1. Self-management: A Practical Primer for Family Practitioners Lisa McCarthy RPh BScPhm PharmD Michele MacDonald-Werstuck RD MSc CDE Inge Schabort MB ChB CCFP October 29, 2009

2. Disclosure Presenters perceive no conflict of interest with this presentation. Slides will be available at: www.stonechurchclinic.ca

3. Introducing Susan... 41 year old female, Type 1 diabetes –Attended all diabetes education in the area, sent back to you by the specialist due to non- adherence A1c 0.095 Progressing retinopathy, neuropathy eGFR 15 A source of frustration to you and your team, what do you do?

4. Today’s Goal Discuss some strategies that you can try with your Susan’s when you get home... –And your not-so-challenging folks too!

5. Burden of Chronic Illness in Canada 2/3 deaths in Canada due to chronic disease –cancer, CVD, type 2 diabetes, chronic obstructive lung disorders Significant impact on health care system, economy, quality of life Improving the Health of Canadians. Chronic Disease Prevention Alliance of Canada, 2007.

6. Burden Cont’d Through healthier diet, regular activity and avoidance of tobacco –Estimates 80% premature heart disease, stroke, diabetes and 40% cancers could be prevented This is not news to health care providers or patients, yet there is still a gap Improving the Health of Canadians. Chronic Disease Prevention Alliance of Canada, 2007.

7. Objectives At the end of the session, participants will be able to: 1)Define self-management. 2)Describe the rationale for its gaining momentum as means for empowering patients. 3)Explain how family physicians can support patient self-management efforts efficiently in day-to-day practice.

8. 3 Terms to Know Self-Management Self-Efficacy Self-Management Support

9. Self-Management Defined “The tasks that an individual must undertake to live well with one or more chronic conditions. –These tasks include having confidence to deal with: 1) medical management (tasks associated with the condition) 2) role management (tasks required for everyday living) 3) emotional management (coping with anger, fear, frustration and sadness).” Institute of Medicine, Report of a Summit, Sept 2004

10. Self-Efficacy Confidence that one can carry out a behaviour necessary to reach a desired goal (Bandura 1986) **Successful achievement of a goal is more important than the goal itself** Bodenheimer, T et al. JAMA 2002;288(19):2469-2475.

11. WAIT! Not all of my patients want to be self-managers... Patient self-management is inevitable –Patients decide what they eat, to exercise or not and whether to take prescribed medications “The question is not whether patients with chronic conditions can manage their illness, but how they manage (Bodenheimer et al 2002)” Bodenheimer, T et al. JAMA 2002;288(19):2469-2475.

12. Self-management Support (SMS) “requires a provider or health care team to perform a certain set of tasks to create the self- efficacy necessary for a patient to deal confidently with their own range of emotional, physical, + physiological symptoms of their chronic disease” McGowan P. In: Dorland J, McColl MA, editors. Emerging Approaches to Chronic Disease Management in Primary Health Care: Managing chronic disease in the twenty-first century. Queens University School of Policy; 2007.

13. SMS Cont’d SMS is not the same as patient education. Helps patients to adopt healthy behaviours and problem solve. Overall goal of SMS –Increase patients’ confidence in their ability to change their own health behaviours Supporting Patient Self-Management Module, www.practicesupport.bc.ca

14. “That’s great, does it work?”

15. The Evidence Literature supporting patient self- management has many limitations –Differing definitions of SMS + multifactor interventions 2006 systematic review of systematic reviews –Compiled 11 systematic reviews Diabetes (6) Asthma, COPD, Hypertension, Arthritis (2 each) Zwar N et al. 2006. Available at: http://www.anu.edu.au/aphcri/Domain/ChronicDisea seMgmt/Approved_25_Zwar.pdf

16. Outcome MeasuresNumber of Studies Positive Findings Number of Studies HCP Guideline Adherence11 Patient Service Use03 Patient Physiologic Measure of Disease 911 Patient Quality of Life23 Patient Medication Adherence 23 Patient knowledge55 Zwar N et al. 2006. Available at: http://www.anu.edu.au/aphcri/Domain/ChronicDiseaseMgmt/Approved_25_Zwar.pdf

17. Goal Setting and Action Plans

18. Let’s Share What are some of the goals you have for “your Susan’s”? What are “your Susan’s” goals for herself?

19. SMART Goals Specific Measurable Action-Oriented Realistic & Relevant Time-Based

20. Goal Setting Steps 1) What are you going to do? 2) How much are you going to do? 3) When are you going to do it? 4) How often are you going to do it?

