Patient as Partners Improving Health and Cost Outcomes with Self-Care and Chronic Disease Self-Management NatPaCT Conference Programme Learning from Kaiser.

Patient as PartnersPatient as PartnersImproving Health and Cost Improving Health and Cost

Outcomes with Self-Care and Outcomes with Self-Care and Chronic Disease Self-ManagementChronic Disease Self-Management

NatPaCT Conference ProgrammeNatPaCT Conference ProgrammeLearning from Kaiser Permanente Learning from Kaiser Permanente

– How can the NHS make better use of its resources – How can the NHS make better use of its resources and improve patient care?and improve patient care?

Tuesday 4 November 2003 – The Brewery, LondonTuesday 4 November 2003 – The Brewery, London

David S. Sobel, MD, MPHDavid S. Sobel, MD, MPHDirector, Patient Education and Health PromotionDirector, Patient Education and Health Promotion

Kaiser Permanente Northern CaliforniaKaiser Permanente Northern California1950 Franklin Street., 13th Floor, Oakland, CA 946121950 Franklin Street., 13th Floor, Oakland, CA 94612

Phone: 510-987-3579Phone: 510-987-3579Fax: 510-873-5379Fax: 510-873-5379

E-mail: [email protected]: [email protected]

Strategy for Changing Strategy for Changing Culture and PracticeCulture and Practice

Look forLook for inefficiencies, mismatches, and capacityinefficiencies, mismatches, and capacity overlooked evidence and dataoverlooked evidence and data ““win, win, win” opportunitieswin, win, win” opportunities

Strategy for Changing Strategy for Changing Culture and PracticeCulture and Practice

Rethink CareRethink Care

1.1. Patients as primary providers of acute illnessPatients as primary providers of acute illness

2.2. Self-management of chronic illnessSelf-management of chronic illness

3.3. Behavioral interventions to address psychosocial Behavioral interventions to address psychosocial needsneeds

Restructure CareRestructure Care Telephone, group appointments, web-based careTelephone, group appointments, web-based care

Retrain for Collaborative CareRetrain for Collaborative Care

Enhance understanding, skills, and confidence of Enhance understanding, skills, and confidence of members and professional staff as partners in caremembers and professional staff as partners in care

Rethinking Care 1: Rethinking Care 1: Self-Care for Acute IllnessSelf-Care for Acute Illness

PatientPatientas Consumeras Consumer

PatientPatientas Provideras Provider

Hidden Health Care SystemHidden Health Care System

Self-CareSelf-Care80%80%

Professional CareProfessional Care20%20%22

11

33

Self-Care: Self-Care: Patients as ProvidersPatients as Providers

Over 80% of all medical symptoms are self-Over 80% of all medical symptoms are self-diagnosed and self-treated without diagnosed and self-treated without professional care.professional care.

Patients are the true primary care providers Patients are the true primary care providers of medical care for themselves and their of medical care for themselves and their families.families.

How can health care systems educate, How can health care systems educate, equip, and empower the true primary care equip, and empower the true primary care providers… providers… patientspatients??

Kaiser PermanenteKaiser Permanente Self-Care ProgramSelf-Care Program

Vision: “Partners in Health”Vision: “Partners in Health” A system intervention that changes the culture A system intervention that changes the culture

of care and supports members making safe, of care and supports members making safe, appropriate, and informed health care choicesappropriate, and informed health care choices

KP Healthwise HandbooksKP Healthwise Handbooks distributed to all distributed to all membersmembers

Provider training and reinforcementProvider training and reinforcement Continuing systemwide reinforcementContinuing systemwide reinforcement

Kaiser PermanenteKaiser Permanente

Healthwise HandbookHealthwise Handbook

Kaiser PermanenteKaiser Permanente Self-Care ProgramSelf-Care Program

ResultsResults High use of the KP Healthwise HandbookHigh use of the KP Healthwise Handbook

70% in previous 6 months70% in previous 6 months Improved member self-care confidenceImproved member self-care confidence

71% more confident71% more confident Increased member satisfactionIncreased member satisfaction

