1. Patrick McGowan, PhD University of Victoria
Self-management support: an effective prescription for patients and providers
Patrick McGowan, PhD
University of Victoria

2. Agenda Describe self-management support Community programs
Self-management support delivered by HCP’s
Effectiveness of self-management support
Lessons learned

3. Levels of Evidence
Ia – Evidence from meta-analysis or systematic review of randomized controlled trials.
Ib – Evidence from at least one randomized controlled trial.
IIa – Evidence from at least one well-designed controlled study without randomization.
IIb – Evidence from at least one other type of well-designed quasi-experimental study without randomization.
III – Evidence from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV – Evidence from expert committee or opinions and/or clinical experiences of respected authorities.

5. The Expanded Chronic Care Model

6. Clinicians are present for only a fraction of the patient’s life
Clinicians are present for only a fraction of the patient’s life. (Barlow, 2003)
Motivation is not enough. People also need self-confidence and certain skills that we can model and teach.
Nearly all outcomes are mediated through the patient’s behavior. (Bodenheimer et al., 2002)

10. Ongoing Challenge
There is no single commonly agreed definition of self-management support!

12. Core Self-Management Skills
Problem solving
Decision making
Resource utilization
Patient-provider relationships
Taking action

13. Distinction
Self-management refers to the behaviours that individuals engage in outside the health care context. Self-management support refers to how individuals are supported in their self- management goals and activities by health care professionals.

14. What health care providers do…
Self-management support is defined as the
systematic provision of education and
supportive interventions by health care staff
to increase patients’ skills and confidence in
managing their health problems, including
regular assessment of progress and problems,
goal setting, and problem-solving support.

15. Self-management support Intervention or outcome?
Independent variable Dependent variable
Self-management - intervention Self-management - outcomes
- strategies used by HCP’s - skills
- peer led self-management programs - attitudes
- behaviours

17. Self-Management Support Programs Aim to
Change Patient Behavior
Self-management support programs assume a complex sequence of effects. Developers expect these programs to change patients’ behavior by increasing the patients’ self-efficacy and knowledge.
This sequence of assumptions gives self-management support programs multiple objectives and multiple endpoints for evaluation.
The pivotal objective, however, is to change people’s behavior.

18. Self-Management Support - Sequence
Self-management intervention ↓
↑Patient’s confidence
↑knowledge & skills
↑Patient’s behaviour*
↑Health professional’s behaviour
↑Disease control
↑Health outcomes
↓Healthcare utilization
↑Patient satisfaction
Costs
RAND 2007
*Pivotal objective is to change people’s behaviour

19. What is Self-Efficacy?
“One’s belief that one can perform a specific behaviour or task in the future.”
Dr. Albert Bandura

20. Self-efficacy affects every phase of health behaviour change
whether one even considers changing a health behaviour
how much one benefits from the changed behaviour
how well one maintains the change achieved
how vulnerable one is to relapse

21. Self-efficacy Enhancing Strategies Self-efficacy: Health outcomes
Mastery Learning
Modeling
Reinterpreting Symptoms
Persuasion

22. Types of group self-management programs
The Chronic Disease Self-Management Program (in English, Chinese, Punjabi)
The Chronic Pain Self-Management Program (in English)
The Diabetes Self-Management Program (in English, Chinese, Punjabi)
The Arthritis/Fibromyalgia Self-Management Program (in English)
The Active Choices Program (in English)
The Online Chronic Disease Self-Management Program (in English)

26. Self-Management Programs
Persons with any type of chronic health conditions
Self-referral
Spouses and significant others may participate
Led by pairs of lay persons with chronic health conditions
Leaders receive a 4-day training workshop

27. 6. Leaders follow a scripted Leader’s Manual
7. Course is given once a week for 2 ½ hours for 6 weeks
8. Ideal class size is 10 to 12 persons
9. Participants receive “Living a Healthy Life with Chronic Conditions” workbook
10. No cost to participants

29. self-management programs?
What do people learn in
self-management programs?
Information
From the program
From other participants
Practical Skills
Getting started skills (e.g., exercise)
Problem-solving skills
Communication skills
Working with health care professionals
Dealing with anger/fear/frustration

30. Practical Skills (cont’d)
Dealing with depression
Dealing with fatigue
Dealing with shortness of breath
Evaluating treatment options
Cognitive Techniques
Self-talk
Relaxation techniques

32. Core Self-Management Strategies
Problem solving
Action plans
Making decisions

36. Between 2000 and today….
Conducted 496 four-day leader training workshops
Trained 4843 Program Leaders
Leaders conducted 2382 six-week self-management programs
To 27,259 persons with chronic health conditions

38. Minimal Intervention Strategy
Self-management is a
Minimal Intervention Strategy
Minimal interventions are defined as those interventions that
yield varied therapeutic effects with little expense in time or
money and have few side effects.
Rose, 1985; Hovell et al.,1986; Geller et al., 1991.

