Advanced Self-Management Support Developing Personal Action Plans with Patients RWJ Depression in Primary Care Annual Conference

What Is Self-Management? “The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.”“The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.” Barlow et al, Patient education Counseling 2002; 48:177 Reference the work of Kate Lorig, Stanford. Evidence SMS improves health while reducing utilization, costs: Randomized trial. Medical Care. 37 (1):5-14, 1999

Self-Management Support: Patient Activation Empower and Prepare the patient to manage their health and mental health care.Empower and Prepare the patient to manage their health and mental health care. Emphasize the patient’s central role.Emphasize the patient’s central role. Very different from “health education.” Technical skills vs. problem-solving/activation.Very different from “health education.” Technical skills vs. problem-solving/activation. The 5 (or 6) A’s: Assess, Advise, Agree, Assist, Arrange (Address emotions)The 5 (or 6) A’s: Assess, Advise, Agree, Assist, Arrange (Address emotions) Organize your practice to provide ongoing SMS to all patients.Organize your practice to provide ongoing SMS to all patients.

Patient Education vs. Self- Management Support Information and skills are taughtInformation and skills are taught Usually disease- specificUsually disease- specific Assumes that knowledge creates behavior changeAssumes that knowledge creates behavior change Goal is complianceGoal is compliance Health care professionals are the teachersHealth care professionals are the teachers Skills to solve pt. Identified problems are taught Skills are generalizable Assumes that confidence yields better outcomes Goal is increased self- efficacy Teachers can be professionals or peers Bodenheimer et al JAMA 2002;288:2469

5 As and Self-Management Glasgow RE, et al (2002) Ann Beh Med 24(2): Personal Action Plan 1. List specific goals behavioral terms 2.List barriers and strategies to address barriers 3.Specify Follow-up Plan 4.Share plan with practice team and patient’s social support ASSESS : Beliefs, Behavior & Knowledge ADVISE : Provide specific Information about health risks and benefits of change AGREE: Collaboratively set goals based on patient’s conviction and confidence in their ability to change or adhere ASSIST : Identify personal barriers, strategies, problem- solving techniques and Social / environmental support ARRANGE : Specify plan for follow-up: visits, phone calls, mailed reminders

Challenge: Integrating Self- Management into the routine of a busy primary care practice. The Opportunities: Before the patient visitBefore the patient visit During the patient visitDuring the patient visit After the patient visitAfter the patient visit The entire care team should be aware of the patient’s self-management goal (s)

Before the Encounter trigger interest: Assess Why? depression is de-energizing Pre-visit contact (phone, mail, ) Waiting room assessments (PHQ) Patient education material, i.e. “physical activity helps depression” in exam room Posters : “Ask Me 3” Pamphlets: Talking to your provider, How’s my Health.com Community outreach: dep screening day; depression info to local media

During the Encounter Advise, Agree, Assist, Arrange Review assessments (PHQ, Depression Action Plan) Advise behavior change in personal, meaningful way Feedback on achievements vs. goals Identify priorities for visit Develop/Revise Patient Action Plan Targeted patient educ. materials Referral for Group

After the Encounter Referrals: (Depression peer support, Arthritis or Diabetes groups) Additional 5A’s counseling w/CM or BH specialist Phone calls for follow-up/reinforcement Mailed patient education Newsletters Follow-up visits, Link the information back to the care team (chart)

Quality of Self Management Goal Setting SM goal setting should be patient- centered (not paper-centered) Tools help to highlight EB guidelines for behavioral change to facilitate optimal outcomes, but should not be prescriptive. SM goal setting should be patient- centered (not paper-centered) Tools help to highlight EB guidelines for behavioral change to facilitate optimal outcomes, but should not be prescriptive. However, because depression is de- energizing, a SM tool can help trigger behavioral action.However, because depression is de- energizing, a SM tool can help trigger behavioral action.

Goal setting should be concrete and behaviorally specific AND Manageable Goals that are too general, such as, “I will take my medication,” are not very helpful for motivating self-action.Goals that are too general, such as, “I will take my medication,” are not very helpful for motivating self-action. Example of a behaviorally specific goal, “ I will take my medication every evening before I go to bed and my confidence level is 8 on a 1-10 scale that I will meet this goal.”Example of a behaviorally specific goal, “ I will take my medication every evening before I go to bed and my confidence level is 8 on a 1-10 scale that I will meet this goal.” Goals that are too big: “I want to lose 20 pounds” must be broken down into an action plan.Goals that are too big: “I want to lose 20 pounds” must be broken down into an action plan.