60% more positive about Kaiser Permanente60% more positive about Kaiser Permanente More appropriate utilization & improved accessibilityMore appropriate utilization & improved accessibility

50% report saving a call or visit to MD50% report saving a call or visit to MD 6% medical visits and 6% medical visits and 5%telephone calls5%telephone calls

Improved provider and staff satisfactionImproved provider and staff satisfaction

Rethinking Care 2: Rethinking Care 2: Self-Management of Chronic IllnessSelf-Management of Chronic Illness

PatientPatientas Consumeras Consumer

PatientPatientas Provideras Provider

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

E. WagnerE. Wagner

Living with Chronic DiseaseLiving with Chronic Disease

Managing the IllnessManaging the Illness Taking medicationsTaking medications Changing diet and exerciseChanging diet and exercise Managing symptoms of pain, fatigue, insomnia, Managing symptoms of pain, fatigue, insomnia,

shortness of breath, etc.shortness of breath, etc. Interacting with the medical care systemInteracting with the medical care system

Managing Daily Activities and RolesManaging Daily Activities and Roles Maintaining roles as spouse, parent, worker, etc.Maintaining roles as spouse, parent, worker, etc.

Managing the EmotionsManaging the Emotions Managing anger, fear, depression, isolation, etc.Managing anger, fear, depression, isolation, etc.

Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M: Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M: Living a Healthy Living a Healthy Life with Chronic ConditionsLife with Chronic Conditions, Palo Alto, CA: Bull Pub. Co., 2000, Palo Alto, CA: Bull Pub. Co., 2000

Healthier Living with Healthier Living with Ongoing Health Conditions*Ongoing Health Conditions*

Lay-led, small interactive groups Lay-led, small interactive groups (2 hours/week for 7 weeks)(2 hours/week for 7 weeks)

Mixed chronic disease and co-morbiditiesMixed chronic disease and co-morbidities ContentContent

Goal setting and problem-solvingGoal setting and problem-solving Cognitive symptom managementCognitive symptom management Design of exercise programsDesign of exercise programs Management of fatigue, sleep, pain, anger, Management of fatigue, sleep, pain, anger,

depressiondepression Appropriate use of medicationsAppropriate use of medications Patient/physician communicationPatient/physician communication Use of advanced directivesUse of advanced directives

Lorig K et al Lorig K et al Medical CareMedical Care 1999;37:5-14. 1999;37:5-14. http://patienteducation.stanford.edu/http://patienteducation.stanford.edu/

*aka Chronic Conditions Self-Management *aka Chronic Conditions Self-Management Program, Expert Patient Programme Program, Expert Patient Programme

Healthier Living with Healthier Living with Ongoing Health ConditionsOngoing Health Conditions

Improves health behaviors and health statusImproves health behaviors and health status Cost effective (estimated 5:1 to 10:1 ROI)Cost effective (estimated 5:1 to 10:1 ROI) Outcomes are long-lasting and robust (2+yrs.)Outcomes are long-lasting and robust (2+yrs.) Replicable and dissemination can yield outcomes Replicable and dissemination can yield outcomes

as good, or better.as good, or better.

Lorig KR, Sobel DS, Lorig KR, Sobel DS, Effective Clin PracticeEffective Clin Practice 2001;4:256-262 2001;4:256-262Lorig KR, Lorig KR, Medical CareMedical Care 2001;39:1217-1223 2001;39:1217-1223

Chronic Disease Chronic Disease Self-Management ProgramSelf-Management Program

LESSONSLESSONS General coping skills education for heterogeneous General coping skills education for heterogeneous

conditions complements disease specific informationconditions complements disease specific information Patients are the “experts” in living and coping with Patients are the “experts” in living and coping with

chronic illnesschronic illness Modeling more effective than “save and rescue”Modeling more effective than “save and rescue” No significant difference in participants’ outcome with No significant difference in participants’ outcome with

lay vs professional leaderslay vs professional leaders Confidence predicts improvement in health outcomesConfidence predicts improvement in health outcomes People benefit themselves from helping other peoplePeople benefit themselves from helping other people Process is more important than contentProcess is more important than content

Rethinking Care 3: Rethinking Care 3: Behavioral MedicineBehavioral Medicine

BodyBodyas Machineas Machine

MindMindas HMOas HMO

Sobel DS: The cost-effectiveness of mind-body medicine interventions. In The Biological Basis for Mind Body Interactions, Progress in Brain Research, Vol 122, EA Mayer and CB Saper (Eds.), Elsevier, 2000:393-412.

