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MSK Train the Trainer 1 Patient Self-Management Connie Davis, MN, ARNP [email protected] www.pspbc.ca Faculty/Presenter Disclosure Speaker’s Name: Speaker’s Name Relationships with commercial interests: - Grants/Research Support: PharmaCorp ABC - Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd - Consulting Fees: MedX Group Inc. - Other: Employee of XYZ Hospital Group 2 Disclosure of Commercial Support This program has received financial support from [organization name] in the form of [describe support here – e.g. educational grant]. This program has received in-kind support from [organization name] in the form of [describe the support here – e.g. logistical support]. Potential for conflict(s) of interest: - [Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. - [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program: [enter generic and brand name here]. 3 Mitigating Potential Bias [Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to “Quick Tips” document 4 Certification Up to 21 Mainpro+ Certified credits for GPs awarded upon completion of: › All 3 Learning Sessions (NOTE: Credits and payment will be based on the exact number of hours in session) › At least 1 Action Period › The Post-Activity Reflective Questionnaire (2 months after LS3) Up to 10.5 Section 1 credits for Specialists › All 3 Learning Sessions (NOTE: Credits and payment will be based on the exact number of hours in session) › The Post-Activity Reflective Questionnaire (2 months after LS3) 5 Update/revise Action Plan Report of AP1 experiences & successes Payment for: PMV (optional) LS1 Action Period 1 6 Refine implementation; embed & sustain improvements attempted in practice via Action Plan + AP2 requirements Interactive group learning Finalize Action Plan Report of AP2 experiences & successes Payment for: LS2 Action Period 2 LS3 Reflection Interactive group learning Learning Session 3 Create Action Plan (using template) Planning & initial implementation in practice; review of Action Plan & improvements attempted in practice + AP1 requirements Action Period 2 Interactive group learning Learning Session 2 Opportunity for in-practice visit to introduce applicable EMR-enabled tools & templates prior to LS1 Action Period 1 Learning Session 1 Pre-Module Visit Learning Session & Action Period Workflow Reinforce & validate practice improvements GPs & Specialists complete PostActivity Reflective Questionnaire (PARQ) 2 months after LS3 & submit to PSP Central Payment Stream 1 (ideal) Current Rates: GPs Specialists MOAs Hourly Rate $125.73 $148.31 $20.00 Action Period 1 $880.10 $1,038.16 N/A Action Period 2 $660.07 $778.62 N/A Payment made after attending LS2 Payment made after attending LS3 GPs: GPs: PMV = $125.73 LS2 = $440.05 ($125.73 x 3.5hrs max.) LS1 = $440.05 ($125.73 x 3.5hrs max.) AP2 = $660.08 AP1 = $880.10 LS3 = $440.05 ($125.73 x 3.5hrs max.) TOTAL $1,445.88 TOTAL Specialists Specialists LS1 = $519.08 ($148.31 x 3.5hrs max.) LS2 = $519.08 ($148.31 x 3.5hrs max.) AP1 = $1,038.16 AP2 = $778.62 $1,557.24 LS3 = $519.08 ($148.31 x 3.5hrs max.) TOTAL TOTAL MOAs $1,816.78 MOAs PMV = $20.00 LS1 = $80.00 ($20.00 x 4hrs max.) LS2 = $80.00 ($20.00 x 4hrs max.) $100.00 LS3 = $80.00 ($20.00 x 4hrs max.) TOTAL TOTAL 7 $1,540.18 $160.00 What do I hope to accomplish? Define self-management, self-management support, and selfefficacy Describe what is known about self-efficacy and its influence on behavior and health Describe Brief Action Planning as an approach for improving self-management of MSK conditions Link to resources for self-management 8 Think about a time when you accomplished something that challenged you… 9 When you accomplished it, how did you feel? 10 Did that success lead to anything else? If so, what? Mt Outram, BC, photo by C Davis 11 What is self-efficacy? 12 Self-efficacy People’s beliefs about their capabilities to perform specific behaviors and their ability to exercise influence over events that affect their lives. - Albert Bandura Mt Frosty, BC, photo by C Davis 13 What is self-management? Self-management relates to the tasks that an individual must undertake to live well with one or more chronic conditions. These tasks include gaining confidence to deal with medical management, role management and emotional management. - Adams, Greiner and Corrigan (2004) 14 What is self-management support? 