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NatPaCT Conference Programme

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1 NatPaCT Conference Programme
Patient as Partners Improving Health and Cost Outcomes with Self-Care and Chronic Disease Self-Management NatPaCT Conference Programme Learning from Kaiser Permanente – How can the NHS make better use of its resources and improve patient care? Tuesday 4 November 2003 – The Brewery, London

2 David S. Sobel, MD, MPH Director, Patient Education and Health Promotion Kaiser Permanente Northern California 1950 Franklin Street., 13th Floor, Oakland, CA Phone: Fax:

3 Strategy for Changing Culture and Practice
Look for inefficiencies, mismatches, and capacity overlooked evidence and data “win, win, win” opportunities

4 Strategy for Changing Culture and Practice
Rethink Care Patients as primary providers of acute illness Self-management of chronic illness Behavioral interventions to address psychosocial needs Restructure Care Telephone, group appointments, web-based care Retrain for Collaborative Care Enhance understanding, skills, and confidence of members and professional staff as partners in care

5 Rethinking Care 1: Self-Care for Acute Illness
Patient as Consumer as Provider

6 Hidden Health Care System
3 Professional Care 20% 2 1 Self-Care 80%

7 Self-Care: Patients as Providers
Over 80% of all medical symptoms are self-diagnosed and self-treated without professional care. Patients are the true primary care providers of medical care for themselves and their families. How can health care systems educate, equip, and empower the true primary care providers… patients?

8 Kaiser Permanente Self-Care Program
Vision: “Partners in Health” A system intervention that changes the culture of care and supports members making safe, appropriate, and informed health care choices KP Healthwise Handbooks distributed to all members Provider training and reinforcement Continuing systemwide reinforcement

9 Kaiser Permanente Healthwise Handbook

10 Kaiser Permanente Self-Care Program
Results High use of the KP Healthwise Handbook 70% in previous 6 months Improved member self-care confidence 71% more confident Increased member satisfaction 60% more positive about Kaiser Permanente More appropriate utilization & improved accessibility 50% report saving a call or visit to MD ê6% medical visits and ê5%telephone calls Improved provider and staff satisfaction

11 Rethinking Care 2: Self-Management of Chronic Illness
Patient as Consumer as Provider

12 Clinical Information Systems Self- Management Support
Chronic Care Model Community Health System Resources and Policies Health Care Organization Clinical Information Systems Self- Management Support Delivery System Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes E. Wagner

13 Living with Chronic Disease
Managing the Illness Taking medications Changing diet and exercise Managing symptoms of pain, fatigue, insomnia, shortness of breath, etc. Interacting with the medical care system Managing Daily Activities and Roles Maintaining roles as spouse, parent, worker, etc. Managing the Emotions Managing anger, fear, depression, isolation, etc. Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M: Living a Healthy Life with Chronic Conditions, Palo Alto, CA: Bull Pub. Co., 2000

14 Healthier Living with Ongoing Health Conditions*
Lay-led, small interactive groups (2 hours/week for 7 weeks) Mixed chronic disease and co-morbidities Content Goal setting and problem-solving Cognitive symptom management Design of exercise programs Management of fatigue, sleep, pain, anger, depression Appropriate use of medications Patient/physician communication Use of advanced directives Lorig K et al Medical Care 1999;37:5-14. *aka Chronic Conditions Self-Management Program, Expert Patient Programme

15 Healthier Living with Ongoing Health Conditions
Improves health behaviors and health status Cost effective (estimated 5:1 to 10:1 ROI) Outcomes are long-lasting and robust (2+yrs.) Replicable and dissemination can yield outcomes as good, or better. Lorig KR, Sobel DS, Effective Clin Practice 2001;4: Lorig KR, Medical Care 2001;39:

16 Chronic Disease Self-Management Program
LESSONS General coping skills education for heterogeneous conditions complements disease specific information Patients are the “experts” in living and coping with chronic illness Modeling more effective than “save and rescue” No significant difference in participants’ outcome with lay vs professional leaders Confidence predicts improvement in health outcomes People benefit themselves from helping other people Process is more important than content

17 Rethinking Care 3: Behavioral Medicine
Body as Machine Mind as HMO Sobel DS: The cost-effectiveness of mind-body medicine interventions. In The Biological Basis for Mind Body Interactions, Progress in Brain Research, Vol 122, EA Mayer and CB Saper (Eds.), Elsevier, 2000:

18 Somatic Symptom Superhighway
Final Common Pathway Psychiatric Disorder Emotional Distress Medical Illness Somatic Symptoms

