national quality center (nqc)1 nys hivqual workshop: supporting patient self- management july 17,...

National Quality Center (NQC)1

NYS HIVQUAL Workshop:

Supporting Patient Self-Management

July 17, 2009

Nanette Brey Magnani [email protected] &

Meera Vohra [email protected] NYSDOH AIDS Institute


Agenda

• Group Exercise: Health Care Self-Management Continuum

• Presentation: Literature Review• Group Exercise: Case Study• Group Exercise: The “To Do” List• Group Exercise: Patient Self-Management Support• Presentation: Harlem Hospital• Group Discussion• Evaluation and Wrap up


Activity 1: Personalizing Self-Management

9:15am• Health care self-management continuum• Share personal experiences with managing

health and health care


Presentation

9:35am

Literature Review


Patient self-management is…

“The capability of patients with chronic illnesses, in a complementary partnership with their health care providers, to manage the symptoms, treatment, lifestyle behavior changes, and the many physical and psycho-social challenges that they face each day.”

A composite of definitions in the literature


The Problem

• Patients often have difficulty in taking care of the long-term, day-to-day management of their own health. They may: Miss appointments or follow-up referrals Not follow diet or activity recommendations Take medications or supplements that interfere with

prescribed therapies Ignore or not recognize signs of adverse events or disease

progression Behave in ways that put themselves at risk including not

adhering with prescribed medical therapies

• Clinicians have limited time to address these issues


Growing Support for Patient Self-Management

“Increasing evidence shows that self-management support reduces hospitalizations, emergency department use, and overall managed care costs.”

“Physician support of patient self-management is one of the key elements of a system’s-oriented chronic care model.”

Coleman and Newton. Supporting self-management in patients with chronic illness. Am Fam Physician 2005;72(8):1503-10

Patient self-management is used effectively in many chronic illnesses and is an essential component of the Chronic

Care Model (CCM)


Asthma

Studies of asthma patient self management programs show that they can…

reduce morbidity improve lung function enhance feelings of self control reduce absenteeism from school and number of days with restricted

activity reduce nocturnal episodes reduce visits to an emergency department

Guevarra P et al.Effects of educational interventions for self management of asthma in children and adolescents: a systematic review and meta-analysis. BMJ 2003;326:1308-13


Arthritis

• In multiple randomized trials, the Arthritis Patient Self-management Program has been found to improve health behaviors self-efficacy health status cost savings1,2

• Patient self-management of arthritis reduced anxiety and depression and improved participants’ perceived self-efficacy to manage symptoms.3

1. Lorig K and Holman H. Arthritis Self-Management Studies: A Twelve-Year Review. Health Education Quarterly. 1993;20(1):17-28

2. Lorig K, et al. Arthritis Self;Management Program Variations: Three Studies. Arthritis Care and Research. 1998;11(6):448-454 3. Buszewicz M et al. Self management of arthritis in primary care:

randomised controlled trial. BMJ 2006;Online First bmj.com


Diabetes

Most well-studied disease category Group visits and individualized problem- solving are

effective self-management tools resulting in• Improved recommended prevention behaviors • Improved health status (SF-36)• Fewer specialty and ED visits• Enhanced patient satisfaction and self-efficacy

• Improved HbA1c levels

Wagner E et al. Chronic care clinics for diabetes in primary care. Diabetes Care 2001;25:695-700; Anderson R et al. Patient empowerment: results of randomized controlled trial. Diabetes Care 1995;18(7):943-949


Systematic Review of 39 Diabetes Studies Using at least one component of the CCM

• 17 of 20 studies that included a patient self-management component found positive outcomes ↓ health care costs ↓ length of hospital stay ↑ health outcomes (e.g., improved HbA1c)

Bodenheimer T, et al. Improving Primary care for Patients with Chronic Illness:

The Chronic care Model, Part 2. JAMA. 2002;288(15): 1909-1914


The body of evidence shows that supporting patient self-management…

reduces hospitalizations reduces ER visits reduces overall managed care costs increases patient satisfaction with care improves health outcomes (e.g.,)

