Presentation is loading. Please wait.

Presentation is loading. Please wait.

Engaging Patients in Their Care Theory into Action Alan Glaseroff MD CMO, Humboldt Del Norte IPA Wisconsin Dalles Oct 6, 2009.

Similar presentations


Presentation on theme: "Engaging Patients in Their Care Theory into Action Alan Glaseroff MD CMO, Humboldt Del Norte IPA Wisconsin Dalles Oct 6, 2009."— Presentation transcript:

1 Engaging Patients in Their Care Theory into Action Alan Glaseroff MD CMO, Humboldt Del Norte IPA Wisconsin Dalles Oct 6, 2009

2 A National Crisis? “Those With Multiple Conditions Cause Bulk Of Medicare Spending Growth” “Those With Multiple Conditions Cause Bulk Of Medicare Spending Growth” Sunday Health Policy UpDate (Health Affairs Web Exclusive) August 27, 2006 “Virtually all of the growth in Medicare spending over the past 15 years can be traced to patients who were treated for five or more medical conditions during the year, according to a new study by economists Kenneth Thorpe and David Howard released today as a Web Exclusive on the Web site of the journal Health Affairs. These beneficiaries alone accounted for 76 percent of total Medicare spending in 2002, up from 52.2 percent in 1987.” “Virtually all of the growth in Medicare spending over the past 15 years can be traced to patients who were treated for five or more medical conditions during the year, according to a new study by economists Kenneth Thorpe and David Howard released today as a Web Exclusive on the Web site of the journal Health Affairs. These beneficiaries alone accounted for 76 percent of total Medicare spending in 2002, up from 52.2 percent in 1987.”

3 Determinants of Health and Their Contribution to Premature Death Schroeder, NEJM 357; 12 15% 5% 10% 40% 30% Social Environmental Medical Behavioral Genetic

4 Patients Home Hospital Services Primary Care Medical Home Friends and Family Specialists Community We are less important than we think… The “empowered patient’s medical home” …? Place of Worship Workplace Internet

5 Core of Care Primary care is about building the “productive relationship”

6 Aligning Forces for Quality Chronic Care Model elements: IPA-led community wide improvement effort Chronic Care Model elements: IPA-led community wide improvement effort Health IT: Chronic Disease registry Health IT: Chronic Disease registry Decision Support: E-referrals, disease specific guidelines at the point of care Decision Support: E-referrals, disease specific guidelines at the point of care Self-Management Support: Health Education Alliance Self-Management Support: Health Education Alliance Delivery System Design: Care Support Delivery System Design: Care Support Primary Care Renewal: IPA-led “build your own medical home” collaborative Primary Care Renewal: IPA-led “build your own medical home” collaborative Our Pathways to Health: peer-led SMS Our Pathways to Health: peer-led SMS Care Transitions: RN-led hospital program for ED and post-admit patients Care Transitions: RN-led hospital program for ED and post-admit patients Comparative Performance Reporting: “Triple Aim” Comparative Performance Reporting: “Triple Aim” Population Health: HMO and PPO Measures (HEDIS) Population Health: HMO and PPO Measures (HEDIS) Patient Experience: CAHPS (PAS in CA) Patient Experience: CAHPS (PAS in CA) Efficiency Measures: Total Cost of Care, ED visits, bed days, generics, imaging for LBP, 30-day readmits, evidence-based cervical cancer screening Efficiency Measures: Total Cost of Care, ED visits, bed days, generics, imaging for LBP, 30-day readmits, evidence-based cervical cancer screening

7 Primary Care Renewal “The only way to know is to try…” Primary Care Renewal “The only way to know is to try…” “Build Your Own Medical Home” “Build Your Own Medical Home” Defining “key principles” allows each to create the medical home ideas and practices that “work for them” and might be useful to others… Defining “key principles” allows each to create the medical home ideas and practices that “work for them” and might be useful to others…

8 A process A way of seeing Examining Data PDSAs Team meetings Population Management Proactively engaging patients New Actions in Practice

9

10 Self-Management Support “Our Pathways to Health” Patient Education Patient Education Information and skills are taught Information and skills are taught Usually disease-specific Usually disease-specific Assumes that knowledge creates behavior change Assumes that knowledge creates behavior change Goal is compliance Goal is compliance Teachers are health care professionals Teachers are health care professionals Didactic Didactic Self-Management Self-Management Skills to solve patient- identified problems are taught Skills to solve patient- identified problems are taught Skills are generalizable to all chronic conditions Skills are generalizable to all chronic conditions Assumes that confidence yields better outcomes Assumes that confidence yields better outcomes Goal is to increase self- efficacy Goal is to increase self- efficacy Teachers can be professionals or peers Teachers can be professionals or peers Interactive Interactive. adapted from Bodenheimer, Lorig, et al JAMA 2002;288:2469.

