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What, Why, and How Healthcare Professionals Can Do

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1 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 Institute for Optimizing Health Outcomes March 2012

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 Institute for Optimizing Health Outcomes March 2012

3 Learning objectives After this program, the participant will be able to: Define the importance of an engaged patient for treatment adherence and health behaviour change Identify the knowledge and skills of engaged self-managing patients Know the five-step model of patient engagement and concepts of self-management support Know role of motivational interviewing/decisional balance to increase patient readiness to engage Implement roles of patients and healthcare professionals as partners in chronic disease self-management Institute for Optimizing Health Outcomes March 2012

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 (5’11”) = 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 Institute for Optimizing Health Outcomes March 2012

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.) Institute for Optimizing Health Outcomes March 2012

6 Case 3: What’s 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 Institute for Optimizing Health Outcomes March 2012

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 days/year Globally, NCDs caused by four 21st-century lifestyle behaviours: tobacco use, unhealthy diet, lack physical activity, and alcohol over-use. Nearly half of all Canadians (16.5 million) have one or more chronic conditions, and the number is increasing with an aging population The provider-based acute care model cannot and should not be used to manage chronic conditions A chronic condition requires the patient 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. Institute for Optimizing Health Outcomes March 2012

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. Nearly half of all Canadians (16.5 million) have one or more chronic conditions, and the number is increasing with an aging population The provider-based acute care model cannot and should not be used to manage chronic conditions A chronic condition requires the patient 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. Institute for Optimizing Health Outcomes March 2012

9 Problem of Patients Not Adhering to Treatment Recommendations?
14-21% of patients never fill prescription 30-50% don’t 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 What do you estimate to be the adherence rates in your patients? Many GPs estimate between 10-50% adherence to their recommendations (i.e., patients go away and do NOT do what the doctor has suggested) WHO (2003) Adherence to long-term therapies: Evidence for Action. Geneva, WHO Polonsky, W (1999) Diabetes burnout: what to do when you can’t take it anymore. Amer Diabetes Assn (November 01, 1999) Institute for Optimizing Health Outcomes March 2012

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 Institute for Optimizing Health Outcomes June 2011

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) Non-adherence to medications has direct impact on patient outcomes Very serious adverse effects leading to hospitalization Impact on healthcare utilization and cost to the healthcare system Institute for Optimizing Health Outcomes March 2012

12 Why Don’t 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? In this workshop, participants will work individually and in small groups to apply principles and techniques to their own lives. This is more meaningful and illustrates the power of health coaching. It also demonstrates that health coaching is not really about chronic disease management but can be applied to any aspect of life and to any behaviour that a person may want to change. However, in this workshop, we will focus on health-related behaviours. Institute for Optimizing Health Outcomes March 2012

13 Not Enough or Too Much Information?
Diet’n GP Diab Ed Patient Pathology Take Meds Attend Groups Quit Smoking Practice Nurse Self- manage Use Aids OT Psych Monitor Symptoms This is what we are trying to avoid. But, unfortunately it is what happens in many well intentioned programs that require patients to see multiple health professionals . Even if each HP sets only one goal, look what that does to the patient. Is that patient-centred? What happens when each health professional wants patients to set multiple goals? The drop off rate for goal achievement is rapid as you add more goals. Diet’n Nutrition Physio Ex Phys Pod’st Rehab Program Exercises Move More Attend Appoint’s Institute for Optimizing Health Outcomes March 2012 13

14 Common Responses to Treatment Advice?
Fear Hopelessness Guilt Resistance Frustration Despair How many of you recognize these reactions in your clients when you make a diagnosis and even more importantly, when you recommend a treatment that includes lifestyle change and medical treatment recommendations. The problem is that all of these emotional reactions tend to lead to the same response (change slide)… Confusion Anger Shame Institute for Optimizing Health Outcomes March 2012

15 Cognitive, Behavioral & Emotional Avoidance Response
…Cognitive, behavioural and emotional avoidance!! Patient: denies having disease or condition…”I don’t really have this condition because I can still …” Patient runs away from intense emotional reaction…”I just don’t think about it…” Institute for Optimizing Health Outcomes March 2012

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) This presentation discusses health coaching in the context of chronic condition prevention and self management You can see that there a lot of verbs in this definition. A lot of things we require patients to do. Patients won’t do these things unless they believe it is important to them and that they have the ability to carry out the required actions. This often requires support from health professionals. You can’t give patients responsibility, they need to take it. Institute for Optimizing Health Outcomes March 2012

17 To make behavioural changes (adhere to treatment, make lifestyle changes), patients must:
Know what to do (treatment recommendations) Be ready to make necessary changes = believe change is important and do-able Have the capacity to carry out the chosen actions: Have the skills and resources to initiate and maintain health behaviour changes Identify and use problem-solving skills to address barriers to change Health coaching, or self-management support, integral to chronic care model. Collaborating, supportive care team Role of health coach mirrors the role of patients in self-management Glasgow, et al. (2003). Implementing Practical Interventions to Support Chronic Illness Self-Management in Health Care Settings: Lessons Learned and Recommendations. The Joint Commission Journal on Quality and Safety, November, 2003 Institute for Optimizing Health Outcomes March 2012

