March 2012 Institute for
Optimizing Health Outcomes 4 Slide 5 Case 2: Ready to Self-Manage?
Mark, 32-year-old financial advisor, married 2 years; no kids
Indications: BP (130/80); Height/Weight/BMI (5 11/160/22.3); FPG
(200+ or 11.1); HA1C (7.5) Lifestyle: High activity (30-90 mins
aerobic exercise 4- 6/week); high carb diet; low alcohol (3-5
drinks/week) Family history: Thyroid, celiac; father died of ALS
Diagnosed 2 years ago with Diabetes (Type 1.5?) Treatment:
Compliant with low carb diet and exercise. Low compliance with
insulin (no pump) and blood glucose testing 4-6 times daily (rec.)
March 2012 Institute for Optimizing Health Outcomes 5 Slide 6 Case
3: Whats Happening? Ursula, 14-year-old, grade 9 HS, mid-size
community Indications: LDL cholesterol (2.6 mmol/L), SBP (120
mmHg), BMI (23.6 kg/m2), HA1C (9.5%) Diagnosed: Type 1 Diabetes
diagnosed as infant Lifestyle: Outgoing, likes music, drama,
swimming, dance, and internet activities Family: Only child, mother
primary caregiver for diabetes Treatment: Self-administering since
age 12; until recently, compliant with diet, glucose testing and
insulin 4-6 times daily; recently, irregular testing, insulin, and
diet control March 2012 Institute for Optimizing Health Outcomes 6
Slide 7 Is Chronic Disease Problem? About 50% of Canadians (16.5
million) have 1 or more chronic conditions Globally, WHO identifies
noncommunicable (chronic) diseases as killing more people than all
other causes combined; 2/3 of 57 million deaths due to CVD, cancer,
diabetes, and chronic lung disease In developed countries, CD
patients average 12 hours with HCPs, leaving them to self-manage
364.5 days/year Globally, NCDs caused by four 21 st -century
lifestyle behaviours: tobacco use, unhealthy diet, lack physical
activity, and alcohol over-use. March 2012 Institute for Optimizing
Health Outcomes 7 Slide 8 Why Self-Management for Chronic Disease?
About 50% of Canadians (16.5 million) have 1 or more chronic
conditions Traditional provider-based acute care model not
appropriate to managing chronic conditions Patient need to take an
active, informed role in managing treatment and making lifestyle
changes Patients who actively manage their own health feel better
and have better health outcomes Research indicates that
self-management is important but does not have lasting benefits
without support from the healthcare professional, that is, health
coaching. March 2012 Institute for Optimizing Health Outcomes 8
Slide 9 Problem of Patients Not Adhering to Treatment
Recommendations? 14-21% of patients never fill prescription 30-50%
dont take medications in recommended manner 66% with hypertension
have poor BP control due to non-adherence 50% adherence to chronic
conditions treatment incl. lifestyle changes WHO, 2003 21% Type 1
diabetes patients NEVER check Blood glucose levels Polonsky, 1999
36-39% non-adherence to MS disease-modifying injection therapies
(among patients who choose to engage in treatment) Treadaway et al,
2009 9 March 2012 Institute for Optimizing Health Outcomes Slide 10
Lack of Adherence to Diabetes Management Lack of adherence to BG
monitoring (Vicenze et al, 2004) Only 40% of patients with Type 1
diabetes measure as frequently as recommended Only 33% of patients
with Type 2 diabetes measure as recommended Patients with diabetes
(enrolled in diabetes management) do not spend time on self-care
(Safford et al, 2005) 21% of diabetic patients never test blood
glucose 38% of diabetic patients never engage in foot care 38% of
diabetic patients never exercise 54% of diabetic patients never
spend time shopping and cooking June 2011 Institute for Optimizing
Health Outcomes 10 Slide 11 Problems of Non-Adherence to
Medications Responsible for: Up to 10 % of hospital admissions 23%
of nursing-home admissions (McKenney and Harrison, 1976;
Strandberg, 1984) 22% of drug reaction hospitalizations (McKenney,
73) 11 March 2012 Institute for Optimizing Health Outcomes Slide 12
