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STANFORD CHRONIC DISEASE SELFMANAGEMENT MODEL Application in a Community Health Worker Program Underwritten partially STANFORD CHRONIC DISEASE SELFMANAGEMENT MODEL Application in a Community Health Worker Program Underwritten partially by a grant from Med. TAPP HCA Joan Thoman, Ph. D, RN, CNS, CDE Pamela Rutar, Ed. D, RN, CNE Cleveland State University School of Nursing November 17, 2016

THIS SESSION IS ABOUT: n n The Stanford Chronic Disease Self. Management Model The THIS SESSION IS ABOUT: n n The Stanford Chronic Disease Self. Management Model The application to a Community Health Worker Program

IMPACTS OF CHRONIC DISEASE n Chronic disease will increase 300% by 2049 n Chronic IMPACTS OF CHRONIC DISEASE n Chronic disease will increase 300% by 2049 n Chronic disease results in pain, debilitation, disability, dependence, lost physical function, and less mobility n Chronic diseases include: heart disease, cancer, stroke, arthritis, asthma, lung disease, cancer, diabetes, hypertension, osteoporosis, multiple sclerosis, Parkinson’s disease… Stanford University Patient Education Center, http: //patienteducation. stanford. edu/

FINANCIAL REALITY - RISING COSTS… n n Chronic disease costs: 75 -95% of health FINANCIAL REALITY - RISING COSTS… n n Chronic disease costs: 75 -95% of health care expenditures! By 2030: Anticipated increase in healthcare costs tied to chronic disease, 25% to 54% Partnership for Solutions: Better Lives for People with Chronic Conditions, WA State, Health Affairs, 2005, 24 (1) 80 -92, National Council on Aging

PEOPLE WITH CHRONIC DISEASE REPORT… n Significantly reduced productivity n Living with less income PEOPLE WITH CHRONIC DISEASE REPORT… n Significantly reduced productivity n Living with less income n Accomplishing less n Spending more time in bed sick n Having poor mental health LStanford University Patient Education Center http: //patienteducation. stanford. edu/ , Lorig, K. 2003, National Council on Aging

WHAT IS SELF-MANAGEMENT? The individual’s ability to manage the symptoms, treatment, physical and social WHAT IS SELF-MANAGEMENT? The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition. ” “ Stanford University Patient Education Center, http: //patienteducation. stanford. edu/, Barlow, 2002.

SELF-MANAGEMENT BENEFITS PATIENTS… Builds confidence (self-efficacy) to perform 3 tasks - Disease management - SELF-MANAGEMENT BENEFITS PATIENTS… Builds confidence (self-efficacy) to perform 3 tasks - Disease management - Role Management - Emotional Management Focuses on improved health status and appropriate health care utilization

SELF-MANAGEMENT DIFFERS FROM PATIENT EDUCATION Self-Management - Manage life with disease - Increase skills SELF-MANAGEMENT DIFFERS FROM PATIENT EDUCATION Self-Management - Manage life with disease - Increase skills & self-confidence - Problem solve and make decisions Patient Education - Change behaviors - Increase knowledge - Use specific tools (e. g. , Care Plans)

PATIENT ED. VS SELF-MGMT. Information and skills are taught Usually disease-specific Assumes that knowledge PATIENT ED. VS SELF-MGMT. Information and skills are taught Usually disease-specific Assumes that knowledge creates behavior change Goal is compliance Health care professionals are the teachers Skills to solve pt. Identified problems are taught Skills are generalizable Assumes that confidence yields better outcomes Goal is increased selfefficacy Teachers can be professionals or peers

SELF-MANAGEMENT ALSO ENCOMPASSES § The patient and health professional working together. § Often involves SELF-MANAGEMENT ALSO ENCOMPASSES § The patient and health professional working together. § Often involves the family. § An holistic approach to care (i. e. , medical and psycho- social components of a condition). § Pro-active and adaptive strategies that aim to empower the individual.

MANAGEMENT SO IMPORTANT? WHAT IS DIFFERENT? Clinical outcomes are dependent on patient actions. Patient MANAGEMENT SO IMPORTANT? WHAT IS DIFFERENT? Clinical outcomes are dependent on patient actions. Patient self-management is inevitable. The provider’s role is to be in partnership with the patient Professionals are experts about diseases, patients are experts about their own lives.

CHRONIC DISEASE SELFMANAGEMENT ASSUMPTIONS n n n Patients with different chronic diseases have similar CHRONIC DISEASE SELFMANAGEMENT ASSUMPTIONS n n n Patients with different chronic diseases have similar self-management problems and disease -related tasks. Patients can learn to take day-to-day responsibility for their diseases. Confident, knowledgeable patients practicing self-management will experience improved health status and use fewer health resources. Stanford University Patient Education Center, http: //patienteducation. stanford. edu/ Lorig and Holeman 2003

SELF-MANAGEMENT FRAMEWORK n Patients accept responsibility to manage or comanage their own disease conditions. SELF-MANAGEMENT FRAMEWORK n Patients accept responsibility to manage or comanage their own disease conditions. n Patients become active participants in a system of coordinated health care, intervention and communication. n Patients are encouraged to solve their own problems with information, but not orders, from professionals. Stanford University Patient Education Center, National Council on Aging

