Chronic Disease Management Institute

Patrick McGowan, PhDUniversity of Victoria

Informed,ActivatedPatient

ProductiveInteractions

Prepared, Proactive Practice Team

Functional and Clinical Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community Health Care Organization

Chronic Care Model

Differences Between Acute and Chronic DiseaseDifferences Between Acute and Chronic Disease

 ACUTE DISEASE CHRONIC DISEASE

BEGINNING Rapid Gradual

CAUSE Usually one Many

DURATION Short Indefinite

DIAGNOSIS Commonly accurate Often uncertain, especially early

DIAGNOSTIC TESTS Often decisive Often of limited value

TREATMENT Cure common Cure rare

ROLE OF PROFESSIONAL

Select and conduct therapy

Teacher and partner

ROLE OF PATIENT Follow ordersPartner of health professionals, responsible for daily management

1. Recognize and act on symptoms

2. Making most effective use of medications and treatments

3. Deal with acute attacks or exacerbations (manage emergencies)

4. Maintain their nutrition and diet

5. Maintain adequate exercise

6. Give up smoking

7. Use stress reduction techniques

8. Interact effectively with their health providers

9. Use community resources

10. Manage work and the resources of employment services

11. Manage relations with significant others

12. Manage their psychological responses to his illness.

New TasksNew Tasks

Traditional Patient EducationTraditional Patient Education– Asthma

Proper use of inhaler Self-monitoring Environmental control measures

– Diabetes Insulin injection Blood-glucose monitoring Healthy eating (glucose levels)

–  Heart disease Medication Information on pacemakers, arrhythmias, chest pain, acute

complications healthy eating (cholesterol)

– Rheumatoid arthritis Medication Joint protection & use of adaptive equipment

Important Realizations!Important Realizations!

• Clinicians are present only for a small fraction of Clinicians are present only for a small fraction of the timethe time

• Nearly all outcomes are mediated through a Nearly all outcomes are mediated through a person’s own behaviourperson’s own behaviour

• Motivation is important but not enough!Motivation is important but not enough!

• Chronic conditions are different to acute Chronic conditions are different to acute conditionsconditions

Patient Contact with Health Patient Contact with Health ProfessionalsProfessionals

Time managing at home over 1 yearTime managing at home over 1 year

GP visits per annum = 1 hourGP visits per annum = 1 hour

Visits to specialists = 1 hourVisits to specialists = 1 hour

PT, OT, Dietitian = 10 hoursPT, OT, Dietitian = 10 hours

Total = 12 hours with professionalsTotal = 12 hours with professionals

364.5 days managing on their own or 364.5 days managing on their own or 8748 hours8748 hours

Barlow, J. Interdisciplinary Research Centre in Health, School of Health & Social Sciences, Coventry University, May 2003.

Determinants of Health and Their Contribution to Premature

Death

Schroeder, NEJM 357; 12

15%

5%

10%

40%

30% Social

Environmental

Medical

Behavioral

Genetic

What People Learn at Diabetes Education CentresWhat People Learn at Diabetes Education Centres

Diabetes - what, causes, how diabetes is diagnosed, 2 types of diabetes, symptoms)Blood sugar - low blood sugar (hypoglycaemia) or high blood sugar (hyperglycemia), role of the glucometer, how to monitor blood glucose, when to check blood sugars, goal targets of blood glucoseBlood pressure - why does blood pressure matter, goal target for health blood pressureInsulin - what it is and how it works in the bodyHealthy eating - how to count carbohydrates, healthy eating guide, label reading, food groups, calcium and fibre, eating at restaurants, heart smart eating, sodium content of foods, weight controlMedications - oral medications, drug interactionsExercise - importance of exercise, guidelines for exercise, target heart rateFoot care - how to prevent infections, cuts, other breaks in the skin, and other injuriesHow to detect problems early - and to treat them promptlyComplications - diabetes and blood pressure, blood pressure medications, eye damage, kidney damage, damage to nerves, periodontal disease, heart, strokeSick days - guidelines for when you are experiencing a brief illnessTravelling with diabetes - extra medicationMedical maintenance - Hgb A1C test done 2 to 4 times per year, blood pressure tested at each doctor visit, urine screened annually for microalbuminurea, eyes examined every 1 to 2 years, lipid profile annually if elevated or as needed

Definition of ParadigmDefinition of Paradigm

Thomas Kuhn defined a paradigm as ….

“A worldview that is essentially an interrelated

collection of beliefs shared by scientists (for our

purposes, health care professionals), i.e., a set of

agreements about how problems are to beunderstood.”

Paradigm…Paradigm…

Kuhn recognized that the way problems are defined, in part, determines the nature of the strategies designed to solve them.

Anderson, R.M., & Funnell, M.M. (2004). Patient empowerment: reflections on the challenge of fostering the adoption of a new paradigm. Patient Education and Counseling.

The right paradigm??The right paradigm??

25 Years of Research focussing on the25 Years of Research focussing on the““problem of noncompliance / non-problem of noncompliance / non-

adherence”adherence”

Has failed to solve the problem!Has failed to solve the problem!

Medline – 1450 citations in area of Medline – 1450 citations in area of diabetesdiabetes

Assumptions re: noncomplianceAssumptions re: noncompliance

1. noncompliance is a valid and useful construct for understanding behaviour

2. patient is the source of the problem, and

3. the solution to noncompliance is for the patient to defer to the expertise of the HCP’s and follow the recommendations they have given him to change his behaviour

Are we socialized to the wrong Are we socialized to the wrong paradigm?paradigm?