• Glycemic control• Nocturnal asthma symptoms• Blood pressure control

Coleman and Newton, Am Fam Physician, 2005


Few Self-Management Studies with HIV Patients

• No strong evidence yet of efficacy• Only pilot studies have been done• Increase in self efficacy correlated with increase

in CD4 count and decrease in viral load*• More studies needed of in-office interventions

and system supports

*Ironson G, Weiss S et al(2005) The impact of improved self-efficacy on HIV viral load and distress in culturally diverse women living with AIDS: the SMART/EST Women’s Project. AIDS Care 17:222-36


Stanford HIV S-M Education Pilot Study

• Pilot test of a group self-management course for HIV/AIDS patients ↓ symptom severity index in the education session group and ↓

in the control group. ↑ self-efficacy in the educational group and ↓ in the control

group. secondary outcomes (pain fatigue, psychosocial symptoms,

changes in stress/relaxation exercises, and HIV/AIDS knowledge were not significantly different in the two groups.

• No follow-up of this pilot study reported to date.

Gifford A, Pilot Randomized Trial of Education to Improve Self-Management Skills

of Men with Symptomatic HIV/AIDS. JAIDSHR. 1998;18136-144.


Limitations of Patient Self-Management Education

In a meta-analysis of 71 trials of self-management education across several chronic disease states the authors concluded that…

• While self-management education programs are conceptually appealing, the findings of this review suggest that not all self-management education programs for all diseases or for all patients are effective.

Patient self-management programs which tailor educational content and methodology to individual patients and which are integrated into medical care may prove to be more effective than structured self-management education courses, for which only specific patient subgroups may be ready.

Warsi A, et al. Self-management Education Programs in Chronic Disease. Arch Inter Med. 2004;164:1641-1649.


In summaryHelping patients be better self-managers can…

• Improve Patient health outcomes Patient health-promoting behaviors Patient self-efficacy Communication with providers Utilization of community resources Containment of health care costs The quality and efficacy of HIV care


Activity 2: Patient Case Study

9:50am• Andy and Zeke

Brothers with similar health challenges Different degrees of success with self-management Different health outcomes Different concerns

• Small group brainstorming activity

Case study based on Bodenheimer et al, JAMA 2002


Activity 3: The To-Do List

10:20am• Small group activity to plan an approach to

collaborative care with Zeke• Primary care issues• Assessing Zeke’s concerns, needs, strengths and

priorities• Zeke is HIV-positive

How does this affect his care? What are the key management tasks? Whose responsibility? (Zeke, providers, both?)


Activity 4: Patient Self-Management Supports

10:50am• Identifying the need for patient self-

management supports• Brainstorming the most appropriate supports for

individual tasks• Review of patient self-management supports

Patient-centered Provider-centered System-centered


Integrating Patient Self Management into Clinical Practice

Harlem Hospital

New York City

Jenny Knight, FNPJenny Knight, FNP

Harlem Hospital Center, NYHarlem Hospital Center, [email protected]


• Our team was part of a one-year national learning community sponsored by the Institute for Healthcare Improvement on patient self-management (included 20 sites, 2 other HIV)

• The Family-Centered Care Program (FCP) was our target population

• Participated in extended follow-up project to measure sustainability of change

Harlem Hospital


Population of Focus

• 25% of FCP patients are recent immigrants from West Africa

• The remaining 75% of FCP patients are predominantly African-American or Hispanic

• Many face legal, linguistic and cultural barriers to care

• The self-management model is well-suited to assist these patients in overcoming barriers and achieving better health outcomes


Introducing Self-Management

• Developed a goal setting tool to set a patient-driven healthcare goal and develop an action plan during the clinic visit

• Developed a model to accomplish this within the time constraints of the clinic setting


My Action Plan for Better HealthHarlem Family Center

This month I will:

Improve my foodChoices

Reduce my stress

Take my meds everyday

Attend a support group

Exercise more often

Follow up with a medical appointment(go to the dentist)

Cut down or stop smoking (or drinking or drug use)

Other:

Describe it: (How, where, what, when, how often)

Barriers (what might get in the way):

Plans to over come barriers (what could you do to handle the barriers?):