11 Care Transitions in the Chronic Care Model The intervention focuses on four conceptual “pillars” to empower patients: The intervention focuses on four conceptual “pillars” to empower patients: 1. Medication self-management: Patient is knowledgeable about medications and has a medication management system. 2. Use of a dynamic patient-centered record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care plan across providers and settings. The patient or informal caregiver manages the PHR. 3. Primary Care and Specialist Follow-Up: Patient schedules and completes follow-up visit with the primary care physician or specialist physician and is empowered to be an active participant in these interactions. 4. Knowledge of Red Flags: Patient is knowledgeable about indications that their condition is worsening and how to respond.

12 Self-Management Support Delivery System Design Decision Support Clinical Information Systems Individual Social Support System Medical/ Social Health System Access MedicalHome PracticeTeam: Patient: SelfManage-ment

13 Putting It All Together…

14 “Why wouldn’t a person with a chronic condition do everything in their power to live long and feel well?”

15 Why Do Our Patients Struggle? (“strong” endorsements by physicians) poor self-discipline53.2% poor will-power50.0% not scared enough36.9% not intelligent enough16.3% Polonsky, Boswell and Edelman, 1996

16 “Do As I Say, Not As I Do…” Attributional Bias Attributional Bias “I’m too busy…” “I’m too busy…” “My patients come first…” “My patients come first…” “I’ll start exercising when I retire…” “I’ll start exercising when I retire…” Character defects in patients, situational stressors in ourselves: Character defects in patients, situational stressors in ourselves: “Life gets in the way”

17 What Else Gets in the Way?

18

19

20 Why Do Our Patients Struggle? Almost no one is unmotivated to live a long and healthy life.Almost no one is unmotivated to live a long and healthy life. The rewards for good diabetes care areThe rewards for good diabetes care are -relatively subtle -mostly long-term “If you do everything perfectly, you can expect to feel…nothing!” What a concept to motivate a person to strive hard on a daily basis!“If you do everything perfectly, you can expect to feel…nothing!” What a concept to motivate a person to strive hard on a daily basis!

21 Unachievable Self-Care Plans Unachievable Self-Care Plans Unclear -“I’m supposed to start exercising.” Unrealistic -“My doctor told me to lose 10 lbs before the next visit.” -“Taking care of my diabetes means I’m supposed to eat perfectly and never cheat.”

22

23 WHAT DOESN’T WORK Labeling patient as “unmotivated,” “unwilling to change,” or “non-compliant” Taking sides in the patient’s ambivalence -Giving advice -Transmitting unwanted/unneeded information -Threatening bad outcomes -“What part do you think will fall off first?” -Urging more willpower -“If you would just try harder…” Caring more than the patient…

24 Key Competency: Motivational Interviewing Patient-centered, goal-oriented method for enhancing intrinsic motivation to change by exploring and resolving ambivalence Patient-centered, goal-oriented method for enhancing intrinsic motivation to change by exploring and resolving ambivalence MI is collaborative, evocative, and supports autonomy MI is collaborative, evocative, and supports autonomy Express empathy, develop discrepancy, support self-efficacy, and roll with resistance Express empathy, develop discrepancy, support self-efficacy, and roll with resistance Helping the patient build their own will, discover the change ideas that work for them, and execute a individualized plan of action Helping the patient build their own will, discover the change ideas that work for them, and execute a individualized plan of action Dancing vs Wrestling

25 The Overarching Approach The patient must feel there is hope and benefit in doing a good job. GOALS: BELIEVE SELF- MANAGEMENT IS WORTHWHILE: The patient must feel there is hope and benefit in doing a good job.

26 FACTS AND FICTIONS 1.Diabetes is the leading cause of adult blindness, amputations and kidney failure. True or false? ________________________________________ A.. A. False. Poorly controlled diabetes is the leading cause of adult blindness, amputations and kidney failure.

