Group Medical Visits Health Literacy Patient Self-Management

1. Group Medical Visits Health LiteracyPatient Self-Management Learning Session 1 <To be run in combination with GMV content>

2. <Insert GMV slides here>

3. Stepped Care for Self-management Support Expert Techniques Advanced Techniques (MI, PST, Care Mgr, etc.) Self-management Support Basics: Goal Setting, Action Planning, Problem solving, Follow up Patient Role in Self-management Cultural Humility Health Literacy

4. Health Literacy 4

5. Health Literacy is: “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (I.O.M, 2004)

6. But there is another important component: “The ability of professionals and institutions to communicate effectively so that community members can make informed decisions and take appropriate actions to protect and promote their health.” adapted from Rootman and Gordon-El-Bihbety, 2008 and Health and Literacy Partnerships, Focus on Basics, World Education, Vol. 9, Issue B, September, 2008.

7. Why should you care about health literacy? • Affects large numbers of patients • Contributes to improved health outcomes • Decreases incidence of chronic disease • Decreases health care costs Dr. Irving Rootman

8. The Patient’s Perspective… I had a pain in my stomach. The doctor did some tests. He said I had a blgrkrdmr. I didn’t understand the word he used. I asked him, “What is a blgrkrdmr?” He said it was a grtiytuhr of the ptorjfmbtgbba. I still didn’t understand. He asked me, “Do you understand?” I just said yes. Literacy Manitoba

9. Health Literacy Video Clip • Tiny.cc/k5h8d

10. Health Literacy Tools • Health literacy office practice survey • Teach Back (video) • Plain Language check list • Brown Bag medication review

11. Easy to Use Patient Survey to Determine Patient Understanding

12. Plain Language-Checklist Literacy Partners of Manitoba

13. Brown Bag Medication Review • All meds, herbals, traditionals, OTC to visit in a bag • Ask • How do you take this medication? • What is it for? • Check refill dates • Do you use any aides? (mediset, blisterpack, etc.) Ohio Patient Safety Institute

14. Try Teach Back • After information or instruction has been given, say: • “Could you tell me back what we just talked about to see if I was able to make it clear?” • “After you leave this appointment a family member or friend might ask you what happened today. What are you going to tell them about what you are going to do?” • If teaching a skill, use “Show me.” • “Show me how you are going to do this at home so I know if I was clear.” American Medical Association

15. Table Discussions: Health Literacy tools • At your tables decide how you will use the tools. • Reflective questions: • Who will do what? When? and How? • Make a plan • Report back about each tool

16. How Will I Recognize People Who Have Literacy Problems? “Treat every person as if they might have health literacy problems.” Dr. Darren DeWalt

17. Health Literacy Universal Precautions Toolkit http://www.ahrq.gov/qual/literacy/ Agency for Healthcare Research and Quality

18. For more information...... • Additional resources can be found at www.gpscbc.ca/psp/practice-support-program

19. Patient Self-Management

20. What is Self-Management? Self-management relates to the tasks that an individual must undertake to live well with one or more chronic conditions. These tasks include gaining confidence to deal with medical management, role management, and emotional management. Adams, Greiner, and Corrigan (2004)

21. Self-Management Key Concepts: • Partner with patients to make sure they understand the central role as a partner in their own care • Make sure patients have and UNDERSTAND their own health information • Find out what it is that the PATIENT wants to change • Help patients build the confidence to deal with their conditions the other 364.5 days of the year (when they’re not in your office) • Follow-up with patients to make sure they’re on track – see if they’re running into barriers, provide suggestions

22. Literature – Kate Lorig Results show: • Self-management improves elements of health status • ED/outpatient visits and health distress were reduced • Self-efficacy improved Kate Lorig, et al., 2001. Chronic disease self-management program: 2-year health status and health care utilization outcomes .

23. What is Self-Management Support? Self-management support is defined as the systematic provision of education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems, including regular assessment or progress and problems, goal setting, and problem-solving support. Adams et. Al. (2004)

24. Self-Management Support Key Concepts: • Two-way communication process that encourages interaction between the patient and members of the health care team • Self-management support is not the same as patient education. • Helps the patient learn how to adopt healthy behaviours and problem-solve. • Overall goal of self-management support is to increase the patient’s self-confidence in their ability to change their own behaviours.