On a scale of 1 – 10: How important is this goal: ________(1 = Not important at all, 5 = somewhat important, 10 = the most important)

On a scale of 1 – 10: How sure am I that I can make this goal: ______(1 = Not sure at all, 5 = somewhat sure,10 = 100% sure)

Follow up Plan:

Signature:Clinician Signature:


Refine Goal Setting Delivery

Optimize Goal-setting in

Mom/Baby Clinic

Implement – Goal Setting Delivery

Design

A PS D

APS

D

A PS D

D SP A

Data

D SP A

Cycle 1: Providers use goal-setting tools with patients

Cycle 2: RN uses goal-setting tool with patients prior to providerVisit at one clinic session. Provider reinforces goals/plan

Cycle 3: Team approach implemented in Mom/Baby Clinic. Case manager plays role in supporting plan

Cycle 4: Expand approach to two RN/Provider teams in Adult HIV clinic


Team Approach

• Piloted in Mom-Baby Clinic Later expanded to several providers in ID Clinic

• Nurse sets goal with pt during triage• Provider reviewed goals with pt during visit• Case manager available to reinforce goals• Goal and action plan filed in patients’ chart


Goal-setting was Patient-Driven

• Easier than expected to generate goals from patients

• Encouraged the patient to identify the goal themselves, come with action plan, identify barriers, come up with solution that worked for them

• Skills included: asking opening ended questions, reflective listening, summarizing


Impact of Goal-Setting

• Can solve impasse around behavior change• Gives providers deeper understanding of the

patient• Improves relationship between patient-nurse

and patient-provider• Empowers pt to make needed behavior

changes, or at least think about them if they are not ready


Case Study: Improving Adherence

37 yr old female with AIDS, newborn at home, with recent illnesses, weight loss, and depression. Stopped taking her meds.

• Goal: “To take my medicines every morning after eating”• Barriers: “Tired of taking pills”• Plans to overcome barrier: “Think about tomorrow!”,

“Remind myself why I am taking them”• Follow –up: Reported 100% adherence on self-reported

follow-up survey; a more positive outlook• Objective measures: CD4 increased from 153 to 360

and VL decreased from 15,400 copies to undetectable; weight increased by 13 lbs


Case Study: Substance Abuse

28 yr old with HIV, relatively medically well, but with depression, active marijuana use, multiple missed clinic visits, and chaotic life circumstances. Active ACS case: all three kids in mandated foster care

• Goal: Stop marijuana use to get children back, “must have clean urines”

• Barriers: friends, depression, lack of activities• Plans to overcome barriers: attend parenting classes,

attend drug support group, take meds for depression• Follow-up: additional barriers identified as drug

supplying boyfriend and drug-infested neighborhood• Objective measures: persistently positive urines; but

improved compliance with follow-up visits; VL initially showed a significant decrease (though not maintained); CD4 stable


Case Study: Coordination of Care

46 yr old male with AIDS with hx of substance use and poor adherence.

• Returned to NYC 8/06 after several months of incarceration in Virginia with CD4 277 and VL <50 and reengaged in care

• By 11/06 CD4 180, VL > 100,000. Pt was at the hospital daily attending support programs (HATS, COBRA, HABARI, Harm Reduction, Nutrition, Hep C)


Setting a Goal

• Held case management meeting with all programs, provider and patient

• At that meeting developed goal and action plan with pt

• Goal: Take medications every day• Plan: Take my pills every morning at home

after breakfast


Problem-Solving

• Barriers: Forgetting/Frustration/Substance Abuse

• Plans to overcome barriers: Keep dose in bag/jacket Check in with HATS (adherence support daily) Continue 1:1 counseling with Habari (Housing, psych referral) Continue 1:1 counseling with Harm Reduction Program

• Follow up: At next medical visit, pt reported 100% adherence 1/07 CD4 233, VL 2,880


Group Discussion

11:35am

Participant exchange and discussion on activities and tools/resources for supporting patient self-management.


Evaluation and Wrap up

11:50-12:00 noon

Thank you for your participation.

national quality center (nqc)1 nys hivqual workshop: supporting patient self- management july 17,...

Documents