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 problemsolving support. - Adams et al 2004 15 Patient education and self-management support Patient education Information and skills are taught Usually disease-specific May assume that knowledge creates behavior change Goal is often compliance Health care professionals are the teachers Bodenheimer et al JAMA 2002;288:2469 16 Self-management support 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 Stepped Care for Self-management Support Healthy Communities and Supportive Family, Friends, and Caregivers Expert Methods Advanced Approaches (MI, Case/Care Mgmt, PST, Group, etc.) Behavior Change Support: Goal Setting, Action Planning, Problem solving, Follow-up Culture 17 Health Literacy Patients as Partners, British Columbia Activation How does self-efficacy impact health? High self-efficacy is associated with better › recovery level after a heart attack or heart surgery › coping with cancer or end-stage kidney disease › adherence to medication › lung function in chronic lung disease › living with chronic fatigue syndrome › pain management › adherence to prescribed exercise routines › control of alcohol or drug use • 18 - cited in Bandura, 1998 How can you increase self-efficacy? 19 Ways to increase self-efficacy Skills mastery Modeling Reinterpreting symptoms Social persuasion - Lorig & Holman, Ann Behav Med 2003 20 Skills mastery Learning new skills and being successful What can work: › Action plans to break big goals into smaller, more realistic steps › Education programs that teach skills Joshua Bell 21 Modeling Seeing and hearing from others like you who have been successful What can work › Group visits › Peer supports › Profiles, biographies of successful self-managers 22 Reinterpreting Symptoms Poor sleep Physical limitations Fatigue Symptoms are not just caused by the disease, but can be due to other factors. What can work: › breathing techniques Shortness of breath SYMPTOMS a vicious cycle › relaxation Pain › healthy eating Stress/ anxiety Depression › physical activity › sleep hygiene Difficult emotions Lorig et al, Living a Healthy Life with Chronic Conditions, Bull Publishing, 2012 23 Social Persuasion Encouragement, expression of hope What can work › structure for success (ex: small action plans) › group visits › peer support › affirmations (not praise) 24 Can you really improve self-efficacy? 25 Chronic Disease Self-Management Program Develop and studied by Kate Lorig and colleagues at Stanford Lay-leaders, 6 sessions, 2 1/2 hours each Addresses multiple conditions Includes planning and problem solving, skill acquisition “Everything you wish people knew” Outcomes: improved health behaviors and health status, fewer hospitalizations some sustained for 2 years Lorig, Med Care 1999;37:5, 2002;39:1217 26 What was that? 27 For the numbers people… Treatment Exercise in people with LBP NNT 5-9 Time 3 months Weight reduction OA 3 4 months Non-tramadol opioids for OA 25 12 weeks (50% reduction in pain rating, median=51mg morphine equivalent) Froud et al, 2009; Tools for Practice, 19 Mar 2012, Zhang et al, OA & cartilage 2010 28 NNT, cont Tramadol for OA (for every 8 pts treated, 6 12 weeks Topical NSAIDS for OA 4.6 14 weeks Optimal tx comorbid MSK & depression (optimized antidepressants 4.8 1 yr 1 stopped due to AE) followed by 12 wks self-management education) References: Tools for Practice, 19 Mar 2012; 24 Jan 2011; Kroenke et al JAMA, 2009 29 Lunch 30 What can we do to help people with MSK conditions? 31 What is Brief Action Planning? A self-management support tool based on the principles and practice of Motivational Interviewing It is › structured › patient-centered › evidence-informed Reims et al, Brief Action Planning White Paper, 2013 available at www.centreCMI.ca 32 Spirit of Motivational Interviewing Compassion Acceptance Partnership Evocation Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, 3ed, 2013 33 “Is there anything you would like to do for your health in the next week or two?” Behavioral Menu Elicit a Commitment Statement SMART Behavioral Plan “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” If Confidence <7, Problem Solve Barriers “Would you like to check in with me to review how you are doing with your plan?” Follow-up 34 Time to Practice Work in pairs Each will help the other make an action plan (or not) for something they really want to do (real play!) We will go one step at a time, so I will stop you after each step. 35 Question 1 “Is there anything you would like to do for your health in the next week or two?” 36 Skill #1 Behavioral Menu Offer a behavioral menu when needed or requested. 