Stanford Self Management Programs: Learning to Live Well

1. Stanford Self Management Programs:Learning to Live Well Mary Hertel, RN EBHP Coordinator/ Trainer, T-Trainer CDSMP, Master Trainer CPSMP Central MN Council on Aging (Area Agency on Aging) Jenny Fransen, RN, Care Coordinator and CDSMP Facilitator at Courage Center Stephanie Foo, MPH, Outcomes and Research Project Specialist at Courage Center Split Rock 2, City Side Tuesday 2:45 pm to 4pm

2. Information to be presented: • Define Evidence Based programs using the Stanford Self Management program as an example • Discuss Research and demonstrated outcomes • How EBP can fit within the patient engagement model, compare/contrast with patient education • Overview of specific EBP’s including Stanford Self-Management programs • Describe how you or your organization can get more involved

3. What is Evidence Based health promotion programming? • Simply put it is: programs based on research.

4. What evidence do we need?

5. Evidence based:

6. Why the interest in Evidence Based Programs?

7. The Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Productive Interactions Patient Centered Timely and Efficient Coordinated Evidence-based and Safe Informed, Empowered Patient and Family Prepared, Proactive Practice Team www.improvingchroniccare.org Improved Outcomes

8. EBPs have Demonstrated Outcomes

9. Consider: “people with chronic conditions rarely spend more than 1% of their life at a healthcare facility. It is the other 99% of one’s life - when an individual is at home - that determines whether they return to full health or not.”

10. Chronically ill patients make many daily health decisions: • Diet, exercise, medication, when to seek medical care • Sometimes make unwise decisions • may not fully understand implications of particular health decision • may lack support to make better choices

11. Can Clients Be Engaged? 23% adopted new health behaviors (but unsure could maintain if stressed) Remaining 77%: • Remain passive recipients (12%) • Lack basic facts to follow treatment recommendations (29%) • Have facts, but no skills, confidence (36%) Hibbard, J. H., Mahoney, E. R., Stock, R., & Tusler, M. (2007). Do increases in patient activation result in improved self-management behaviors? Health Services Research, 42, 1443-1463.

12. How can Evidence Based Programs help?

13. Advantages of Evidence Based Programs: • First, they can significantly improve the health and well-being of older adults in the community. • Second, they can help attract new participants and funders through innovative programming. • Third, they can create powerful partnerships with other organizations, including health care providers Evidence-based programming provides value

14. Evidence Based Programs (using Stanford as example) Stanford University Self Management Programs(in Minnesota): • Chronic Disease Self Management (Living Well with Chronic Conditions) • Chronic Pain Self Management • Diabetic Self Management

15. Self-Management Differs From Patient Education (but we need both) Self-management Patient Education - Change behaviors Information, technical skills Disease–specific knowledge - Use specific tools (e.g., Care Plans, Action Plans) - Manage life with disease • Problem solve and make decisions • Improve clients confidence in abilities to make changes • Increase skills & self-confidence

16. 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.

17. What is the Stanford Chronic Disease Self-Management Program (CDSMP) “Living Well with Chronic Conditions” • Developed by Stanford University’s patient education program • Stanford Programs are licensed • Leader Training 4 days lead by 2 MasterTrainers • Structured 10-15 participants in a six-week workshop series done by 2 certified leaders • Participative instruction with peer support • Designed to enhance medical treatment • Evidence-based: a tested model (intervention) that has demonstrated results

18. CDSMP Techniques • Goal setting and action planning • Feedback/ problem solving • Decision Making • Management tools

19. Living Well With Chronic Conditions Workshops (CDSMP) • • Curriculum including: • Exercise and nutrition • Medication usage • Stress management and managing fatigue • Talking with your doctor or health professional, family and friends • Evaluating treatment choices • Dealing with emotions, frustration and depression • Living Well With Chronic Conditions Workshop

20. Living Well With Chronic Conditions Workshops (CDSMP)

21. Keys to Success • The format addresses specific problems and goals for people with ongoing health problems. It is not a drop-in support group. • The workshops are not prescriptive. Participants choose their own goals and track their own progress toward success. • Pair of trained peer leaders offer guidance and support, but participants find practical solutions individually and together. Living Well With Chronic Conditions Workshop

22. Stanford’s CDSMP is Evidence-based • Found to benefit targeted populations. Including a decrease in health care costs • Demonstrated it does not cause harm. • Demonstrated it does not waste resources. CDSMP can facilitate the Triple Aim Goals

23. Evidence CDSMP participants experienced the following outcomes 6 months after starting the CDSMP program More energy and less fatigue; Decreased disability; Fewer physician visits and hospitalizations. Lorig et al., 1999 • Increased exercise; • Better coping strategies and symptom management; • Better communication with their physicians; • Improvement in their self-rated health, disability, social and role activities, and health distress;

24. Chronic Conditions Reported and compiled by MDH • Arthritis/other 54% • Hypertension 51% • High Chol 36% • Chronic Pain 30% • Diabetes 24% • Heart Disease 22% • Osteoporosis 20% • Cancer 15% • Depression 14% • Lung disease 12% • AMD 9% • Stroke 8% • Asthma 6% • Emphysema or COPD 3% • Parkinson’s Disease 3% • Kidney disease 2% • MS 2% • Other 21%

25. Healthy Living with Courage • CDSMP adapted for people with disabilities • Offered at Courage Center • Rehabilitation and resource center with co-located primary care, psychiatry, and physiatry • Facilitated by registered nurse care coordinator and volunteer

26. The need for a self-management program is great… Persons with disabilities • Likely to have multiple secondary conditions • More likely to be physically inactive • More likely to experience pain • Face greater barriers to accessing timely primary care National Center for Health Statistics, 2011.