Why Dont Patients Make Behaviour Changes? Knowledge is not enough
Who here has perfect health (behaviour)? Who knows what he/she
needs to do to live more healthily? Behaviour change is hard Who
here prefers to do things that give pleasure rather than things
that cause pain? Have you ever continued to do something that has
bad consequences? Have you ever stopped doing something that is
good for you? March 2012 12 Institute for Optimizing Health
Outcomes Slide 13 Not Enough or Too Much Information? Dietn GP Diab
Ed Patient Psych Practice Nurse Ex PhysPodst Physio OT Dietn Take
Meds Use Aids Monitor Symptoms Exercises Nutrition Attend Appoints
Attend Groups Quit Smoking Pathology Rehab Program Move More Self-
manage 13 March 2012 Institute for Optimizing Health Outcomes Slide
14 Common Responses to Treatment Advice? Hopelessness Despair Guilt
Resistance Anger Fear Frustration Shame Confusion 14 March 2012
Institute for Optimizing Health Outcomes Slide 15 Cognitive,
Behavioral & Emotional Avoidance Response 15 March 2012
Institute for Optimizing Health Outcomes Slide 16 Empowered
Patients = Self-Managing Patients = Better Outcomes Self-management
involves [the person with the chronic health condition] engaging in
activities that protect & promote health, monitoring and
managing symptoms & signs of illness, managing the impacts of
illness on functioning, emotions and interpersonal relationships
and adhering to treatment regimes. (Gruman & Von Korff, 1966)
Patients who self monitor their condition have been shown to have
better outcomes. Self-care programmes aim to increase the interest
and involvement of people in their own care, and by doing so,
empower them to manage their condition. (WHO, 2010) 16 March 2012
Institute for Optimizing Health Outcomes Slide 17 To make
behavioural changes (adhere to treatment, make lifestyle changes),
patients must: 1. Know what to do (treatment recommendations) 2. Be
ready to make necessary changes = believe change is important and
do-able 3. Have the capacity to carry out the chosen actions: a)
Have the skills and resources to initiate and maintain health
behaviour changes b) Identify and use problem-solving skills to
address barriers to change 17 March 2012 Institute for Optimizing
Health Outcomes Slide 18 HCPs Coach Patients to Self- Management To
achieve better health outcomes, patients must adhere to treatment
recommendations and lifestyle changes To self manage, patients need
to know their conditions and treatment options, commit to making
healthy behaviour choices, have confidence that they can carry out
desired actions, and can problem solve barriers To sustain
self-management (behaviour change), patients need support from
health providers (and the system) Health providers who use health
coaching support patients with knowledge, motivation, and problem-
solving skills March 2012 18 Institute for Optimizing Health
Outcomes Slide 19 HCP Recommends Evidence-Based Treatment &
Lifestyle Changes Patient Achieves Better Health Outcomes Myth:
Evidence-Based Recommendations Lead to Better Health Outcomes?
March 2012 19 Institute for Optimizing Health Outcomes Slide 20 HCP
Recommends Evidence-Based Treatment & Lifestyle Changes HCP
Coaches to Increase Readiness to Change HCP and Patient Co-create
Achievable Action Plan Patient Adheres to Treatment & New
Behaviours Patient Achieves Physiological Targets Patient Achieves
Better Health Outcomes Reality: Long Road from Evidence-Based
Recommendations to Health Outcomes March 2012 20 Institute for
Optimizing Health Outcomes Slide 21 5 Steps of Patient Engagement
5. Assist in developing strategies to address barriers to maintain
change 4. Facilitate client action plan 3. Increase client
confidence (set SMART goals, ie, specific, measurable, achievable,
realistic, time-based) 2. Increase client readiness to change
health behaviour (choose behaviours that are important) 1.