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 Better health outcomes requires patient adherence to treatment recommendations and lifestyle changes Self-managing patients know their conditions and treatment options, are committed to making healthy behaviour choices, have confidence that they can carry out desired actions, and know how to problem solve barriers Effective self-management of chronic disease requires health system and health provider support Role of self-management support (health coach) is to provide patients with knowledge, motivation, and problem-solving skills Institute for Optimizing Health Outcomes March 2012

19 Myth: Evidence-Based Recommendations Lead to Better Health Outcomes?
HCP Recommends Evidence-Based Treatment & Lifestyle Changes Patient Achieves Better Health Outcomes Animated Slide HCP starts with recommendations for evidence-based treatment and lifestyle changes (matched to patient’s condition and health risks) The goal is for the patient to achieve better health outcomes. But there is no direct path from recommendations (no matter how good) to individual outcomes. To improve health outcomes, the patient has to achieve the physiological targets, such as HA1C levels, blood pressure, healthy weight (BMI) To reach physiological targets, the patient has to adhere to treatment (including medications) and sustain behavioural changes To make behaviour changes, most patients need a plan of action, broken down into do-able steps. While it is up to the patient to decide what is do-able, the HCP can help to identify options and to problem solve barriers to changes. Prior to developing an action plan, the patient must be “ready” to make changes. One role of the HCP is to increase readiness by working with the patient to increase the importance of the target outcomes, the benefits of the behaviour change, and his/her confidence in being able to make the desired changes.. The target Institute for Optimizing Health Outcomes March 2012

20 Reality: Long Road from Evidence-Based Recommendations to Health Outcomes
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 Animated Slide HCP starts with recommendations for evidence-based treatment and lifestyle changes (matched to patient’s condition and health risks) The goal is for the patient to achieve better health outcomes. But there is no direct path from recommendations (no matter how good) to individual outcomes. To improve health outcomes, the patient has to achieve the physiological targets, such as HA1C levels, blood pressure, healthy weight (BMI) To reach physiological targets, the patient has to adhere to treatment (including medications) and sustain behavioural changes To make behaviour changes, most patients need a plan of action, broken down into do-able steps. While it is up to the patient to decide what is do-able, the HCP can help to identify options and to problem solve barriers to changes. Prior to developing an action plan, the patient must be “ready” to make changes. One role of the HCP is to increase readiness by working with the patient to increase the importance of the target outcomes, the benefits of the behaviour change, and his/her confidence in being able to make the desired changes.. The target Institute for Optimizing Health Outcomes March 2012

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 These form the basis of the workshop. The steps allow the patient to own the issue and to lead Five steps correspond to stages of change and to roles identified by Glasgow et al. Important that client achieves each stage before proceeding to next. For example, trying to get patient to identify a health behaviour to change before he/she has indicated “readiness” or belief that change is important and/or beneficial, will only increase resistance, or choice of a health behaviour change that will not be pursued Patient cannot be helped to develop action plan until has set a SMART (specific, measurable, achievable, realistic, time-based) goal, e.g., walk 15 minutes 3 times a week at noon for next 5 weeks) These steps are not a straight line forward but may require iterations or going back over previous steps. Identifying barriers may occur at any stage (e.g, what are barriers client perceives that keep him/her from identifying an important health issue). Institute for Optimizing Health Outcomes March 2012

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? Institute for Optimizing Health Outcomes March 2012

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 don’t change your approach with CD patients, what might be the long-term impact on patients, your practice, your clinic? Institute for Optimizing Health Outcomes March 2012

24 Usual Best Practice or SMS/Coaching
 2010 Health Change Associates Usual Best Practice or SMS/Coaching Question: What are Pros & Cons of Current Practice vs. Health Coaching for CDM Patients? Continue Usual Care Make Some Changes Good Outcomes 1. What’s working now? Patient education Staff time and skills Number of patients served Available emergency care 3. What wuld be long-term benefits For patients—better outcomes? For HCPs—job satisfaction, less time in future? For clinic or healthcare facility—better performance and appropriate usage? Not so Good Outcomes 4. What are long-term consequences if no change? For patients—continued dependence and lack change For HCPs—frustration of increasing patient load and basic care For facility—no 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 ? Key examples: Digging down to benefits of changing: EP working on increasing his vegetable intake for energy Manager of a health centre working on reducing alcohol intake 4 year old with an eating disorder Digging down to consequences of not changing: Participant working on whether to have more contact with her brother. Demonstration - what’s an issue you’d like to look at that relates to your own client base? Workshop the example. Does this sound a bit complex for some patients? Example: person snacking at night; explore benefits of snacking; explore challenges of “not snacking” at night; explore benefits of “not snacking”; and explore challenges of continuing to snack. Ask question: does this change the importance of setting up way to “not snack” at night. The purpose of this slide is to explain how to do decisional balance and demonstrate using an example worked with the group. Ask: What’s an issue you’d like to look at that relates to your own client base? Workshop the example. Give the client a name and some demographics prior to starting. Ask: What would XX say if you asked him/her what’s good about what they are currently doing? Continue on through the rest of the questions using the prompts in each quadrant to guide you. Use the Examples hyperlink on the slide to attach and talk through actual client examples. “Is anything you have mentioned important enough to make you want to work on this?” Institute for Optimizing Health Outcomes March 2012 Examples