49. SMS Training for Educators

50. Gestational Diabetes

51. a year within a 50 km radius Result 87% of population in communities
Percentage of British Columbians with chronic health conditions who will have access to self-management education programs    Goal: 75% in 2010   Access = the program is offered at least once
a year within a 50 km radius
Result 87% of population in communities
of 3,000+ had access.

52. Mean Family Income of Persons in the Treatment
and Control Groups in HSDA’s
Treatment Group
Control Group
Difference (%)
11. East Kootenay
$54,128
$55,493
-$1,365
-2.5%
12. Kootenay Boundary
$50,391
$50,587
-$196
-0.4%
13. Okanagan
$50,731
$51,183
-$452
-0.9%
14. Thompson Cariboo Shuswap
$53,357
$51,480
$1,877
3.6%
21. Fraser East
$53,110
$54,440
-$1,330
22. Fraser North
$59,326
$60,123
-$797
-1.3%
23. Fraser South
$63,489
$65,348
-$1,859
-2.9%
31. Richmond
$58,006
$56,005
$2,001
3.5%
32. Vancouver
$57,943
$56,946
$997
1.7%
33. North Shore / Coast Garibaldi
$65,114
$68,621
-$3,507
-5.2%
41. South Vancouver Island
$58,342
$60,797
-$2,455
-4.1%
42. Central Vancouver Island
$50,231
$50,954
-$723
-1.4%
43. North Vancouver Island
$54,798
$53,688
$1,110
2.0%
51. Northwest
$58,127
$53,728
$4,399
7.9%
52. Northern Interior
$59,030
$57,897
$1,133
1.9%
53. Northeast
$64,019
$65,274
-$1,255
-1.9%
OVERALL MEAN
$56,939.19
$57,578.33
-$639
-1.1%
Standard Error of Mean
$162.06
$93.95
$187.33

53. Mean family incomes, St Errors and confidence intervals
for Treatment and Control Groups
Mean Family Income St Error of Mean
Treatment Group $56, $162.06
Control Group $57, $93.95
Difference -$ $187.33
Conclusion
There is only a 1.1% difference between the mean income of CDSMP participants and controls. People who take the CDSMP have similar mean family incomes as people who do not take the CDSMP in every Health Service Delivery Area.

54. Self-management support by health care professionals

55. The Expanded Chronic Care Model

56. ASSESSING READINESS & STRATEGIES STANFORD GROUP PROGRAMS
ACTION PLANS
PROBLEM SOLVING
MAKING DECISIONS
COMMUNICATION SKILLS
ASSESSING READINESS & STRATEGIES
STANFORD GROUP PROGRAMS 
BRIEF ACTION PLANNING
5 A’s
M.I.
CHOICES & CHANGES

59. Assess Establish rapport
Establish visit agenda
Assess client readiness
Use health risk appraisals
Advise Ask-tell-ask
Closing the Loop
Agree Action plans and follow-up
Assist Motivational Interviewing
Teach problem solving
Awareness of community resources
Arrange Follow-up

61. Four main categories of outcomes
Self-efficacy, knowledge, experience, empowerment and satisfaction with care
Patient engagement in more “healthy” behaviours or general behaviour change
Clinical and quality of life outcomes
Cost and resource implications for health and social services

62. Evidence of impact tends to be greatest for self-efficacy and weakest for health care utilization and costs however… Outcomes vary depending on the type of intervention and health condition of the target patient group

63. Caution
Some studies suggest that the evidence for supporting self-management is only moderate but this is because a wide range of activity is described as ‘self-management support’ and some interventions may be more effective than others.