Quality of Goal Setting Quality of Goal Setting Specify the Activity (e.g. physical activity)Specify the Activity (e.g. physical activity) Specify the duration (how long each period of physical activity)Specify the duration (how long each period of physical activity) Specify the frequency (how often will the physical activity occur)Specify the frequency (how often will the physical activity occur) Specify the location (where the activity will occur)Specify the location (where the activity will occur) Specify the confidence level (patient’s confidence on a 1-10 scale in being able to accomplish the goal) Excellent opportunity for problem-solvingSpecify the confidence level (patient’s confidence on a 1-10 scale in being able to accomplish the goal) Excellent opportunity for problem-solving

From general to specific (From meaningless to meaningful) I am going to walk more this week.I am going to walk more this week. I plan to take 20-minute walks this week.I plan to take 20-minute walks this week. I plan 20-minute walks Monday, Wednesday and Friday this week.I plan 20-minute walks Monday, Wednesday and Friday this week. I plan 20-minute walks to the store and back on Monday, Wednesday and Friday this week.I plan 20-minute walks to the store and back on Monday, Wednesday and Friday this week. My confidence level is 9 that I will walk for 20 minutes to the mall and back on Monday, Wednesday and Friday this week.My confidence level is 9 that I will walk for 20 minutes to the mall and back on Monday, Wednesday and Friday this week.

Personal Action Plan 1. Something you WANT to do 2. Describe HowWhere WhatFrequency When 3. Barriers 4. Plans to overcome barriers 5. Confidence rating (1-10) 6. Follow-Up plan Source: Lorig et al, 2001

Personal Action Plan 1. Something you WANT to do: “Get more physical activity.” 2. Describe: How: “Walk with a friend.” Where: “From house to corner.” What: “Walk comfortable pace.”Frequency: “Once a day on Monday, Weds. and Friday.” When: “After morning TV show.” 3. Barriers? “I might forget.” 4. Plans to overcome barriers? “Put a note by remote, and ask friend to call me.” 5. Confidence level? (1-10) “7” 6. Follow-Up plan: “CM will call me next 3 PM.

PATIENT-ACTION PLAN [ ultra-brief ] 1.“What would you like to do for your depression from now to our next appt?” or “What is your most important problem?” –concrete –patient-centered –very specific 2. “How confident are you on a 1 to 10 scale that you will be able to carry out this goal?” –must be >7 or –review barriers (develop solutions) or –revise goal 3. “Let’s arrange a way to check on how you are doing?” –Phone call, –Involve CM or family – visit to the clinic

CareSouth Carolina Outcome Measures for depression improvement and self- management goal setting 67 % of Patients (in POF) and 41 % (of combined spread sites) with Major Depression (first PHQ over 10) achieve a 50% reduction in PHQ score within 4 months of treatment. National HDC Goal > 40 %. and67 % of Patients (in POF) and 41 % (of combined spread sites) with Major Depression (first PHQ over 10) achieve a 50% reduction in PHQ score within 4 months of treatment. National HDC Goal > 40 %. and 90.7 % of patients with depression have documented Self Management goals. National HDC goal > 70%.90.7 % of patients with depression have documented Self Management goals. National HDC goal > 70%.

Practice Setting Goals and Measuring Confidence: 1.Think of a problem or a goal you would like to achieve (something you want to do.) 2.Pair with someone next to you. 3.Determine a goal which would lead to problem-resolution or goal attainment. “Have you thought of anything that might help….” 4.Use the quality criteria to develop a meaningful action plan. 5. Take turns with goal setting.

ARRANGE FOLLOW-UP! By , phone, mail, or visit. Schedule follow-up contacts to provide ongoing assistance and support to adjust the plan as needed, including referrals to more intensive treatment or other community resources. Always review the plan at next visit. Think how bad it would feel to set a goal and never have anyone review your progress!

Crossing The Quality Chasm Rules for Patient-Centered Care Customization based on patient needs and values.Customization based on patient needs and values. The patient as the source of control.The patient as the source of control. Shared knowledge and the free-flow of information.Shared knowledge and the free-flow of information. The need for transparency.The need for transparency. Anticipation of Needs. The health system should anticipate patient needs, rather than react to events.Anticipation of Needs. The health system should anticipate patient needs, rather than react to events.