Somatic Symptom SuperhighwaySomatic Symptom Superhighway

Medical IllnessMedical Illness

Psychiatric DisorderPsychiatric DisorderEmotional Emotional DistressDistress

Somatic SymptomsSomatic Symptoms

Final Common PathwayFinal Common Pathway

Psychological Status of Psychological Status of Primary Care PatientsPrimary Care Patients

0

10

20

30

40

50

60

70

80

90

Psychiatric Disorder Psychological Distress

Causes of Common Symptoms Causes of Common Symptoms in Primary Care Medicinein Primary Care Medicine

Kroenke, Kroenke, Am J MedAm J Med 1989:86:262-6 1989:86:262-6

Psychological10%

Organic16%

Unknown74%

Chest pain, fatigue, dizziness, headache, back pain, Chest pain, fatigue, dizziness, headache, back pain, edema, dsypnea, insomnia, abdominal pain, numbnessedema, dsypnea, insomnia, abdominal pain, numbness

Depressive SymptomsDepressive Symptoms

Depressive Depressive symptomssymptoms more debilitating in more debilitating in terms of physical and social functioning terms of physical and social functioning than:than:

diabetesdiabetes arthritisarthritis gastrointestinal disordersgastrointestinal disorders back problemsback problems hypertensionhypertension

Wells et al. Wells et al. JAMAJAMA 1989;262:914-930 1989;262:914-930

Psychosocial DysfunctionPsychosocial Dysfunctionin Medical Carein Medical Care

Common Common Undiagnosed or inadequately treatedUndiagnosed or inadequately treated Significant impact on:Significant impact on:

functional status and disabilityfunctional status and disability medical utilization and costsmedical utilization and costs medical morbidity and mortalitymedical morbidity and mortality

Health Care services mismatched to needsHealth Care services mismatched to needs Need to develop integrated behavioral health Need to develop integrated behavioral health

education serviceseducation servicesSobel DS: Rethinking medicine: Improving health outcomes with cost-effective Sobel DS: Rethinking medicine: Improving health outcomes with cost-effective psychosocial interventions. psychosocial interventions. Psychosomatic MedicinePsychosomatic Medicine 57:234-244, 1995. 57:234-244, 1995.

Mind/Body Medicine Program EvaluationMind/Body Medicine Program EvaluationPre- and Post-Class Pre- and Post-Class

SCL-90 Sub-scale MeasuresSCL-90 Sub-scale Measures

% C

lass

ife

d a

s P

sy

ch

% C

lass

ife

d a

s P

sy

ch

Ou

tpa

tien

t C

ase

s o

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CL

-90

Ou

tpa

tien

t C

ase

s o

n S

CL

-90

Nancy Gordon - DOR (June, 2000)Nancy Gordon - DOR (June, 2000)

12 NCal Facilities12 NCal Facilities

0%0%

10%10%

20%20%

30%30%

40%40%

50%50%

60%60%

70%70%

DepressionDepression(n=124)(n=124)

SomatizationSomatization(n=120)(n=120)

AnxietyAnxiety(n=121)(n=121)

62.1% 61.2% 60.0%

28.2%21.5%

31.7%

Intake Post-Program

00

500500

10001000

15001500

20002000

25002500

30003000

ADPADP+34%+34%

ERER- 45%- 45%

MedMed-37%-37%

UrgUrg-22%-22%

PsyPsy- 41%- 41%

Utilization Change for Utilization Change for Mind/Body Medicine ParticipantsMind/Body Medicine Participants

TotalTotalVisitsVisits

Ngissah, Levine, & Walsh (1998 - N. Valley) Ngissah, Levine, & Walsh (1998 - N. Valley)

