how chronic care self-management can benefit your patients and your practice healthier living
TRANSCRIPT
How Chronic Care Self-Management Can Benefit Your Patients and Your Practice
Healthier Living
Today’s presenters:
Devin Detwiler-Cunningham, Telligen
Connie Young, Colo. Dept. of Human Services
Jeffrey Kulp, M.D., AgeWell Medical Associates, Colorado Springs
Eileen Gallagher, M.D., Boulder Medical Center
Anju Visweswaraiah, M.D., University of Colorado Health Family Medicine, Westminster
Healthier Living
Overview: Healthier Living /Chronic Disease Self-Management Program
Self-management defined:
self - man· age· ment noun
management of or by oneself; the taking of responsibility for one's own behavior and well-being
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Overview: Healthier Living /Chronic Disease Self-Management Program
The basics: Six-week workshop that empowers participants
to make better choices, set goals and take action to improve their health
Evidence-based program developed by Stanford University
Requires 2 – 2 ½ hours per week for six weeks
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Overview: Healthier Living /Chronic Disease Self-Management Program
The basics (continued): Informal and interactive, not lecture Encourages mutual support among participants Supports weekly action planning (setting and
reaching realistic goals) Led by lay leaders
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Overview: Healthier Living /Chronic Disease Self-Management Program
Topics: Nutrition
Exercise
Medication management
Relaxation, emotion management and mindfulness
Pain management
Communication
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Overview: Healthier Living /Chronic Disease Self-Management Program
Two settings: In-person Online
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Overview: Healthier Living /Chronic Disease Self-Management Program
Stanford’s participant surveys have reported significant improvement in:
Pain levels
Physical activity
Medication compliance
Physician communication
3 percent reduction in hospitalizations at 6 months
5 percent reduction in ER visits at both 6 and 12 months
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Overview: Healthier Living /Chronic Disease Self-Management Program
Class types: Broad-based class for all chronic conditions Diabetes-specific (These are diabetes self-
management workshops, not medically oriented diabetes education)
Cancer-specific Chronic pain-specific Spanish language
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Patient Self-Management at AgeWell
Jeffrey T. Kulp, M.D., AgeWell Medical Associates, Colorado Springs
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Patient Self-Management at AgeWell
Patient Self-Management at AgeWell
Unfamiliar concept to older providers (as well as older patients)
Patient empowerment (“This is YOUR health condition” vs “Do-as-I-say”). Adults don’t like being told what to do!
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Patient Self-Management at AgeWell
Bi-directional communication Shared: Problem identification and
problem solving Goal-setting Prioritizing Identifying barriers
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Patient Self-Management at AgeWell
AgeWell was introduced through Patient-Centered Medical Home (PCMH) effort -- Self-care support is key to PCMH recognition
Consortium for Older Adult Wellness (COAW) / Healthier Living Colorado (Stanford curriculum) offered a “package” of self-management support that helped us fulfill the PCMH requirement
Providers/staff recommended program to all patients (they all have at least one chronic condition!)
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Patient Self-Management at AgeWell
Patient response has been enthusiastic Results:
Older adults (and providers) can do this! Encounters tend to take longer – patients
come prepared with data, lists, questions (and teaching and reinforcing self-management) is time consuming
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Patient Self-Management at AgeWell
Results (continued): Patient follow-through is significantly higher
when goal setting is shared Outcomes are measurably better For self-management to be sustained,
patients need positive feedback, continual encouragement, new goals
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Patient Self-Management at AgeWell
Opportunities: Self-management instruction and support
work best when delivered by inter-disciplinary care team
Non-compliance (adherence) takes on a different meaning
The “engaged, activated patient” is the future of health care
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Description: Healthier Living /Chronic Disease Self-Management Program
Eileen Gallagher, M.D., Boulder Medical Center
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Description: Healthier Living /Chronic Disease Self-Management Program
Value of group visits: Shared ideas Support Community Peer group Friendships
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Description: Healthier Living /Chronic Disease Self-Management Program
Common management styles among patients: Suffer with illness Only take medications Undergo all the best treatments Be proactive in day-to-day management
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Description: Healthier Living /Chronic Disease Self-Management Program
Self-management tasks:
Take care of the illness Carry out normal activities Manage emotional challenges
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Description: Healthier Living /Chronic Disease Self-Management Program
Teaches people a healthier way to live with self-management/chronic care model:
Overcome physical and emotional barriers Achieve increased physical capacity and
pleasure from life Learn ideas and tips to make life easier Empower participants to “positively manage”
their illness, not let their illness manage them
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Description: Healthier Living /Chronic Disease Self-Management Program
Patient decision-making:
Ultimately, self-management and the chronic care model are about patients making a choice about managing their disease or letting it manage them.
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Description: Healthier Living /Chronic Disease Self-Management Program
Patients use new tools to: Decide what they want to accomplish Look for alternative ways to accomplish the goals Start with short-term action plan or agreement Carry out the action plan Assess the results, making changes as needed Reward for achievement
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Outreach, patient recruitment and program implementation
Anju Visweswaraiah, M.D., University of Colorado Health Family Medicine, Westminster
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Outreach and patient recruitment
Using “whole-clinic” approach to identify patients for self-management support groups:
Approach developed by a medical assistant Training programs for coaches in collaboration
with clinic administration Patient outreach and recruitment by entire
clinic – identified by provider, MA, nurses
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Outreach and patient recruitment
Conversations during patient visits Medical assistant phone calls to patients
identified on registries Nurse and SW outreach to high-risk patients
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Patient satisfaction with Healthier Living workshops
Patients report:
Better understanding of their health and health conditions
Realizing their role in disease management as central to care
More self-aware re: identifying personal habits and barriers to disease management
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Patient satisfaction with Healthier Living workshops
Camaraderie with clinic staff who lead the course
Better ability to communicate with providers about needs and barriers
Patient successes and testimonials
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Implementing and sustaining the Healthier Living program
Implementation logistics Funding Using staff as leaders
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Next steps: Options for implementing Healthier Living program for your patients
In-person classes: Check for available classes on:
www.selfmanagementcolorado.org (classes can be requested in additional locations – see link at bottom of web page).
