May 10, 2012 | Kim Wicklund, MPH Self-management support and patient education for chronic conditions at Group Health Small steps to big changes.

May 10, 2012 | Kim Wicklund, MPH

Self-management support and patient education for chronic conditions at Group HealthSmall steps to big changes

Randy’s story

Whether you think you can do a thing or you can’t

do a thing, you’re right.

– Henry Ford

Chronic Conditions in U.S.

Among the American adult population:

50% have at least one chronic condition

25% have multiple chronic conditions

75% of people age ≥65 have multiple chronic conditions

½ of those with hypertension, and over 60% of those with diabetes and hyperlipidemia do not have conditions well controlled

Vogeli, Shields, Lee 2007 JGIMMedical Panel Expenditure Survey 2006Schneider et al. 2009Bodenheimer, Wagner, Grumbach 2002 JAMA

Chronic Care Model

Rationale for self-management support

Through SMS people gain knowledge, skills, and self-confidence

Majority of care for chronic conditions is complex and challenging self care

SMS improves patient outcomes and controls costs

Various SMS approaches: care managers, one-on-one, group, telephonic coaching, online, peer

Need effective models that are affordable and have population level impact

Chronic Disease Self-Management Program

Developed at Stanford Patient Health Education Research Center

6-week workshop (2.5 hrs/wk) based on self-efficacy theory

Designed for people with one or more chronic conditions

Leaders have personal experience with chronic conditions

Premise– people with chronic conditions share similar challenges and need to master a generic set of self-management skills

Contributes to improvements in psychological health status, self-efficacy and select health behaviors. Modest effects can have significance across large population. (CDC 5/2011)

CDSMP at Group Health

Started in 1998

18 medical centers

65 volunteer leaders

Average age: 65

Most common conditions: diabetes, arthritis, asthma/COPD, heart disease, depression

Reach 2009-2011: 1,615 Group Health patients

Recruitment: letters, care team, ghc.org, flyers, word of mouth

Challenges of scaling CDSMP

Limited access for network members in eastern and central Washington

Capacity determined by volunteer leader and room availability

Schedule is sporadic

Chronic condition flare-ups can impact attendance

Difficult to commit to weekly 2 ½ hour sessions

Discomfort discussing sensitive topics face to face

Online CDSMP

Online CDSMP pilot

Funded by GHF

Partners: NCOA, Stanford, GHRI

Target: 500 participants

Timeline: June, 2009-June, 2011

Eligibility:

• Adult Group Health member

• Any chronic condition

• Enhanced access to MGH

Intervention

Follows structure of in-person program

6-week highly interactive online workshop

25 participants per workshop

Two peer moderators

New lessons posted each week

Participants log on at their convenience 2-3 times/week

Time commitment of 2-3 hours/week

Home page

Evaluation questions

1. Will the online program expand CDSMP’s reach to Group Health members who are not reached by the in-person workshops?

2. Will participants in the online program at Group Health experience similar benefits to those reported in Stanford’s evaluation?

3. What resources and expertise are needed to administer the online program at Group Health?

4. Is the online format a viable strategy for bringing the CDSMP intervention to scale at Group Health?

Participant flow

Stage in process TotalSigned up as interested 1043

Enrolled 473 (45%)

Attended ≥1 session 91%

Completed ≥4 sessions 66%

Data for baseline and 6 months 50%

Evaluation

Health Status Self-mgt behaviors

Healthcare Utilization

Self-efficacy

• Social/role activity limitations

• Depression

• Pain severity

• Shortness of breath

• Self-rated general health

• Health distress

• Exercise

• Communica-tion w/MD

• Cognitive symptom management

• Medication management

• Smoking status

• Visits to physician

• Visits to ED

• Hospital stays

• Nights in hospital

6 item self-efficacy scale

Demographics Online

(n= 478) In-person (n= 1615)

Age: 18 – 39 40 – 64 >=65

Age range Mean age

13% 66% 21% 20 – 89 54

2% 32% 66% 17 – 96 68

Gender Female

83%

69%

Education High school or less College/Undergraduate

18.3% 57.8%

Race White African American Asian/PI

86.7% 4.7% 4.4%

Marital status Single Married/domestic ptnr Separated/Divorced Widowed

15.8% 66.6% 15.2% 2.4%

Health status Excellent/very good Good/fair Poor

20.2% 72.6% 7.2%

Conclusions

1. Online program expanded CDSMP’s reach

2. Benefits were similar to but not consistent with Stanford’s

3. Resources and expertise needed to administer the online program are reasonable

Mixed staffing model– GH Administrator; NCOA mentor and facilitators

Costs– per workshop: $4350; per participant: $174; per completer: $255

4. Online format is a viable strategy for helping to bring the CDSMP to scale at Group Health

Other strategies

Employer pilots

Testing 3 approaches:

1. Worksite-based workshops (King County)

4 workshops- 56 employees

Gold status for documented attendance of ≥4 sessions

2. Formal reporting of participation (SHWT)

GH/SHWT reporting process for incentivizing employees attending ≥4 sessions online or in person

3. Employee self report on participation (Group Health)

≥4 sessions in person or online for 400 wellness points

317 reported met goal

Disease-specific pilot

Living Well with Diabetes (DSMP)

GHF Partnership for Innovation grant to pilot 8-10 workshops

To date offered 8 workshops to 128 people (14 scheduled)

Evaluating impact on self-management behaviors, blood sugar knowledge, medication management

“Today I received my latest blood and kidney test results, and for the first time in my adult life they all were within normal ranges. My A1c was 5.7….”

Integrating referrals into care

Point of care prompts in EMR

CMEs and nursing education

Clinical Pearls

Standard tools

Health Profile

After Visit Summaries

Brochures

MyGroupHealth

Reach 1999-2011

Total members enrolled in LWCC1999 to 2011

(Online program implemented J une 2009)

0

100

200

300

400

500

600

700

800

900

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Online

Total

In person

Patient education resources

Myths about patient education

If patients have more information, they’ll have better outcomes.

If I don’t share everything I know with my patients, they won’t fully understand their condition and what they need to do.

If my patients hear medical jargon, that’s ok. They’ll be able to understand it from the context.

My patient is well educated, so s/he will understand complex words and ideas.

My patient didn’t ask any questions so s/he must have understood my instructions.

The reality for many patients

Most patients forget up to 80% of what their clinician tells them as soon as they leave the office

Nearly 50% of what patients do remember they remember incorrectly 

Implications:

– Non-adherence and disengagement

– Patient safety concerns

– Medication errors

– Missed surgeries and other appointments

Strategies for providing information

Break the information into understandable chunks

Use plain language

Limit key points to 3 or fewer

Focus on action-oriented messages

Repeat key messages

Use analogies to help explain concepts

Use images and graphics

Tailor the message to the patient

Give consistent messages

Modular approach

Graphics clarify key concepts

Action planning

Action plan for diabetes management

Patient instructions provided in AVS

Lessons Learned

Lessons learned

We have an ethical obligation to provide effective SMS

Patients want and need different options for engaging in SMS

People cycle through readiness and need to hear about SMS from different sources at different times

Clinical teams need ongoing reminders about the program

Employers are an underutilized resource for promoting SMS

Incorporating SMS concepts into patient education supports awareness of care team and patients about SMS

Future directions

Next steps

Continue exploring how to integrate referrals into standard work

Continue to identify alternative ways to reach network members

Update functionality and design of online program

Further analyze evaluation data

Explore more partnerships with employers (SU, Puyallup Tribe)

Partner with community programs to address gap areas

Create online community of LWCC alumni to provide ongoing support

Considering SMS program for youth or young adults

Discussion