N=609N=609

6-Mo. Pre 6-Mo. Post

RethinkingRethinking Health Improvement InterventionsHealth Improvement Interventions

HealthHealthOutcomesOutcomes

AttitudesAttitudesBeliefsBeliefsMoodsMoods

Health Health BehaviorBehaviorChangeChange

Lorig K, Arthritis and Rheumatism. 1989;32:91-95

Confidence CountsConfidence Counts

Psychosocial Psychosocial SkillsSkills

Targeting CoreTargeting Core Attitudes, Beliefs, and MoodsAttitudes, Beliefs, and Moods

CORECOREAttitudesAttitudesBeliefsBeliefsMoodsMoods

Problems Problems in Livingin Living

Behavioral Behavioral Risk Risk

ReductionReduction

Mental Mental IllnessIllness

Quality of LifeQuality of Life

Medical Medical ConditionsConditions

Ornstein R, Sobel D: Ornstein R, Sobel D: Healthy PleasuresHealthy Pleasures. Addison-Wesley, 1989. Addison-Wesley, 1989

Restructuring CareRestructuring Care

Group Group AppointmentsAppointments

andandWeb-basedWeb-based

CareCare

Medical Medical Office VisitsOffice Visits

Medical Group AppointmentsMedical Group Appointments(Group Visits, Cluster Visits, etc.)(Group Visits, Cluster Visits, etc.)

Scheduled or ‘drop-in’ visit for group of patients with similar Scheduled or ‘drop-in’ visit for group of patients with similar or mixed health conditionsor mixed health conditions

Under direction of physician or other licensed health care Under direction of physician or other licensed health care professionalprofessional

Provision of individualized clinical servicesProvision of individualized clinical services Medical Assessment Medical Assessment

history, physical assessment, triage, referralhistory, physical assessment, triage, referral Medical InterventionMedical Intervention

medication prescription/adjustment, lab testsmedication prescription/adjustment, lab tests

Diabetes Cooperative Care ClinicDiabetes Cooperative Care Clinic

Randomized clinical trial, n=185, f/u 1yr, 2hr group monthly x 6Randomized clinical trial, n=185, f/u 1yr, 2hr group monthly x 6

OutcomesOutcomes lower HgbA1C (lower HgbA1C ( 1.3% vs. 1.3% vs. 0.22% controls, p<0.0001)0.22% controls, p<0.0001) more home blood glucose monitoringmore home blood glucose monitoring reduced hospital and outpatient utilization reduced hospital and outpatient utilization

hospitalizations 80% more frequent in controlhospitalizations 80% more frequent in control fewer physician and nonphysician visits fewer physician and nonphysician visits

increased self-efficacy increased self-efficacy diet, management of low BG and BG when sickdiet, management of low BG and BG when sick

increased satisfactionincreased satisfaction

Sadur CN, Diabetes Care, Sadur CN, Diabetes Care, 1999;12:2011-20171999;12:2011-2017

Restructure Care:Restructure Care:Web-Based Care at kp.orgWeb-Based Care at kp.org

www.kaiserpermanente.org

Get Health AdviceGet Health Advice

Appointment/Rx RefillsAppointment/Rx Refills

Physician Personal

Home Page:A Personal

Portal to Kaiser

Permanente Online

Services

Retraining for Retraining for Collaborative CareCollaborative Care

Traditional, Traditional, PaternalisticPaternalistic

CareCare

CollaborativeCollaborativeCareCare

How Traditional Care Differs How Traditional Care Differs from Collaborative Carefrom Collaborative Care

IssueIssue Traditional Care/Traditional Care/Patient EducationPatient Education

Collaborative Care/Collaborative Care/Self-Management EducationSelf-Management Education

RelationshipsRelationships Professional are expert. Professional are expert. Patients are passive.Patients are passive.

Shared expertise with active Shared expertise with active patients. Patient expert in their patients. Patient expert in their experience of diseaseexperience of disease

Needs Needs AssessmentAssessment

Provider defines what Provider defines what patients need to know. patients need to know.