SELF-MANAGEMENT SKILLS Problem-solving n Decision-making n Resource Utilization n Formation of a patientprovider partnership SELF-MANAGEMENT SKILLS Problem-solving n Decision-making n Resource Utilization n Formation of a patientprovider partnership n Action-planning n Self-tailoring n Stanford University Patient Education Center, http: //patienteducation. stanford. edu/, Lorig and Holeman 2003

CHRONIC DISEASE SELF-MANAGEMENT MEANS… n n n Taking care of your illness (using medicines, CHRONIC DISEASE SELF-MANAGEMENT MEANS… n n n Taking care of your illness (using medicines, exercise, diet, technology, physician partnership) Carrying out normal activities (employment, chores, social life) Managing emotional changes (anger, uncertainty about the future, changed expectations and goals, and depression) It means having a combination of … SKILLS, SUPPORT, PRACTICE and CONFIDENCE

Chronic Care Model Community Health System Health Care Organization Resources and Policies Self. Management Chronic Care Model Community Health System Health Care Organization Resources and Policies Self. Management Support Informed, Activated Patient Delivery System Design Productive Interactions Decision Support Clinical Information Systems Prepared, Proactive Practice Team Improved Outcomes

Self-Management in CCM ASSESS : Beliefs, Behavior & Knowledge ARRANGE : Specify plan for Self-Management in CCM ASSESS : Beliefs, Behavior & Knowledge ARRANGE : Specify plan for follow-up (e. g. , visits, phone calls, mailed Personal Action Plan reminders 1. 2. 3. 4. ADVISE : Provide specific Information about health risks and benefits of change List specific goals in behavioral terms List barriers and strategies to address barriers Specify Follow-up Plan Share plan with practice team and patient’s social support ASSIST : Identify personal barriers, strategies, problem-solving techniques and social/environmental support Glasgow RE, et al (2002) Ann Beh Med 24(2): 80 -87 AGREE: Collaboratively set goals based on patient’s interest and confidence in their ability to change the behavior

CHRONIC DISEASE SELFMANAGEMENT PROGRAM (CDSMP) …THE STANFORD MODEL n Developed by Stanford University’s patient CHRONIC DISEASE SELFMANAGEMENT PROGRAM (CDSMP) …THE STANFORD MODEL n Developed by Stanford University’s patient education program n Structured w/~15 participants in a six-week series of workshops Participative instruction with peer support n Designed to enhance medical treatment n Outcome-driven: impacts show potential for reduced or avoided costs n Evidence-based: a tested model (intervention) that has demonstrated results n

STANFORD’S CDSMP IS EVIDENCE-BASED n Found to truly benefit targeted populations. n Demonstrated it STANFORD’S CDSMP IS EVIDENCE-BASED n Found to truly benefit targeted populations. n Demonstrated it does not cause harm. n Demonstrated it does not waste resources. National Council on Aging, https: //www. ncoa. org/wpcontent/uploads/cha_tools_checklists. pdf

THE STANFORD CDSMP MODEL WHY THESE TECHNIQUES WORK… n n n Peer educators Constant THE STANFORD CDSMP MODEL WHY THESE TECHNIQUES WORK… n n n Peer educators Constant modeling Active problem-solving Formal brainstorming Goal-setting Action planning National council on Aging, http: //sohealthyoregon. org/wpcontent/uploads/2016/02/Chronic-Disease-presentation. Eugene 081. pdf

CDSMP CONTENT Content/Week Overview of self-management and chronic health conditions 2 3 4 5 CDSMP CONTENT Content/Week Overview of self-management and chronic health conditions 2 3 4 5 6 P P P Feedback / Problem solving P P P P P Anger / Fear / Frustration Fitness / Exercise P P P Better breathing Fatigue P P P Nutrition Advance directives Communication P P P Medications Making treatment decisions Depression P P P Informing the healthcare team Working with your healthcare professional Future plans P P P Making an action plan Relaxation / Cognitive symptom management 1 P

PARTICIPANT’S LEARN HOW TO MANAGE THE SYMPTOM CYCLE Disease Fatigue Tense Muscles VICIOUS CYCLE PARTICIPANT’S LEARN HOW TO MANAGE THE SYMPTOM CYCLE Disease Fatigue Tense Muscles VICIOUS CYCLE Depression Stress/Anxiety Anger/Frustration/Fear

PARTICIPANT’S LEARN AND PRACTICE ACTION PLANNING Something YOU want to do Reasonable Behavior-specific Answer PARTICIPANT’S LEARN AND PRACTICE ACTION PLANNING Something YOU want to do Reasonable Behavior-specific Answer the questions: What? How much? When? How often? § Confidence level of 7 or more § §

THE STANFORD MODEL: CONTENT… “MEETS THE TEST OF COMMON SENSE” n n n Techniques THE STANFORD MODEL: CONTENT… “MEETS THE TEST OF COMMON SENSE” n n n Techniques to deal with frustration, fatigue, pain, and isolation. Exercises/activities for maintaining and improving strength, flexibility, and endurance. Medication management. Approaches for improving communication with friends, family and health professionals. Nutrition information. Treatment evaluation information.

