Presentation on theme: "Patrick McGowan, PhD University of Victoria"— Presentation transcript:
1Patrick McGowan, PhD University of Victoria Self-management support: an effective prescription for patients and providersPatrick McGowan, PhDUniversity of Victoria
2Agenda Describe self-management support Community programs Self-management support delivered by HCP’sEffectiveness of self-management supportLessons learned
3Levels of EvidenceIa – 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.
6Clinicians 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)
12Core Self-Management Skills Problem solvingDecision makingResource utilizationPatient-provider relationshipsTaking action
13DistinctionSelf-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.
14What health care providers do… Self-management support is defined as thesystematic provision of education andsupportive interventions by health care staffto increase patients’ skills and confidence inmanaging their health problems, includingregular assessment of progress and problems,goal setting, and problem-solving support.
15Self-management support Intervention or outcome? Independent variable Dependent variableSelf-management - intervention Self-management - outcomes- strategies used by HCP’s - skills- peer led self-management programs - attitudes- behaviours
17Self-Management Support Programs Aim to Change Patient BehaviorSelf-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.
18Self-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 satisfactionCostsRAND 2007*Pivotal objective is to change people’s behaviour
19What is Self-Efficacy?“One’s belief that one can perform a specific behaviour or task in the future.”Dr. Albert Bandura
20Self-efficacy affects every phase of health behaviour change whether one even considers changing a health behaviourhow much one benefits from the changed behaviourhow well one maintains the change achievedhow vulnerable one is to relapse
21Self-efficacy Enhancing Strategies Self-efficacy: Health outcomes Mastery LearningModelingReinterpreting SymptomsPersuasion
22Types 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)
26Self-Management Programs Persons with any type of chronic health conditionsSelf-referralSpouses and significant others may participateLed by pairs of lay persons with chronic health conditionsLeaders receive a 4-day training workshop
276. Leaders follow a scripted Leader’s Manual 7. Course is given once a week for 2 ½ hours for 6 weeks8. Ideal class size is 10 to 12 persons9. Participants receive “Living a Healthy Life with Chronic Conditions” workbook10. No cost to participants
29self-management programs? What do people learn inself-management programs?InformationFrom the programFrom other participantsPractical SkillsGetting started skills (e.g., exercise)Problem-solving skillsCommunication skillsWorking with health care professionalsDealing with anger/fear/frustration
30Practical Skills (cont’d) Dealing with depressionDealing with fatigueDealing with shortness of breathEvaluating treatment optionsCognitive TechniquesSelf-talkRelaxation techniques
36Between 2000 and today….Conducted 496 four-day leader training workshopsTrained 4843 Program LeadersLeaders conducted 2382 six-week self-management programsTo 27,259 persons with chronic health conditions
38Minimal Intervention Strategy Self-management is aMinimal Intervention StrategyMinimal interventions are defined as those interventions thatyield varied therapeutic effects with little expense in time ormoney and have few side effects.Rose, 1985; Hovell et al.,1986; Geller et al., 1991.
51a 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 oncea year within a 50 km radiusResult 87% of population in communitiesof 3,000+ had access.
52Mean Family Income of Persons in the Treatment and Control Groups in HSDA’sTreatment GroupControl GroupDifference (%)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$1,8773.6%21. Fraser East$53,110$54,440-$1,33022. 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$2,0013.5%32. Vancouver$57,943$56,946$9971.7%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$1,1102.0%51. Northwest$58,127$53,728$4,3997.9%52. Northern Interior$59,030$57,897$1,1331.9%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
53Mean family incomes, St Errors and confidence intervals for Treatment and Control GroupsMean Family Income St Error of MeanTreatment Group $56, $162.06Control Group $57, $93.95Difference -$ $187.33ConclusionThere 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.
54Self-management support by health care professionals
59Assess Establish rapport Establish visit agendaAssess client readinessUse health risk appraisalsAdvise Ask-tell-askClosing the LoopAgree Action plans and follow-upAssist Motivational InterviewingTeach problem solvingAwareness of community resourcesArrange Follow-up
61Four main categories of outcomes Self-efficacy, knowledge, experience, empowerment and satisfaction with carePatient engagement in more “healthy” behaviours or general behaviour changeClinical and quality of life outcomesCost and resource implications for health and social services
62Evidence 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
63CautionSome 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.
65Levels of EvidenceIa – 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.
67Self-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.
71The 5A’s approach to Self-Management Support 1. Getting patients to complete a Health Risk Appraisal at home. Thisprovides an opportunity for patients to obtain independent objectiveinformation about their health and what they need to do to address theseconcerns. The information the client receives from the appraisal isdiscussed with the health professional. Ib2. Assessing the patient’s readiness to change a behavior. This helps thehealth professional to use an appropriate behaviour change strategy withthe patient. III3. Setting a visit agenda with patients ensures that both the healthprofessionals’ and patients’ concerns are addressed in the visit. IIb4. Establishing rapport with patients – ensures patients have opportunitiesto express their priority concerns. III
724. 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. Ia6. Ensuring that follow-up takes place facilitates the success of making action plans. Ia7. Appropriately trained nurses should use motivational interviewing. Ia8. The “ask-tell-ask” strategy is a technique to ensure the patient gets the information he/she is after. III9. The “closing the loop” technique is used to ensure the patient understands the information provided by the health professional. III
74Activation 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.
77PAM 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
78At 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%.
79Lessons 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 needs3. Recognize that people are different, and tailor interventions appropriately
804. Changing professional roles, behaviours and 4. Changing professional roles, behaviours and mindsets is vital, challenging, but not impossible5. Train whole teams, not just individuals6. Engage health care professionals as change agents
817. 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
8210. Have a change strategy in place from the start, one that is clear about goals but flexible on implementation11. Consider sustainability from the outset12. Evaluation should be designed into change processes from the start, balancing robustness and feasibility considerations
83Barriers to embedding self-management support Health care professional characteristicsmindsets and preconceptions- concerns about risk- knowledge of wider support services
84Challenges Senior level support and ongoing commitment Core team to drive changeAlignment with wider priorities and agendasIT systems and system capacitySupportive commissioning and payment systems
89Shared 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.
90Both SMS and Shared Decision Making are both underpinned by the same principles and expectations for respect and collaboration between patients and professionalsneither can be successful without a more equal distribution of power in the professional-patient relationship“working with” rather than “doing for”