Patient defined problemsPatient defined problems

ContentContent Disease managementDisease management Disease, role, and emotional Disease, role, and emotional managementmanagement

ProcessProcess Prescribed behavior change. Prescribed behavior change. Provider solves problems. Provider solves problems. External motivation. Didactic External motivation. Didactic presentations.presentations.

Self-defined goals. Patient Self-defined goals. Patient learns problem-solving skills. learns problem-solving skills. Focus on internal motivation Focus on internal motivation and self-efficacy. Interactive.and self-efficacy. Interactive.

OutcomesOutcomes Knowledge and behaviorKnowledge and behavior Health status and appropriate Health status and appropriate utilizationutilization

adapted from Bodenheimer, Lorig, et al JAMA 2002;288:2469.adapted from Bodenheimer, Lorig, et al JAMA 2002;288:2469.

Retraining for Collaborative CareRetraining for Collaborative Care

Thriving in a Busy Practice: Thriving in a Busy Practice: Clinician-Patient CommunicationClinician-Patient Communication

(“Four Habits of Effective Clinicians”)(“Four Habits of Effective Clinicians”) Brief NegotiationBrief Negotiation Practice Essentials for Care ManagersPractice Essentials for Care Managers Education for Health ActionEducation for Health Action Group Appointment ToolkitGroup Appointment Toolkit

Address member’s needs in 3 domains:Address member’s needs in 3 domains:1. Disease and Health Management1. Disease and Health Management2. Role Management2. Role Management3. Emotional Management3. Emotional Management

Use state-of-art communication/educational strategies:Use state-of-art communication/educational strategies: Transform didactic, information-based approaches into interactive, self-Transform didactic, information-based approaches into interactive, self-

efficacy/confidence enhancing communication that strengthens patients’ efficacy/confidence enhancing communication that strengthens patients’ skills in problem-solving, goal setting and action planning, self-tailoring, skills in problem-solving, goal setting and action planning, self-tailoring, using available resources, forming a partnership with clinician using available resources, forming a partnership with clinician

Ask questions and elicit patient perspective and engagement in action Ask questions and elicit patient perspective and engagement in action planning and problem-solving planning and problem-solving

Use nonjudgmental and positive toneUse nonjudgmental and positive tone Link back to member’s routine source of care and team care and peer Link back to member’s routine source of care and team care and peer

supportsupport

Retraining for Collaborative Care:Retraining for Collaborative Care:Key StrategiesKey Strategies

Patients as Partners: Patients as Partners: Changing Culture and PracticeChanging Culture and Practice

Rethink CareRethink Care1.1. Patients as primary providers of acute illnessPatients as primary providers of acute illness

2.2. Self-management of chronic illnessSelf-management of chronic illness

3.3. Behavioral interventions to address psychosocial Behavioral interventions to address psychosocial needsneeds

Restructure CareRestructure Care Telephone, group appointments, web-based careTelephone, group appointments, web-based care

Retrain for Collaborative CareRetrain for Collaborative Care Enhance understanding, skills, and confidence of Enhance understanding, skills, and confidence of

members and professional staff as partners in caremembers and professional staff as partners in care

AppendicesAppendices

Four Habits of Highly Effective Four Habits of Highly Effective Clinicians Clinicians

1.1. Invest in the BeginningInvest in the Beginning

2.2. Elicit the Patient’s PerspectiveElicit the Patient’s Perspective

3.3. Demonstrate EmpathyDemonstrate Empathy

4.4. Invest in the EndInvest in the End

Frankel RM, Stein T. Frankel RM, Stein T. Getting the Most out of the Clinical Encounter: The Getting the Most out of the Clinical Encounter: The

Four Habits ModelFour Habits Model. The Permanente Journal, Fall 1999, Vol 3, No. 3. The Permanente Journal, Fall 1999, Vol 3, No. 3 http://www.kaiserpermanente.org/medicine/permjournal/fall99pj/frhabits.htmlhttp://www.kaiserpermanente.org/medicine/permjournal/fall99pj/frhabits.html

2003 CMI Evidence-Linked 2003 CMI Evidence-Linked RecommendationsRecommendations

Embed Self-Mgt into Pop Mgt:Embed Self-Mgt into Pop Mgt: Lower intensityLower intensity interventions interventions ((automated

phone messages, staged mailings, videos, online) ) for for all patientsall patients

Higher intensityHigher intensity (e.g. multi-session programs)(e.g. multi-session programs) for those with higher needsfor those with higher needs

Robert Wood Johnson Foundation and Center for the Advancement of Health. Essential Elements of Self-Management Interventions, 2002.