27. Healthy Living with Courage Participants • Two six-week sessions since January 2013 • Nine participants in total, five completed the program • 78% male, 67% white • 44% were 51 years of age and over • 67% had public insurance

28. Healthy Living with Courage Participants

29. Adapting CDSMP • Modifications are necessary to make CDSMP disability sensitive • Some additions were made to the lessons and classroom setup • Exercise issues: “Do what you can do.” • Sensitivity to hearing, vision, and cognitive impairments • Larger room, smaller group • Avoid snacks, serve bottled water instead

30. Addressing Barriers • Persons with disabilities face unique barriers that make attending the program more difficult • Barriers to attendance must be addressed • Transportation • Organization • Financial barriers • Need for additional personal assistance

31. Outcomes • Tracked pre-program and post-program scores for three measures • Center for Disease Control’s Healthy Days measure • Patient Activation Measure • PROMIS Depression Measure (Short Form 8a) • Post-program survey on self-reported improvements and satisfaction with program

32. Measures • CDC’s Healthy Days • Assesses perceived sense of well-being over past 30 days • PROMIS Depression • Measures symptoms of depression over past week • Patient Activation Measure (PAM) • Gauges patient’s knowledge, skills, and confidence in managing own health

33. Outcomes Higher Healthy Days and PAM scores indicate improved outcomes. Lower PROMIS depression scores indicate improved outcomes.

34. Patient Activation Measure • A change of one point is associated with • 1.7% decline in hospitalizations • 3.4% gain in A1c testing or LDL testing • 1.8% gain in A1c control

35. Reported Improvements

36. Program Satisfaction

37. In summary… • Improvements in Healthy Days, PROMIS depression, and PAM scores were detected but were not statistically significant • Small sample size • Measurement period • Post-program survey indicates that participants believe the program helped them better manage their stress and health conditions • Realistic expectations • Self-acceptance • Tools for self-care (action plans, relaxation exercises)

38. Facilitator Feedback • Facilitating the program can be demanding • Time commitment • Consciousness and support of clients’ disability needs • But also very rewarding • “Participants have a sense of pride in their accomplishments and want to continue to succeed in making positive changes in their health. I’ve been seeing patients that attended the program more frequently in our clinic since the class ended.” • Facilitators also benefit from the program

39. Chronic Pain Self-Management CPSMP is a 6 week, 2.5 hours per week workshop developed for people who have a primary or secondary diagnosis of chronic pain. Pain is defined as being chronic or long term when it lasts for longer than 3 to 6 months, or beyond the normal healing time of an injury. During this workshop a variety of topics important to those with chronic pain are covered including: goal setting, relaxation, nutrition, medication management, exercise, communication and problem solving Requires 2 Certified trained Leaders Training is either 4 days or 2 days if CDSMP trained

40. Diabetic Self-Management Program DSMP is a 6 week, 2.5 hours per week. This workshop is for people with type 2 diabetes. It teaches the skills needed in the day-to-day management of diabetes and to maintain and/or increase life’s activities. Requires 2 Certified trained Leaders Training is either 4 days or 2 days if CDSMP trained

41. Implementation of CDSMP in Minnesota Current license holders include: • Central MN Council on Aging(Area Agency on Aging) • 5 Area Agencies on Aging covering all of Minnesota • Minnesota Department of Health • Native American Community Clinic: “Living in Balance” • Sanford Health: “Better Choices, Better Health” • Veterans’ Administration Health System

42. Options for Involvement • Offer the program(s) at your clinic/organization with your staff, and/or volunteer peer leaders. Training is available through the Area Agencies on Aging (please see handout) • Offer the program at your clinic/organization in partnership with a community provider • Refer your patients to programs that your organization offers or to community partners; visit www.mnhealthyaging.org for a listing of workshops • or call Senior Linkage Line 1-800-333-2433

43. MN Healthy Aging website

44. Resources • Minnesota Board on Aging: http://www.mnaging.org/ • National Council on Aging (NCOA): http://www.ncoa.org/ • NCOA: Center for Healthy Aging • http://www.ncoa.org/improve-health/center-for-healthy-aging/ • Online Training Modules: • http://www.ncoa.org/improve-health/center-for-healthy-aging/online-training-modules/ • Highest Tier Evidence-Based Health Promotion/Disease Prevention Programs • http://www.ncoa.org/improve-health/center-for-healthy-aging/content-library/Title-IIID-Highest-Tier-Evidence-FINAL.pdf • Stanford Patient Education Research Center: • http://patienteducation.stanford.edu/ • SAMHSA National registry of Evidence Based Programs and Practices: • http://nrepp.samhsa.gov/Index.aspx

45. Questions ? “Those things that we do for ourselves, day-to-day that improve or maintain our health and make us feel better”

46. Contact information: Mary Hertel: RN, T-Trainer CDSMP, Master Trainer CPSMP, DSMP Central MN Council on Aging (Area Agency on Aging) Direct:320-202-6945 Agency: 320-253-9349 Email: mary.hertel@cmcoa.org Jenny Fransen, RN, Care Coordinator and CDSMP Facilitator at Courage Center Jenny.Fransen@couragecenter.org Stephanie Foo, MPH, Outcomes and Research Project Specialist at Courage Center Stephanie.Foo@couragecenter.org