65. Levels of Evidence
Ia – Evidence from meta-analysis or systematic review of randomized controlled trials.
Ib – Evidence from at least one randomized controlled trial.
IIa – Evidence from at least one well-designed controlled study without randomization.
IIb – Evidence from at least one other type of well-designed quasi-experimental study without randomization.
III – Evidence from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV – Evidence from expert committee or opinions and/or clinical experiences of respected authorities.

67. Self-management works
This review of more than 550 pieces of high quality research suggests that it is worthwhile to support self-management, in particular through focusing on behaviour change and supporting self-efficacy.
Whilst the findings of individual studies are mixed, the totality of evidence suggests that supporting self-management can have benefits for people’s attitudes and behaviours, quality of life, clinical symptoms and use of healthcare resources.

71. The 5A’s approach to Self-Management Support
1. Getting patients to complete a Health Risk Appraisal at home. This
provides an opportunity for patients to obtain independent objective
information about their health and what they need to do to address these
concerns. The information the client receives from the appraisal is
discussed with the health professional. Ib
2. Assessing the patient’s readiness to change a behavior. This helps the
health professional to use an appropriate behaviour change strategy with
the patient. III
3. Setting a visit agenda with patients ensures that both the health
professionals’ and patients’ concerns are addressed in the visit. IIb
4. Establishing rapport with patients – ensures patients have opportunities
to express their priority concerns. III

72. 4. Teaching patients how to make action plans helps patients start and maintain a behaviour. Ia
5. The problem-solving process teaches the patient a process they can use to solve problems when they arise in their daily lives. Ia
6. Ensuring that follow-up takes place facilitates the success of making action plans. Ia
7. Appropriately trained nurses should use motivational interviewing. Ia
8. The “ask-tell-ask” strategy is a technique to ensure the patient gets the information he/she is after. III
9. The “closing the loop” technique is used to ensure the patient understands the information provided by the health professional. III

73. The Expanded Chronic Care Model

74. Activation refers to people’s ability and willingness to take on the role of managing their health and health care.
The Patient Activation Measure (PAM) was designed to assess an individual’s knowledge, skill and confidence in managing their health.
PAM segments people into one of four progressively higher level of activation.

77. PAM scores reflect the degree of patient engagement or participation in their own care
- Increased patient participation was associated with higher PAM scores - Patients with higher PAM scores reported significantly better health and significantly lower rates of doctor office visits, emergency room visits, and hospital nights - Individuals with higher PAM scores are significantly more likely to exhibit healthy behaviours - PAM scores were strongly associated with improved adherence to treatment - PAM score was strongly associated with doctor-patient communication

78. At 6-months post program the proportion of participants:
- who were in Level 1 at baseline had decreased by 11%;
- who were In Level 2 at baseline had decreased by 9%;
- who were In Level 3 at baseline had decreased by 8%; and
- who were In Level 4 at baseline had increased by 27%.

79. Lessons Learned 1. Tools alone are not enough
2. Offer people a range of support options, so they can se lect to suit their preferences and needs
3. Recognize that people are different, and tailor interventions appropriately

80. 4. Changing professional roles, behaviours and
4. Changing professional roles, behaviours and mindsets is vital, challenging, but not impossible
5. Train whole teams, not just individuals
6. Engage health care professionals as change agents

81. 7. Work with the voluntary and community sector 8
7. Work with the voluntary and community sector 8. Local context is a vital factor in implementation 9. Use a whole system approach to implementing

82. 10. Have a change strategy in place from the start, one that is clear about goals but flexible on implementation
11. Consider sustainability from the outset
12. Evaluation should be designed into change processes from the start, balancing robustness and feasibility considerations

83. Barriers to embedding self-management support
Health care professional characteristics
mindsets and preconceptions
- concerns about risk
- knowledge of wider support services

84. Challenges Senior level support and ongoing commitment
Core team to drive change
Alignment with wider priorities and agendas
IT systems and system capacity
Supportive commissioning and payment systems

85. Contact Information
Toll-free line:
Web site:

89. Shared Decision Making
Shared decision making is both a philosophy and a process. It requires a partnership between patients and professionals, working together to select tests, treatments and support packages based on patient preferences, clinician experience and research evidence.

90. Both SMS and Shared Decision Making
are both underpinned by the same principles and expectations for respect and collaboration between patients and professionals
neither can be successful without a more equal distribution of power in the professional-patient relationship
“working with” rather than “doing for”