Von Korff M, Tiemens B. West J Med 2000; 172(2):133-137.Piette JD,e al. Am J Med 2000; 108(1):20-27.Serxner S, et al. Congestive Heart Failure; 1998. May/June:23-28.

2003 CMI Evidence-Linked 2003 CMI Evidence-Linked Recommendations, cont’d.Recommendations, cont’d.

During clinical encounter, support During clinical encounter, support member’s central role in health:member’s central role in health:

Collaborative communication (Collaborative communication (Brief Negotiation, 4 Habits)Brief Negotiation, 4 Habits)

Assess member’s self-mgt needs; provide tailored Assess member’s self-mgt needs; provide tailored feedback and behavioral advisefeedback and behavioral advise

Collaboratively set behavioral goals and action plan. Collaboratively set behavioral goals and action plan. Document and share with member.Document and share with member.

Offer self-mgt resources; refer to programsOffer self-mgt resources; refer to programs F/up to adapt plan and address relapseF/up to adapt plan and address relapseGlasgow RE et al. Ann Behav Med 2002; 24(2):80-87.Stewart MA. CMAJ 1995; 152(9):1423-1433. Petrella RJ, Lattanzio CN. Can Fam Physician 2002; 48:72-80.Rice VH. Heart Lung 1999; 28(6):438-454.Boulware LE, et al. Am J Prev Med 2001; 21(3):221-232.

2003 CMI Evidence-Linked 2003 CMI Evidence-Linked Recommendations, cont’d.Recommendations, cont’d.

Strengthen Adherence to Strengthen Adherence to Prescribed Medications:Prescribed Medications:

Anticipate nonadherence: “Have you ever missed or forgot to take your pills?”

Identify personal barriers and problem solve. Avoid assuming causes of nonadherence

Collaboratively develop a regimen pt is willing and able to follow. Praise efforts to adhere.

As needed, refer for pharmacist consultation

McDonald HP, et al. JAMA 2002; 288(22):2868-2879.Haynes RB , et al. JAMA 2002; 288(22):2880-2883.Yuan Y, et al. Am J Manag Care 2003; 9(1):45-56.

2003 CMI Evidence-Linked 2003 CMI Evidence-Linked Recommendations, cont’d.Recommendations, cont’d.

Turn didactic pt education into self-Turn didactic pt education into self-mgt education mgt education

Beyond knowledge to skills & confidence: Problem solving training (incl. medication adherence)

Goal setting and action planning Peer modeling and support Experiential exercises (relaxation session, read peak flow

meter, pick from a menu)

Forming partnership with clinician

Bodenheimer T et al. JAMA 2002; 288(19):2469-2475.Norris S et al. Diabetes Care 2002; 25(7):1159-1171.Gibson PGM et al. Cochrane Database Syst Rev 2002;2.Barlow J, et al.Patient Educ Couns 2002; 48(2):177-187.

2003 CMI Evidence-Linked 2003 CMI Evidence-Linked Recommendations, cont’d.Recommendations, cont’d.

Offer multiple options to receive self-Offer multiple options to receive self-mgt education:mgt education:

Staged mailings based on readiness to change Telephone group sessions Group visits Internet-based programs Community and work site programs

Serxner S, et al. Congestive Heart Failure 1998; May/June:23-28.Boucher, JL et al. Diabetes Spectrum 1999 12(2).121-123.Wagner EH et al. Diabetes Care 2001; 24(4):695-700.McKay HG, et al. Diabetes Care 2001; 24(8):1328-1334.Norris SL et al. J Prev Med 2002; 22(4 Suppl):39-66.Pelletier KR. Am J Health Promot 2001; 16(2):107-116.