1. Change the Conversation Change the Outcome Self Management Support

2. Disclosure Statement “I have the following financial relationships with the manufacturers) of any commercial product and/or provider of commercial services discussed in this CME activity:” Research Grant: Sepracor Speakers’ Bureau: Merck It is my obligation to disclose to you (the audience) that I am on the Speakers Bureau for Merck and participate in a Research Grant for Sepracor. However, I acknowledge that today’s activity is certified for CME credit and thus cannot be promotional. I will give a balanced presentation using the best available evidence to support my conclusions and recommendations It is my obligation to disclose to you (the audience) that I am on the Speakers Bureau for Merck and participate in a Research Grant for Sepracor. However, I acknowledge that today’s activity is certified for CME credit and thus cannot be promotional. I will give a balanced presentation using the best available evidence to support my conclusions and recommendations.”

3. 1.Discuss concepts and importance of self- management in improving outcomes in chronic care. 2.Identify some tools and processes that assist in providing effective self-management support. 3.Describe ways to incorporate self- management into clinical practice.

4. U.S. Determinants of Health (%) Source: Centers for Disease Control and Prevention

5. Modifying Behavior - the “50%” One of the most significant challenges we face as health care professionals We spend energy and time on how to change the patient’s or family’s behavior There is good evidence that we also need to change ours Are we helping people to change…or are we promoting resistance? If we change our behavior, will the patient and family follow?

6. Definition of Self-Management Gruman and Von Korff, 1996 “Self-management involves [the individual experiencing chronic illness] engaging in activities that protect and promote health, monitoring and managing of symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes”* *Based on a literature review of over 400 articles

7. Why Self-Management? Recognizes that patient/parent has wisdom about the situation; respects their competence Family-centered: acknowledges and supports the patient’s/family’s right to make autonomous choices Non-judgmental support can increase the patient’s/family’s self-acceptance and internal locus of control Small successes can increase self-efficacy and generalize to other areas of the person’s life into the future

8. Self-Management Skills Five core self-management skills are:  problem solving  decision making  accessing appropriate resources  forming a partnership with healthcare providers  taking action toward health goals (Lorig 2003 [S])

9. Self-Management Tasks Incorporating medical management of the chronic illness into one’s life Adjusting one’s life behaviors to accommodate the chronic illness role management Dealing with the emotional consequences of having a chronic illness emotional management Lorig, K. R., and Holman, H.: Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med, 26(1): 1-7, 2003

10. Does Self-Management Support Make a Difference? Self-management education & support: –improves effective home management –reduces symptoms –reduces exacerbations –decreases school absenteeism –decreases number of hospitalizations and emergency room visits Fireman, et. al. Teaching self-management skills to asthmatic children and their parents in an ambulatory care setting. Pediatrics, 68(3): 341-8, 1981, [C] Gibson, et. al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev, (1) 2004, [M]

11. Strong evidence for… Comprehensive care delivery to include: –Self-management support –Care management and disease management Patient education combined with written action plans; neither alone is enough Collaborative communication (i.e. motivational interviewing; shared decision-making) is more effective than advice-giving in promoting adherence and choice Regular assessment and review (follow-up) to identify families at risk for sub-optimal outcomes

12. Model of 5 A’s Cycle to Integrate Self- Management Into Care Delivery Created from concepts originally identified by (Manley 1991 [E] )

13. Strategies for Clinical Practice Establishing an Agenda Using Collaborative Communication/Motivational Interviewing –May actually shorten office visits Assessing Readiness and Self-Management Capability Goal Setting and Action Planning Closing the Loop Clark N, et al. Pediatrics 1998; 101:831

14. Important considerations Level of Motivation (Readiness to Change) Level of Importance (Priority) Level of Confidence (Self-Efficacy)

15. Readiness to change is determined by: Importance – personal values related to the change “Why should I change?” Confidence – self-efficacy “Can I do it?”, “How will I do it?” “Who will help me?” Importance Readiness Confidence

16. Stages of Change Pre-contemplation Contemplation Preparation ActionMaintenanceRelapse Don’t see problem Recognize problem but ambivalent about change Planning solutions or thinking of solutions to problem Actively trying to make changes or modify behavior Holding the change Not really a stage, but anticipated risk ProvidersPatients/families We call this disconnect “denial” and non-compliance

17. Possible Disconnect Most healthcare professionals are at the action stage and use advice-giving - “righting reflex” Only about 20% of patients and families who present to care are ready for action If we proceed as if they are at action (or ready), we increase risk of resistance to change or adoption of a recommended plan of care

18. Matching Interventions to Goals Goals related to lack of knowledge/skill deficits addressed by –didactic methods such as information-giving –or return demonstration

19. Matching Interventions to Goals Goals related to lack of readiness or motivation are addressed by –collaborative communication/motivational techniques until patient identifies and endorses something they want to change/manage

20. Matching Interventions to Goals Goals related to lack of self-efficacy or confidence are addressed by –problem-solving techniques – incremental successes –and support

21. Key MI Skills to promote change Help navigate ambivalence and promote change talk by patient/parent by using OARS: O: Ask open-ended questions (“Can you tell me how…”) A: Affirming to enhance self-efficacy R: Reflective listening (acknowledge content and feelings “you seem frustrated about…”) S: Summarizing (“it sounds like your plan is…”) Goal: Eliciting self-motivational statements (change talk – getting to “well, maybe I will…”)

22. Closing the Loop Arrange a plan for follow-up Research shows that as many as half of patients leave office not understanding what the provider told them Make a note to begin next visit with a check-in on goal that was set this visit Put a copy of action plan in the chart; give a copy to the patient/family

23. Self-Management Tools Assessment completed by patient/family immediately prior to visit Or if time permits during the visit with a provider

24. Progress Tool Provider documents the provider’s assessed level of patient readiness and coaching focus from the visit Self-Management Tools

25. Action Plan: Completed when Patient is in “Action” stage of readiness Patient creates his “own" action plan –Writes it himself –Uses his own words AssessmentProgress Tool Self-Management Guideline Self-Management Tools

26. Case Presentation 13 yo girl with history of asthma, chronic cough, GERD,and poor adherence. –Frequent night-time awakenings –Exercise limitation –GERD symptoms –ACT <19 –Complex social situation (parents divorced, sibs with CF, anxiety, limited resources)

27. Case Presentation Self-management assessment was revealing! –Fears about dying from asthma, etc –Engaged quickly and intensely Child and mother developed excellent plans Enthusiastic and energized Use medication calendar, cut pills –Desired phone follow up at 2 weeks

28. Case Presentation “Chance meeting” at ~ 2 weeks –Eager to share progress –Reported adherence to treatment plan Using calendar, amassing stickers, eager to celebrate Feeling better! Follow up call ???

29. Case Presentation Telephone follow up –Reported taking meds most days (stickers on calendar) Some trouble remembering pm doses –Able to work through other solutions to further improve adherence Self-management process was excellent mechanism to engage this patient

30. Best Lessons Team approach works best; but ownership of process must be made clear –Obtaining action plan requires separate individual and/or time –Team approach valuable to set process in motion and for follow up Consider scheduling separate self-management visits –Group visit item One person cannot do it all –Will not work well if MD alone is responsible for getting plans –Will not work well if MD is not active in process

31. THANK YOU!