Presentation on theme: "NatPaCT Conference Programme"— Presentation transcript:
1 NatPaCT Conference Programme Patient as Partners Improving Health and Cost Outcomes with Self-Care and Chronic Disease Self-ManagementNatPaCT Conference ProgrammeLearning 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 forinefficiencies, mismatches, and capacityoverlooked evidence and data“win, win, win” opportunities
4 Strategy for Changing Culture and Practice Rethink CarePatients as primary providers of acute illnessSelf-management of chronic illnessBehavioral interventions to address psychosocial needsRestructure CareTelephone, group appointments, web-based careRetrain for Collaborative CareEnhance understanding, skills, and confidence of members and professional staff as partners in care
5 Rethinking Care 1: Self-Care for Acute Illness Patientas Consumeras Provider
6 Hidden Health Care System 3Professional Care20%21Self-Care80%
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 choicesKP Healthwise Handbooks distributed to all membersProvider training and reinforcementContinuing systemwide reinforcement
10 Kaiser Permanente Self-Care Program ResultsHigh use of the KP Healthwise Handbook70% in previous 6 monthsImproved member self-care confidence71% more confidentIncreased member satisfaction60% more positive about Kaiser PermanenteMore appropriate utilization & improved accessibility50% report saving a call or visit to MDê6% medical visits and ê5%telephone callsImproved provider and staff satisfaction
11 Rethinking Care 2: Self-Management of Chronic Illness Patientas Consumeras Provider
12 Clinical Information Systems Self- Management Support Chronic Care ModelCommunityHealth SystemResources and PoliciesHealth Care OrganizationClinical Information SystemsSelf- Management SupportDelivery SystemDesignDecisionSupportPrepared,ProactivePractice TeamInformed,ActivatedPatientProductiveInteractionsImproved OutcomesE. Wagner
13 Living with Chronic Disease Managing the IllnessTaking medicationsChanging diet and exerciseManaging symptoms of pain, fatigue, insomnia, shortness of breath, etc.Interacting with the medical care systemManaging Daily Activities and RolesMaintaining roles as spouse, parent, worker, etc.Managing the EmotionsManaging 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-morbiditiesContentGoal setting and problem-solvingCognitive symptom managementDesign of exercise programsManagement of fatigue, sleep, pain, anger, depressionAppropriate use of medicationsPatient/physician communicationUse of advanced directivesLorig 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 statusCost 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 LESSONSGeneral coping skills education for heterogeneous conditions complements disease specific informationPatients are the “experts” in living and coping with chronic illnessModeling more effective than “save and rescue”No significant difference in participants’ outcome with lay vs professional leadersConfidence predicts improvement in health outcomesPeople benefit themselves from helping other peopleProcess is more important than content
17 Rethinking Care 3: Behavioral Medicine Bodyas MachineMindas HMOSobel 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 PathwayPsychiatric DisorderEmotional DistressMedical IllnessSomatic Symptoms
20 Causes of Common Symptoms in Primary Care Medicine Chest pain, fatigue, dizziness, headache, back pain, edema, dsypnea, insomnia, abdominal pain, numbnessKroenke, Am J Med 1989:86:262-6
21 Depressive SymptomsDepressive symptoms more debilitating in terms of physical and social functioning than:diabetesarthritisgastrointestinal disordersback problemshypertensionWells et al. JAMA 1989;262:
22 Psychosocial Dysfunction in Medical Care CommonUndiagnosed or inadequately treatedSignificant impact on:functional status and disabilitymedical utilization and costsmedical morbidity and mortalityHealth Care services mismatched to needsNeed to develop integrated behavioral health education servicesSobel 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 FacilitiesIntakePost-Program70%60%62.1%61.2%60.0%50%40%% Classifed as Psych Outpatient Cases on SCL-9030%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 MeasuresNancy Gordon - DOR (June, 2000)
24 Utilization Change for Mind/Body Medicine Participants 6-Mo. Pre6-Mo. Post3000N=60925002000TotalVisits15001000500ADP+34%ER- 45%Med-37%Urg-22%Psy- 41%Ngissah, Levine, & Walsh ( N. Valley)
25 Rethinking Health Improvement Interventions AttitudesBeliefsMoodsHealthBehaviorChangeHealthOutcomesConfidence CountsLorig K, Arthritis and Rheumatism. 1989;32:91-95
26 Targeting Core Attitudes, Beliefs, and Moods Quality of LifeBehavioral Risk ReductionProblems in LivingPsychosocial SkillsCOREAttitudesBeliefsMoodsMental IllnessMedical ConditionsOrnstein R, Sobel D: Healthy Pleasures. Addison-Wesley, 1989
27 Restructuring Care Group Medical Office Visits Appointments and Web-basedCareMedical 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 conditionsUnder direction of physician or other licensed health care professionalProvision of individualized clinical servicesMedical Assessmenthistory, physical assessment, triage, referralMedical Interventionmedication prescription/adjustment, lab tests
29 Diabetes Cooperative Care Clinic Randomized clinical trial, n=185, f/u 1yr, 2hr group monthly x 6Outcomeslower HgbA1C ( 1.3% vs. 0.22% controls, p<0.0001)more home blood glucose monitoringreduced hospital and outpatient utilizationhospitalizations 80% more frequent in controlfewer physician and nonphysician visitsincreased self-efficacydiet, management of low BG and BG when sickincreased satisfactionSadur CN, Diabetes Care, 1999;12:
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, PaternalisticCareCollaborativeCare
35 How Traditional Care Differs from Collaborative Care IssueTraditional Care/Patient EducationCollaborative Care/Self-Management EducationRelationshipsProfessional are expert. Patients are passive.Shared expertise with active patients. Patient expert in their experience of diseaseNeeds AssessmentProvider defines what patients need to know.Patient defined problemsContentDisease managementDisease, role, and emotional managementProcessPrescribed 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.OutcomesKnowledge and behaviorHealth status and appropriate utilizationadapted 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 NegotiationPractice Essentials for Care ManagersEducation for Health ActionGroup Appointment Toolkit
37 Retraining for Collaborative Care: Key Strategies Address member’s needs in 3 domains:1. Disease and Health Management2. Role Management3. Emotional ManagementUse 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 clinicianAsk questions and elicit patient perspective and engagement in action planning and problem-solvingUse nonjudgmental and positive toneLink back to member’s routine source of care and team care and peer support
38 Patients as Partners: Changing Culture and Practice Rethink CarePatients as primary providers of acute illnessSelf-management of chronic illnessBehavioral interventions to address psychosocial needsRestructure CareTelephone, group appointments, web-based careRetrain for Collaborative CareEnhance understanding, skills, and confidence of members and professional staff as partners in care
40 Four Habits of Highly Effective Clinicians Invest in the BeginningElicit the Patient’s PerspectiveDemonstrate EmpathyInvest in the EndFrankel 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 patientsHigher intensity (e.g. multi-session programs) for those with higher needsRobert 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 adviseCollaboratively set behavioral goals and action plan. Document and share with member.Offer self-mgt resources; refer to programsF/up to adapt plan and address relapseGlasgow 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 nonadherenceCollaboratively develop a regimen pt is willing and able to follow. Praise efforts to adhere.As needed, refer for pharmacist consultationMcDonald 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 educationBeyond knowledge to skills & confidence:Problem solving training (incl. medication adherence)Goal setting and action planningPeer modeling and supportExperiential exercises (relaxation session, read peak flow meter, pick from a menu)Forming partnership with clinicianBodenheimer 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 changeTelephone group sessionsGroup visitsInternet-based programsCommunity and work site programsSerxner 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):