Facilitate client identification of health issue March 2012
Institute for Optimizing Health Outcomes 21 Slide 22 Why Should
HCPs Support Patient Self-Management? What are the most important
issues affecting your practice (ability to deliver good care to
patients)? How important is it to change your usual care, given
everything else that is going on right now? What are the options
for a SMS/health coaching approach in your healthcare practice or
setting? March 2012 22 Institute for Optimizing Health Outcomes
Slide 23 Pros and Cons of SMS/Health Coaching What are the benefits
of continuing to treat patients with chronic disease with the usual
care? What do you think would be the challenges of adopting a
SMS/health coaching approach? If you were to introduce SMS/health
coaching, what might be the long-term benefits, to the patients, to
your practice, to your clinic? If you dont change your approach
with CD patients, what might be the long-term impact on patients,
your practice, your clinic? March 2012 23 Institute for Optimizing
Health Outcomes Slide 24 Continue Usual CareMake Some Changes Good
Outcomes 1. Whats working now? Patient education Staff time and
skills Number of patients served Available emergency care 3. What
wuld be long-term benefits For patientsbetter outcomes? For HCPsjob
satisfaction, less time in future? For clinic or healthcare
facilitybetter performance and appropriate usage? Not so Good
Outcomes 4. What are long-term consequences if no change? For
patientscontinued dependence and lack change For HCPsfrustration of
increasing patient load and basic care For facilityno improvements
in performance and usage 2. What are the challenges of implement
SMS/health coaching? Time for training and practice Time needed for
counselling Pressures of 24/7 staffing ? Usual Best Practice or
SMS/Coaching Question: What are Pros & Cons of Current Practice
vs. Health Coaching for CDM Patients? Is anything you have
mentioned important enough to make you want to work on this?
Examples 2010 Health Change Associates 24 March 2012 Institute for
Optimizing Health Outcomes Slide 25 Role of HCP Depends on Patient
Readiness (to Self-Manage) 25 Patient Knowledge (Risks, Benefits,
Options, Resources) Patient Motivation (Problem Solving,
Self-Confidence) Patient MIA (HiKnowLoMotiv) Patient Missing In
Action Patient seeks reassurance; hesitates, seeks more options HCP
challenges, supports Guidance: Support group, counsellor Rely on
peers, HCPs, family Patient can but wont HCP Directs
(LoKnowLoMotive) Doctor Knows Best HCP diagnoses, chooses, directs
Patient does not question; complies with prescribed treatment
Guidance: Healthcare professional Rely totally on professional
judgment Patient trusts, follows orders Self-Manages
(HiKnowHiMotiv) Patient Self-Directed Patient seeks information;
makes plans, responsible for choice HCP listens, informs, supports
Guidance: Patient peers, caregivers Rely on family and peer support
Patient feels empowered HCP Educates (LoKnow;HiMotive) HCP Educator
HCP educates on disease and options Patient learns what and how to
do HCP clarifies & recommends Guidance: Healthcare
professionals Rely on professional advice Patient learns tools and
strategies March 2012 Institute for Optimizing Health Outcomes
Slide 26 Evidence that CDSM Works 26 Treatment vs Control:
improvements at 6 months in weekly exercise, cognitive symptom
management. communication with physicians, self-reported. health,
health distress, fatigue, disability, and social/role activities
limitations. They had fewer hospitalizations and days, In hospital.
No differences were found in pain/physical discomfort, shortness of
breath, or psychological well being. Lorig, K., Sobel, D., Stewart,
A., Brown, B., Bandura, A., Ritter, P., Gonzalez, V., Laurent, D.
& Holman, H. (1999). Evidence suggesting that a Chronic Disease
Self-Management Program can improve health status while reducing
hospitalization. Medical Care, 37(1), 5 14. March 2012 Institute
for Optimizing Health Outcomes Slide 27 Evidence of CDSM Long-Term
27 Compared with baseline for each of the 2 years, Emergency Room
and outpatient visits and health distress were reduced (P
