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