• the one used for the treatment of acute illness…

• where the patient should surrender varying amounts of control to HCP’s to get their expertise and technology

• where HCP’s take responsibility for solving patient’s problems

Definition of Self-ManagementDefinition of Self-Management

The tasks that individuals must undertake

to live well with one or more chronicconditions. These tasks include having

theconfidence to deal with medical

management,role management and emotional

management of their conditions.

The US Institute of Medicine 2004

What health care providers do...What health care providers do...

Self-management support is defined as the systematic

provision of education and supportive interventions

by health care staff to increase patients’ skills and

confidence in managing their health problems,

including regular assessment of progress and

problems, goal setting, and problem-solving support.

Overview of the Chronic Disease Overview of the Chronic Disease Self-Management ProgramSelf-Management Program

1. Persons with any type of chronic health conditions

2. Self-referral3. Spouses and significant others may

participate4. Led by pairs of lay persons with chronic

health conditions5. Leaders receive a 4-day training

workshop

6. Leaders follow a scripted Leader’s Manual

7. Course is given once a week for 2 ½ hours for 6 weeks

8. Ideal class size is 10 to 12 persons

9. Participants receive “Living a Healthy Life with Chronic Conditions” workbook

10. No cost to participants

Problem solvingDecision makingResource utilizationPatient-provider

relationshipsTaking action

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SOCIAL LEARNING THEORY

INFLUENCES UPON EXPLANATORY

VARIABLES

EXPLANATORY VARIABLES OUTCOMES

Direct experience

Modeling

Behavioural Capability

(having the skills necessary for the performance of the desired

behaviour)

Acquisition and Maintenance of New

Behaviours

Mastery Experiences

Vicarious Persuasion

Verbal Persuasion

Efficacy Expectations(beliefs regarding one’s ability to successfully carry out a course

of action to perform a behaviour)

Direct Reward

Vicarious Reward

Outcome Expectations

(belief that performing a behaviour will have desired effects or consequences)

TraditionalTraditional

Patient EducationPatient EducationSelf-Management Self-Management

EducationEducation

What is What is taught?taught?

Information & Information & technical skills technical skills about the diseaseabout the disease

Skills on how to act Skills on how to act on problemson problems

How are How are problems problems formulatedformulated??

Problems reflect Problems reflect inadequate control inadequate control of the diseaseof the disease

The patient identifies The patient identifies problems problems experienced that experienced that may or may not be may or may not be related to the diseaserelated to the disease

What is the What is the relation of relation of education education to the to the disease?disease?

Education is Education is disease-specific and disease-specific and teaches information teaches information and technical skills and technical skills related to therelated to the diseasedisease

Education provides Education provides problem-solving skills problem-solving skills relevant to the relevant to the consequences of consequences of chronic conditions in chronic conditions in generalgeneral

TraditionalTraditional

Patient EducationPatient EducationSelf-Management Self-Management

EducationEducation

What is What is the the theory theory underlyinunderlying the g the educationeducation??

Disease-specific Disease-specific knowledge creates knowledge creates behaviour change, behaviour change, which in turn produces which in turn produces better clinical better clinical outcomesoutcomes

Greater patient Greater patient confidence in confidence in capacity to make capacity to make life-improving life-improving changes (self-changes (self-efficacy) yields efficacy) yields better clinical better clinical outcomesoutcomes

What is What is the goal?the goal?

Compliance with Compliance with behaviour changes behaviour changes taught to the patient taught to the patient to improve clinical to improve clinical outcomesoutcomes

Increased self-Increased self-efficacy to improve efficacy to improve clinical outcomesclinical outcomes

Who is Who is the the educator?educator?

A health professionalA health professional A health A health professional, peer professional, peer leader, or other leader, or other patients, often in patients, often in group settingsgroup settings

Self-management attitudes, behaviours and skills

- Having knowledge of the condition and /or its management

- Adopting a self-management care plan agreed and negotiated in partnership with health professionals, significant others and / or carers and other supporters

- Actively sharing in decision-making with health professionals, significant others and / or carers and other supporters

- Monitoring and managing signs and symptoms of the condition

- Managing the impact of the condition on physical, emotional, occupational and social functioning

- Adopting lifestyles that address risk factors and promote health by focusing on prevention and early intervention

-Having access to, and confidence in the ability to use support services

NHPAC, 2006

Why is SMS important to Nurses?

As members of integrated, multidisciplinary teams, nurses have an important role in providing self-management support as they are:

a) usually the first and most consistent point of contact; b) in the optimal position of gathering information; c) able to use their skills to engage clients to develop strategies

and use community resources; d) skilled at assessment, ongoing care, education, and family

support; and e) advocates for and with their clients.

(Canadian Nursing Association, 2005)

Ia – Evidence from meta-analysis or systematic review of randomized controlled trials

Ib – Evidence from at least one randomized controlled trial

IIa – Evidence from at least one well-designed controlled study without randomization

IIb – Evidence from at least one other type of well-designed quasi-experimental study without randomization

III – Evidence from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies

IV – Evidence from expert committee or opinions and/or clinical experiences of respected authorities.

“Patients as Partners”

• We want “Informed Activated Patients” and “Prepared, Proactive Practice Teams”

• The mechanism to achieve this is through:

1. Community self-management programs

2. Health care professionals using self-management support strategies.

mcgowan@dccnet.com

Toll-free line: Toll-free line:

1-866-902-37671-866-902-3767

Web site: Web site: www.selfmanagementbc.ca

Contact Information