19 Psychological Status of Primary Care Patients

20 Causes of Common Symptoms in Primary Care Medicine
Chest pain, fatigue, dizziness, headache, back pain, edema, dsypnea, insomnia, abdominal pain, numbness Kroenke, Am J Med 1989:86:262-6

21 Depressive Symptoms Depressive symptoms more debilitating in terms of physical and social functioning than: diabetes arthritis gastrointestinal disorders back problems hypertension Wells et al. JAMA 1989;262:

22 Psychosocial Dysfunction in Medical Care
Common Undiagnosed or inadequately treated Significant impact on: functional status and disability medical utilization and costs medical morbidity and mortality Health Care services mismatched to needs Need to develop integrated behavioral health education services Sobel DS: Rethinking medicine: Improving health outcomes with cost-effective psychosocial interventions. Psychosomatic Medicine 57: , 1995.

23 Mind/Body Medicine Program Evaluation Pre- and Post-Class
12 NCal Facilities Intake Post-Program 70% 60% 62.1% 61.2% 60.0% 50% 40% % Classifed as Psych Outpatient Cases on SCL-90 30% 31.7% 28.2% 20% 21.5% 10% 0% DOR looked at 12 FACILITIES in Northern Calif. Offering MBM program and looked at changes on 3 SCL-90 subscales. The number of patients that could be classified as “outpatient cases” according to the SCL-90 declined by significant percentages for all 3. Depression (n=124) Anxiety (n=121) Somatization (n=120) SCL-90 Sub-scale Measures Nancy Gordon - DOR (June, 2000)

24 Utilization Change for Mind/Body Medicine Participants
6-Mo. Pre 6-Mo. Post 3000 N=609 2500 2000 Total Visits 1500 1000 500 ADP +34% ER - 45% Med -37% Urg -22% Psy - 41% Ngissah, Levine, & Walsh ( N. Valley)

25 Rethinking Health Improvement Interventions
Attitudes Beliefs Moods Health Behavior Change Health Outcomes Confidence Counts Lorig K, Arthritis and Rheumatism. 1989;32:91-95

26 Targeting Core Attitudes, Beliefs, and Moods
Quality of Life Behavioral Risk Reduction Problems in Living Psychosocial Skills CORE Attitudes Beliefs Moods Mental Illness Medical Conditions Ornstein R, Sobel D: Healthy Pleasures. Addison-Wesley, 1989

27 Restructuring Care Group Medical Office Visits Appointments and
Web-based Care Medical Office Visits

28 Medical Group Appointments (Group Visits, Cluster Visits, etc.)
Scheduled or ‘drop-in’ visit for group of patients with similar or mixed health conditions Under direction of physician or other licensed health care professional Provision of individualized clinical services Medical Assessment history, physical assessment, triage, referral Medical Intervention medication prescription/adjustment, lab tests

29 Diabetes Cooperative Care Clinic
Randomized clinical trial, n=185, f/u 1yr, 2hr group monthly x 6 Outcomes lower HgbA1C ( 1.3% vs. 0.22% controls, p<0.0001) more home blood glucose monitoring reduced hospital and outpatient utilization hospitalizations 80% more frequent in control fewer physician and nonphysician visits increased self-efficacy diet, management of low BG and BG when sick increased satisfaction Sadur CN, Diabetes Care, 1999;12:

30 Restructure Care: Web-Based Care at

31 Get Health Advice

32 Appointment/Rx Refills
There are two different types of appointment requests. Members may make appointments online (synchronously) or submit appointment requests through messaging forms (asynchronously). Online appointments are only available in Northern California at this time. Members may make, view, change, or cancel appointments for themselves online. They may also request or cancel appointments for other members if they have delegation privileges.

33 Physician Personal Home Page:
A Personal Portal to Kaiser Permanente Online Services

34 Retraining for Collaborative Care
Traditional, PaternalisticCare Collaborative Care

35 How Traditional Care Differs from Collaborative Care
Issue Traditional Care/ Patient Education Collaborative Care/ Self-Management Education Relationships Professional are expert. Patients are passive. Shared expertise with active patients. Patient expert in their experience of disease Needs Assessment Provider defines what patients need to know. Patient defined problems Content Disease management Disease, role, and emotional management Process Prescribed behavior change. Provider solves problems. External motivation. Didactic presentations. Self-defined goals. Patient learns problem-solving skills. Focus on internal motivation and self-efficacy. Interactive. Outcomes Knowledge and behavior Health status and appropriate utilization adapted from Bodenheimer, Lorig, et al JAMA 2002;288:2469.