25 Role of HCP Depends on Patient Readiness (to Self-Manage)
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 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 won’t Patient Knowledge (Risks, Benefits, Options, Resources) 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 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 Role of the healthcare practitioner is dictated by the readiness of the patient/client. Two parameters of determining readiness: How much knowledge does patient have as to appropriate behaviour or HOW to change? How motivated is client to make and sustain change? What are benefits? What is important to client relative to health goals? If client low in knowledge and low in motivation, HCP takes the lead (or if emergency or acute situation) If client low in (accurate) knowledge but wants to change, then provide accurate information If client has knowledge but is not motivated (lacks will), then no benefit to continued education but focus on motivation (finding what is important or how to link health behaviour to long-term outcomes) If client is knowledgeable and motivated, HCP needs to be available for consult when needed. Which quadrant is “most” and which is “least” time-consuming for HCP? Which is most satisfying to client? Patient Motivation (Problem Solving, Self-Confidence) Institute for Optimizing Health Outcomes March 2012

26 Evidence that CDSM Works
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. These results have been repeated in many settings (though long-term impact difficult to capture). Other research shows that CDSM without follow up (HCP support) has limited long-term impact (6 months to 2 years) adherence to behaviour change. Institute for Optimizing Health Outcomes March 2012

27 Evidence of CDSM Long-Term
Compared with baseline for each of the 2 years, Emergency Room and outpatient visits and health distress were reduced (P<0.05). Self-efficacy improved (P<0.05). No other significant changes. Lorig, K.et al. (2001). Chronic Disease Self-Management Program: Two year health status and health care utilization outcomes. Medical Care, 39(11), 1217 – 1223. Maintenance of change only about 6 months without regular reinforcement and collaboration with healthcare professional; counseling and SMBG device introduction improved HbA over 6- month follow-up Siebolds et al (2006). Self-monitoring of blood glucose-psychological aspects relevant to changes in HbA1C in type 2 diabetic patients treated with diet or diet plus oral antidiabetic medicaiton. Patient Educ Couns, 629(1), 104 – 110. Challenge of tracking patients long-term has limited capacity to capture benefits in terms of health status and/or healthcare utilization. Institute for Optimizing Health Outcomes March 2012

28 Evidence Health Coaching Works - 1
Health coaching improves patient self-efficacy, adherence to treatment and behaviour changes as well as health service utilization and health outcomes. (Kreindler, 2008, Lindner et al, 2003) Coaches working with families of children with asthma on lifestyle and behaviour changes were able to decrease hospitalization, emergency room, and primary care visits (by 45% to 17%) as well as use of medications by 20% (Axelrod et al, 2001). A randomized control trial using health coaching for six months with cardiovascular patients showed improvement in health behaviours and, importantly, a significant decrease in cholesterol levels (Vale et al, 2002). Challenge of tracking patients long-term has limited capacity to capture benefits in terms of health status and/or healthcare utilization. Institute for Optimizing Health Outcomes March 2012

29 Evidence Health Coaching Works - 2
RCT comparing health coaching with usual care for patients with diabetes found significant improvements in HbA1C levels, self- reported treatment adherence, exercise, stress and health status (Wolever et al, 2010). UK Diabetes Year of Care transforms diabetes annual review into constructive dialogue between HCP and patent. Outcomes: Improved experience of care and real changes in self care behaviour. Professionals report improved knowledge and skills, and greater job satisfaction. Practices report better organisation and team work. Productivity is improved: care planning is cost neutral or yields savings (www.diabetes.nhs.uk/year_of_care) Challenge of tracking patients long-term has limited capacity to capture benefits in terms of health status and/or healthcare utilization. Institute for Optimizing Health Outcomes March 2012

30 Summary There are legitimate reasons why people don’t adhere to treatment and lifestyle recommendations Patient engagement can increase adherence rates and improve patient self-management A health coaching approach can guide practitioners in engaging patients in self-care in a time efficient manner, to address barriers to change and achieve better patient health outcomes Health Coaching provides a structure for HCPs to appropriately support patient self-management: empowering patients. Institute for Optimizing Health Outcomes March 2012

31 Thank You For more information contact
The Institute for Optimizing Health Outcomes


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