21. Let’s Practice 1.Choose one behaviour change you would like to embrace in your own life. 2.How could you make this into a SMART goal? Pick something you are comfortable sharing with a partner

22. The Confidence Ruler On a scale of 0 to 10, with 0 being not at all confident and 10 being as confident as you can be, how confident are you that you can achieve your goal? 012345678910 Not At All Confident  A Little Confident Somewhat confident Very ConfidentExtremely Confident http://www.newhealthpartnerships.org

23. Pitfalls to Avoid Assumptions about patient’s knowledge Avoid setting goals for your patients –Remember motivation and confidence If a patient is having a hard time setting a goal, it is OK to help by making suggestions as to what may improve their condition

24. The Challenging Patient Any step toward a potential positive behaviour change is something The goal could be to come up with a list of pros and cons to the recommended behaviour change

25. Strategies for Bringing SMS To Your Practice

26. Before the Visit

27. Pre-visit contact by you or your staff (phone, email, mail) Waiting room assessment forms Patient education materials

29. During the Visit

30. Review waiting room assessments Goal setting and action planning –If follow up visit, make sure to give feedback on achievements and goals Referral for more SMS 5 A’s or 3 questions

31. Referrals for SMS You don’t need to be the expert! There are many out there, your job is to find them –e.g., Stanford Chronic Disease Self- Management Program

32. Starting SMS in a Visit 1) What worries you most about your health? 2) How do you feel about it? 3) What do you think you may be able to do about it? http://www.impactbc.ca/practicesupportprogram/resourcesforregionalsupportteam s/cdmresources/patientself-management

33. Assessing Motivation Ask Assess Advise Assist Arrange Relevance Risks Rewards Roadblocks Repetition From: Michael Valis 2009 Moving Mountains: Helping Patients with Lifestyle Change

35. From: Lewis J. 2008. Diabetes Self Management Support Toolkit for Health Professionals in Ontario

36. Tips Don’t rush into thinking it’s your job to solve the problem Assess the situation and determine: –Is this a problem of motivation? –Is this a problem of behaviour? –Is this a problem of stress or emotion?

37. After the Visit

38. Referrals to other supports Further 5 A’s counseling Phone call follow-up Mailed patient education Peer support Newsletters Follow up visits Email/web sites

39. Take Home Messages You don’t have to be an expert to support self-management in your practice. If you set goals with your patients, critical (and time saving!) to revisit at the next follow-up.

40. Let’s Take It Home SET A GOAL! Over the next week, I will ___________ to support self-management in my practice.

41. Examples... Ask patients their view of the challenges they face (3 questions) Waiting room assessment form Help patients to generate simple and achievable action plans Identify local resources for self-management education

42. Goal Setting 1) What are you going to do? 2) How much are you going to do? 3) When are you going to do it? 4) How often are you going to do it?

43. Resources Review Articles –Bodenheimer T et al. Patient Self-management of Chronic Disease in Primary Care. JAMA 2002;288:2469-75. –Coleman MT, Newton KS. Supporting Self-management in Patients with Chronic Illness. Am Fam Physician 2005;72:1503-10. Tools –Stanford Self-Management Programs. Stanford School of Medicine. http://patienteducation.stanford.edu/programs/ http://patienteducation.stanford.edu/programs/ –Institute for Healthcare Improvement. http://www.ihi.org/IHI/Topics/PatientCenteredCare/SelfManagement Support/ http://www.ihi.org/IHI/Topics/PatientCenteredCare/SelfManagement Support/ –Improving Chronic Illness Care http://www.improvingchroniccare.org http://www.improvingchroniccare.org –

44. Slides will be available at www.stonechurchclinic.ca Contact Information ischabo@mcmaster.ca lmccart@mcmaster.ca macdonmic@hhsc.ca