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 System3
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 kp.org

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):