36 Retraining for Collaborative Care
Thriving in a Busy Practice: Clinician-Patient Communication (“Four Habits of Effective Clinicians”) Brief Negotiation Practice Essentials for Care Managers Education for Health Action Group Appointment Toolkit

37 Retraining for Collaborative Care: Key Strategies
Address member’s needs in 3 domains: 1. Disease and Health Management 2. Role Management 3. Emotional Management Use state-of-art communication/educational strategies: Transform didactic, information-based approaches into interactive, self-efficacy/confidence enhancing communication that strengthens patients’ skills in problem-solving, goal setting and action planning, self-tailoring, using available resources, forming a partnership with clinician Ask questions and elicit patient perspective and engagement in action planning and problem-solving Use nonjudgmental and positive tone Link back to member’s routine source of care and team care and peer support

38 Patients as Partners: Changing Culture and Practice
Rethink Care Patients as primary providers of acute illness Self-management of chronic illness Behavioral interventions to address psychosocial needs Restructure Care Telephone, group appointments, web-based care Retrain for Collaborative Care Enhance understanding, skills, and confidence of members and professional staff as partners in care

39 Appendices

40 Four Habits of Highly Effective Clinicians
Invest in the Beginning Elicit the Patient’s Perspective Demonstrate Empathy Invest in the End Frankel RM, Stein T. Getting the Most out of the Clinical Encounter: The Four Habits Model. The Permanente Journal, Fall 1999, Vol 3, No. 3

41 2003 CMI Evidence-Linked Recommendations
Embed Self-Mgt into Pop Mgt: Lower intensity interventions (automated phone messages, staged mailings, videos, online) for all patients Higher intensity (e.g. multi-session programs) for those with higher needs Robert Wood Johnson Foundation and Center for the Advancement of Health. Essential Elements of Self-Management Interventions, 2002. Von Korff M, Tiemens B. West J Med 2000; 172(2): Piette JD,e al. Am J Med 2000; 108(1):20-27. Serxner S, et al. Congestive Heart Failure; May/June:23-28.

42 2003 CMI Evidence-Linked Recommendations, cont’d.
During clinical encounter, support member’s central role in health: Collaborative communication (Brief Negotiation, 4 Habits) Assess member’s self-mgt needs; provide tailored feedback and behavioral advise Collaboratively set behavioral goals and action plan. Document and share with member. Offer self-mgt resources; refer to programs F/up to adapt plan and address relapse Glasgow RE et al. Ann Behav Med 2002; 24(2):80-87. Stewart MA. CMAJ 1995; 152(9): Petrella RJ, Lattanzio CN. Can Fam Physician 2002; 48:72-80. Rice VH. Heart Lung 1999; 28(6): Boulware LE, et al. Am J Prev Med 2001; 21(3):

43 2003 CMI Evidence-Linked Recommendations, cont’d.
Strengthen Adherence to Prescribed Medications: Anticipate nonadherence: “Have you ever missed or forgot to take your pills?” Identify personal barriers and problem solve. Avoid assuming causes of nonadherence Collaboratively develop a regimen pt is willing and able to follow. Praise efforts to adhere. As needed, refer for pharmacist consultation McDonald HP, et al. JAMA 2002; 288(22): Haynes RB , et al. JAMA 2002; 288(22): Yuan Y, et al. Am J Manag Care 2003; 9(1):45-56.

44 2003 CMI Evidence-Linked Recommendations, cont’d.
Turn didactic pt education into self-mgt education Beyond knowledge to skills & confidence: Problem solving training (incl. medication adherence) Goal setting and action planning Peer modeling and support Experiential exercises (relaxation session, read peak flow meter, pick from a menu) Forming partnership with clinician Bodenheimer T et al. JAMA 2002; 288(19): Norris S et al. Diabetes Care 2002; 25(7): Gibson PGM et al. Cochrane Database Syst Rev 2002;2. Barlow J, et al.Patient Educ Couns 2002; 48(2):

45 2003 CMI Evidence-Linked Recommendations, cont’d.
Offer multiple options to receive self-mgt education: Staged mailings based on readiness to change Telephone group sessions Group visits Internet-based programs Community and work site programs Serxner S, et al. Congestive Heart Failure 1998; May/June:23-28. Boucher, JL et al. Diabetes Spectrum (2) Wagner EH et al. Diabetes Care 2001; 24(4): McKay HG, et al. Diabetes Care 2001; 24(8): Norris SL et al. J Prev Med 2002; 22(4 Suppl):39-66. Pelletier KR. Am J Health Promot 2001; 16(2):

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