37 Behavioral Menu “Is it okay if I share some ideas from other people who are working to improve their health? “ If yes, share two or three ideas briefly in a group. “Maybe one of these would be of interest to you or maybe you have thought of something else while we have been talking?” Exercise Weight management Resuming Daily Activities Taking meds Adapted from Stott et al, Family Practice 1995; Rollnick et al, 1999, 2010 38 Skill #2 SMART Behavioral Plan Action Planning is “SMART”: Specific, Measurable, Achievable, Relevant and Timed • What? • How much? • When? • Where? • How often? Based on the work of Locke (1968) and Locke & Latham . (1990, 2002); Bodenheimer, 2009 39 Skill #3 Elicit a Commitment Statement After the plan has been formulated, the clinician/coach elicits a final “commitment statement.” Strength of the commitment statement predicts success on action plan. Aharonovich, 2008; Amrhein, 2003 40 Question 2 “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” 41 Skill #4 Problem Solving Problem-solving is used for confidence levels less than 7. Bandura, 1983; Lorig et al, Med Care 2001; Bodenheimer review, CHCF 2005; Bodenheimer, Pt Ed Couns 2009. 42 Problem Solving “A ___ (the number they chose) is higher than a zero. That’s good.” “Is there something you could do to raise your confidence?” Yes No Behavioral Menu Revise plan, restate plan and repeat confidence measure 43 Question 3 “Would you like to check in with me to review how you are doing with your plan?” 44 Skill #5 Follow-up Follow-up builds confidence Follow-up often with early action plans and decrease frequency as behavior is more secure. Regular contact over time is better than 1x intervention. Follow-up builds a trusting relationship Resnicow, 2002; Artinian et al, Circulation,2010 45 Follow-up “How did it go with your plan?” Success Partial success Recognize success Recognize partial success Did not try or no success Reassure that this is common occurrence “What would you like to do next?” 46 “Is there anything you would like to do for your health in the next week or two?” Have an idea? Specific Measureable Achievable Relevant Timely Not sure? Behavioral Menu SMART Behavioral Plan Elicit a Commitment Statement Not at this time Permission to check next time 1) Ask permission to share ideas. 2) Share 2-3 ideas. 3) Ask if any of these ideas or something else might work. “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” Confidence <7, Problem Solving Confidence ≥7 “Would you like to set a specific time to check back in with me so we can review how things have been going with the plan?” Follow-up 47 Tips for Giving Information and Advice When? › They ask for information or advice › You ask permission to give it › You have a professional obligation to inform your client of something they don’t know 48 Tips for Giving Information and Advice How? ASK-TELL-ASK and respect their autonomy › ASK Ask what they already know › TELL Fill in any gaps or gently correct misunderstandings Concentrate on key messages › ASK Use Teach-Back Ask what they think about your information or advice 49 What do we know about Brief Action Planning in practice? Family practice › team sport › Question 1 asked in about half the visits › half of those make an action plan › 2/3 will do at least part of their plan Specialty practice › in rheumatology, Question 1 asked routinely will result in ¾ of patients making action plans - unpublished data, CCMI and Handley, 2006 50 What resources are there to support people with MSK conditions? 51 Tools in MSK Toolkit Arthritis education programs resource list Resources for acute and chronic low back pain CHARD Local arthritis resources 52 Purpose of the Personal Health Record Compile health information – share with new providers or foster communication between providers Track symptom changes Prepare for medical visit Set action plan and monitor outcomes of those actions 53 Current Personal Health Record 10 Sections › Personal and health care team information › My health care appointments › Allergies › Medical conditions/surgeries › Medications/supplements › Test results › Pain diary / General health diary › Notes for next health care visit › Reminder for future medical tests › My action plan 54 Arthritis Society Programs Arthritis answers line www.Arthritis.Ca Arthritis self-management program Chronic pain management workshop Lifestyle makeover challenge Take charge! Early intervention for OA Joint works and water works 55 Talk to Your Doctor and other Health Care Professionals Trained peer leaders Started in Prince George, Victoria and the Lower Mainland Workshop focused on › Informed shared decision-making › Communication skills for patients (prepare, ask, clarify, express concerns) Partnering with many organizations as workshop providers 56 Additional Information Arthritis Society Programs & Personal Health Records › Mary Pack Arthritis Program OASIS › education workshops, resources More about motivational approaches › www.centreCMI.ca › www.motivationalinterviewing.org › Motivational Interviewing in Health Care by Rollnick, Miller and Butler, 2007, Guildford Press 57 Thank you! Coquihalla Highway from Mt Henning, photo by C Davis 58