THE STANFORD MODEL: IMPACT All studies looked at behavior, health status and utilization. Findings THE STANFORD MODEL: IMPACT All studies looked at behavior, health status and utilization. Findings included: n n n Improved self-efficacy Reduced use of doctors, hospital emergency rooms Improvements in health status - identified by BOTH the participant and the health provider Ahn, S. , Basu, R. , Smith, M. L. , Jiang, L. , Lorig, K. , Whitelaw, N. , & Ory, M. G. (2013). The impact of chronic disease self-management programs: healthcare savings through a communitybased intervention. BMC Public Health, 13, 1141. http: //doi. org/10. 1186/1471 -2458 -13 -1141

IMPACT (CONTINUED)… Improved quality of life n Specific improvements in healthful behaviors n Improvement IMPACT (CONTINUED)… Improved quality of life n Specific improvements in healthful behaviors n Improvement in overall health status n Decreased hospital stays: . 49 days, per patient, over a two year time period n Decreased physician/emergency room use: 2. 5 fewer visits to the emergency room and to physicians, per patient, over a two year time period n Stanford University Patient Education Center, http: //patienteducation. stanford. edu/

SPECIFIC HEALTH-RELATED IMPACTS… Increased physical activity n Cognitive symptom management n Improved communication with SPECIFIC HEALTH-RELATED IMPACTS… Increased physical activity n Cognitive symptom management n Improved communication with physicians n Better self-reported general health n Improved attitude n Less health distress n Less fatigue n Reduced disability n Fewer social/role limitations n Stanford University Patent Education Center; published articles 1997 -2003 (Lorig, K)

TRAIN THE TRAINER MODEL q Group Leaders Facilitate community workshops for people with chronic TRAIN THE TRAINER MODEL q Group Leaders Facilitate community workshops for people with chronic diseases q Master Trainers In addition to what Leaders do, Master Trainers train Leaders q T-Trainers In addition to what Master Trainers do, TTrainers train Master Trainers

CREATING AN EFFECTIVE CHRONIC DISEASE SELF-MANAGEMENT SYSTEM LOCALLY - KEY INGREDIENTS n n n CREATING AN EFFECTIVE CHRONIC DISEASE SELF-MANAGEMENT SYSTEM LOCALLY - KEY INGREDIENTS n n n Infrastructure Community networks Partnerships Financial support Sustained marketing On-going recruitment Challenges and Successes in Implementing the Chronic Disease Self. Management Program, National Council On Aging, http: //www. healthyagingprograms. org/resources/CDSMPFinal. Report. pdf

COMMUNITY HEALTH WORKER PROGRAM Dual certification as a CHW and a Stanford Chronic Disease COMMUNITY HEALTH WORKER PROGRAM Dual certification as a CHW and a Stanford Chronic Disease Self Management Group Leader In collaboration with Friendly Inn Settlement House, Sisters of Charity Foundation and Fairhill Partners First Class started January, 2016

STANFORD PROGRAMS q Chronic Disease Self-Management Program (CDSMP) Tomando Control de su Salud (Tomando) STANFORD PROGRAMS q Chronic Disease Self-Management Program (CDSMP) Tomando Control de su Salud (Tomando) Chronic Pain Self-Management Program (CPSMP) Cancer: Thriving and Surviving (CTS) Diabetes Self-Management Program (DSMP) Programa de Manejo Personal de la Diabetes (Manejo) Arthritis Self-Management Program (ASMP) Positive Self-Management (PSMP) patienteducation. stanford. edu, October, 2015

COMMUNITY HEALTH WORKER ROLE Educational Advocacy Navigational Referral Clerical Community COMMUNITY HEALTH WORKER ROLE Educational Advocacy Navigational Referral Clerical Community

SUMMARY Chronic Disease Self-Management is: n n n Managing the work of dealing with SUMMARY Chronic Disease Self-Management is: n n n Managing the work of dealing with a chronic disease and/or multiple disease conditions. Managing the work of dealing with daily activities in light of debilitation and disability. Managing emotional changes resulting from or exacerbated by the disease conditions.

ONCE A CHRONIC DISEASE IS PRESENT, ONE CANNOT MANAGE, THE ONLY QUESTION IS “HOW. ONCE A CHRONIC DISEASE IS PRESENT, ONE CANNOT MANAGE, THE ONLY QUESTION IS “HOW. ” Stanford University Patient Education Center, http: //patienteducation. stanford. e du/, Lorig, 2003.

FOR FURTHER INFORMATION Joan Thoman, Ph. D, RN, CNS, CDE j. thoman@csuohio. edu 216 FOR FURTHER INFORMATION Joan Thoman, Ph. D, RN, CNS, CDE j. [email protected] edu 216 -687 -3518 Pam Rutar, Ed. D, RN, CNE p. [email protected] edu 216 -875 -9672 Additional information & results of studies: Stanford University Patient Education Center, http: //patienteducation. stanford. edu/

QUESTIONS? ? QUESTIONS? ?