27 Feelings Can Fuel Change What are your own feelings about diabetes? Judgments (of those who are obese; of smokers; etc…) are common…and dangerous Be honest!!! Put it on a shelf and focus on the patient’s reality

28 Feelings Can Fuel Change What are the patient’s feelings? Think of a patient you’ve seen recently Have you ever asked how he/she feels about his/her diabetes? What “bugs” that person the most about his/her diabetes??? What is working for that person in their current lifestyle? (what is the function in the “dysfunction”) ASK! (then listen)

29 The Overarching Approach The patient must feel there is hope and benefit in doing a good job. GOALS: BELIEVE SELF- MANAGEMENT IS WORTHWHILE The patient must feel there is hope and benefit in doing a good job. ACTION PLANS: KNOW WHAT TO DO The patient must have a clear and achievable plan for self-management

30 Behavior Change Strategies 1.Begin with your patient’s interests Agenda must be personally meaningful for the patient Start with questions, not information: “What questions should we make sure to address today?” “What’s been driving you crazy about diabetes?”

31 Behavior Change Strategies 1.Begin with your patient’s interests 2.Believe that your patient is motivated to live a long, healthy life You are both on the same side

32 Behavior Change Strategies 1.Begin with your patient’s interests 2.Believe that your patient is motivated to live a long, healthy life 3.Help your patient determine exactly what they might want to change Identify and respect patient ambivalence Empathize with their dilemma

33 Listen Well and Summarize “It sounds like you’re inclined in two different directions. On the one hand, you’re somewhat worried about the possible long-term effects of your diabetes if you don’t manage it well– blindness, amputations, things like that. Those are distressing to think about. On the other hand, you’re young and you feel fairly healthy most of the time. You enjoy eating what you like, and the long-term consequences seem far away. You’re concerned, and at the same time you’re not concerned.”

34 Behavior Change Strategies 1.Begin with your patient’s interests 2.Believe that your patient is motivated to live a long, healthy life 3.Help your patient determine exactly what they might want to change Identify and respect ambivalenceIdentify and respect ambivalence Present the bouquetPresent the bouquet 4.Develop a reasonable, detailed action plan

35 The “Action Plan” Intervention 1. Don’t tell patients what to do 2. Negotiate what changes to focus on blending your expertise and patients’ desires 3. Focus on 1 – 2 concrete actions to start Not attitudes, numbers, or actions to stop Not “lose 5 pounds in 2 weeks” Instead…”Walk briskly 20 minutes 3 x/ week, Monday, Wednesday and Friday after lunch”

36 The “Action Plan” Intervention 4. 4.Start with changes that are achievable even if “physiologically silly” 5.Selected actions must be personally meaningful 6.Do the first step right away “What does this mean you’ll do tomorrow AM?”

37 The “Action Plan” Intervention 1. Identify area for behavior change – Importance and confidence should be elevated 2. Determine a specific action plan – Meaningful, action-oriented, measurable, behavioral 3. Make certain that goals are practical/achievable – Break down, specify, and limit steps as needed 4. Ask about obstacles, and problem solve 5. Feed back your understanding of the plan Offer support/sincere encouragement, BUT: OFFER AS LITTLE ADVICE AS POSSIBLE!

38 Behavior Change Strategies 1.Begin with your patient’s interests 2.Believe that your patient is motivated to live a long, healthy life 3.Help your patient determine exactly what they might want to change 4.Develop a reasonable, detailed action plan 5.Stay alert for common obstacles

39 Patient Self-Management Barriers Social devastation (poverty, homelessness, lack of access to health care services, etc) Social devastation (poverty, homelessness, lack of access to health care services, etc) Lack of information Lack of information Cultural disconnect Cultural disconnect Low functional health literacy Low functional health literacy Relative lack of life skills Relative lack of life skills Anxiety/disease-specific distress/depression Anxiety/disease-specific distress/depression

40 Creating Meaning Meaning is a human need. It strengthens us, not by numbing our pain or distracting us from our problems, or even by comforting us. It heals us by reminding us of our integrity, who we are, and what we stand for. It offers a place from which to meet the challenges of life. Part of our responsibility as professionals is to fight for our sense of meaning—against fatigue and numbness, overwork, and unreasonable expectations—to find ways to strengthen it in ourselves and each other. Rachel Naomi Remen, Recapturing the soul of medicine, West J Med :4-5. Rachel Naomi Remen, Recapturing the soul of medicine, West J Med :4-5.

41


Download ppt "Engaging Patients in Their Care Theory into Action Alan Glaseroff MD CMO, Humboldt Del Norte IPA Wisconsin Dalles Oct 6, 2009."

Similar presentations


Ads by Google