Contact the local organization providing Healthier Living workshops in your area (see slides 35-38 In this PowerPoint). Some classes may be offered at no charge; others may be arranged through contracts.
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Next steps: Options for implementing Healthier Living program for your patients
Contact the Consortium for Older Adult Wellness (COAW) regarding consultation and possible start-up funds to implement the program within your clinic/practice.
Consider having some of your staff or volunteers be trained as class leaders (Free leader training is sometimes offered by Healthier Living program license holders. Go to: http://selfmanagementcolorado.org/Partner.aspx ; click on Classes/Choose a Leader Training)
Funding options include charging participants a registration fee; seeking support from local organizations, businesses or foundations for space, materials, grants; and applying Medicare’s Chronic Care Management code for time spent coordinating these services for patients.
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Next steps: Options for implementing Healthier Living program for your patients
Online classes: Refer appropriate patients to an online class. (A
limited number of spots currently are available at no charge on a first-come, first-served basis. Patients must be comfortable with computers, have Internet access and be motivated to work independently.)
Patients can enroll at: https://shared.selfmanage.org/shared/colorado/
Consider joining with other clinics to purchase additional online classes in the future.
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Contacts:
Webinar presenters: Jeffrey Kulp, MD, [email protected]
Anju Visweswaraiah, MD, [email protected]
Connie Young, Colorado Department of Human Services, 303-866-2695, [email protected]
Devin Detwiler-Cunningham, Telligen, 303-875-9131, [email protected]
Out-of-state inquiries:
National Council on Aging: Cora Plass, Chronic Disease Self-Management Education National Resource Center, [email protected]
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Contacts (continued): Organizations providing Healthier Living workshops in chronic disease self-management
American Diabetes Association (located in Denver)Offers Spanish-language chronic disease and diabetes self-management workshops; serves adults 18 years and older
Contact: Monica Chavez-Singleton, [email protected], 720-855-1102, ext. 7032
Boulder County Area Agency on Aging (located in Boulder)Offers chronic disease and diabetes self-management workshops; can arrange workshops for adults 18 years and older
Contact: Melissa Pruitt, [email protected], 303-441-3599
Center for African American Health (located in Denver)Offers diabetes self-management workshops only; serves adults 18 years and older
Contact: Glenda Mitchell, [email protected], 303-355-3423, ext. 117
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Contacts (continued): Organizations providing Healthier Living workshops in chronic disease self-management
Consortium for Older Adult Wellness (located in Denver)Offers chronic disease (in English and Spanish), diabetes (in English and Spanish), chronic pain and cancer self-management workshops, as well as workshops for individuals with neurological conditions; serves adults 18 years and older in various locations statewide
Contact: Maripat Gallas, [email protected], 303-984-1845
South-Central Colorado Seniors, Inc. (located in Alamosa/San Luis Valley) Offers chronic disease and diabetes self-management workshops; serves adults 60 years and older
Contact: Monica Wolfe, [email protected], 719-589-4511
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Contacts (continued): Organizations providing Healthier Living workshops in chronic disease self-management Southeast Colorado Area Health Education Center (located in Pueblo) Offers both chronic disease and diabetes self-management workshops; serves adults 18 years and older
Contacts: Crystal Rider, [email protected]; Eva Muniz-Valdez, [email protected]; or Shanae Gutierrez, [email protected], main number: 719-544-7833
Telligen (Medicare quality improvement organization, located in Denver)Offers diabetes self-management workshops only; serves Medicare, Medicare-Medicaid and Medicare Advantage members statewide
Contact: Meredith Koob, [email protected], 303-260-9346
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Contacts (continued): Organizations providing Healthier Living workshops in chronic disease self-management
University of Colorado Health Northern Region (located in Fort Collins)Offers chronic disease, diabetes, chronic pain and cancer self-management workshops; serves adults 18 years and older
Contact: Ellen Pihlstrom, [email protected], 970-495-7509
Weld County Area Agency on Aging (located in Greeley)Offers chronic disease (in English and Spanish) and diabetes self-management workshops; can arrange workshops for adults 18 years and older; workshops are free for individuals age 60 and over and $25 for Individuals under 60
Contact: Whitney Janzen-Pankratz, [email protected], 970-346-6950, ext. 6117
Healthier Living
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• Licensed provider of Stanford University Self-Management programs since 2007
• One of eight organizations to receive a CDSME grant from the Administration for Community Living
• Grant: Implement Pathways to Health system – links Take Charge of Your Health with clinical settings
• Program is a 6 week workshop taught by 2 certified facilitators
Illinois Resources – Age Options
Connecting Older Adults with Community-based Resources and Options
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• Pathways integrates Take Charge with clinical health care via a referral process
• Providers identify patients with 2 or more chronic conditions for referral to Pathways
• Participating clinics receive:– Patient engagement packets– Health confidence materials– Referral protocol– Provider feedback process– Evaluation forms
Age Options (Continued)
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• If interested in participating with Pathways to health, contact:
Maria D. Oquendo-ScharneckHealth and Diversity Coordinator
Age Options (Continued)