25. What is an informed, activated patient? An informed, activated patient is able to: • Identify personal priorities, values, problems, strengths and supports • Accept some responsibility for making choices • Establish personal goals • Identify possible actions/choices • Stay in touch and ask for help when needed

26. Patient Self-Management Video

27. Motivational Interviewing and Brief Action Planning

28. What is Motivational Interviewing? “a person-centered counseling method for addressing the common problem of ambivalence about change.” William Miller, Stockholm International MI conference, 2010

29. Spirit of Motivational Interviewing • Collaboration Health care professional and patient are equal • Evocation Ideas for change come from the patient • Respect for Autonomy Patient has the right to change or not • Compassion Interaction is grounded in caring Dr Bill Miller, Nov 2010 updated from Miller & Rollnick, Motivational Interviewing, 2002

30. Brief Action Planning

31. 9 Core Principles & the Evidence Base • Individual-centered • Collaborative • Respects right of not changing • SMART • Commitment statement • Behavioral menu • Measure confidence • Follow-up • Occurs in every interaction

32. Core Principle #1 Action planning is individual-centered, i.e. what the person wants, not what he/she is told to do. “Spirit” of Motivational Interviewing: Evocation Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, Guilford Press, 2002

33. Core Principle #2 Action planning is collaborative. “Spirit” of Motivational Interviewing: Collaboration Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, Guilford Press, 2002; Heisler et al, JGIM, 2002

34. Core Principle #3 Action planning respects the right of the individual to change or not to change. “Spirit” of Motivational Interviewing: Autonomy Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, Guilford Press, 2002

35. Core Principle #4 Action planning is ‘SMART’ Specific Measurable Achievable Relevant Timed Based on the work of Locke (1968) and Locke & Latham (1990, 2002); Bodenheimer, 2009

36. Core Principle #5 After the plan has been formulated, the clinician/coach elicits a final “commitment statement.” Strength of the commitment statement predicts success on action plan. (Aharonovich, 2008; Amrhein, 2003)

37. Core Principle #6 Offer a behavioral menu when needed or requested. “Spirit” of Motivational Interviewing: Autonomy Rollnick, Miller & Butler, 2008. Motivational Interviewing in Health Care

38. Behavioral Menu “Here are the things we have talked about. Which one is most important to work on right now?” (write others here) Smoking Exercise Avoiding triggers Taking meds Adapted from Stott et al, Family Practice 1995; Rollnick et al, 1999, 2010

39. Behavioral Menu Examples Gerald L. Ignace Indian Health Center, Milwaukee, WI

40. Core Principle #7 Confidence levels are evaluated and problem-solving utilized for confidence levels less than 7. Higher self-efficacy is associated with healthier behaviors and better outcomes. (Bandura, 1983; Lorig et al, Med Care 2001; Bodenheimer review, CHCF 2005; Bodenheimer, Pt Ed Couns 2009.)

41. Core Principle #8 Action planning includes arranging follow-up or other accountability. (Resnicow, 2002; multiple condition specific studies)

42. Core Principle #9 Action planning is considered in all chronic, planned, or preventive visits. Non-clinical staff are 9 times more likely to engage in goal-setting than clinical staff. Technology (such as howsyourhealth.org) is an option (Bodenheimer, 2009)

43. Brief Action Planning (B.A.P.) “Is there anything you would like to do for your health In the next week or two?” SMART Behavioral Contracting Elicitation of Commitment Statement “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” If Confidence >7 “When would you like to check in with me to review how you are doing with your plan?” Steven Cole, et. al.

44. Brief Action Planning (B.A.P.) Behavioral Menu “Is there anything you would like to do for your health In the next week or two?” Behavioral Menu SMART Behavioral Contracting Elicitation of Commitment Statement “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” If Confidence <7, “Problem Solve” Barriers “When would you like to check in with me to review how you are doing with your plan?” Steven Cole, et. al.

45. Problem solving 1. Identify the problem. 2. List all possible solutions. 3. Pick one. 4. Try it for 2 weeks. 5. If it doesn't’t work, try another. 6. If that doesn't’t work, find a resource for ideas. 7. If that doesn't’t work, accept that the problem may not be solvable now. Source: Lorig et al, 2001

46. Table Discussions for Self-Management • At your tables decide how you will use the tool. • Reflective questions: • Who will do what? When? and How? • Once you have your plan – try it in your small group • Report back to the bigger group

47. Planning for Improvement

48. The Fundamental Questionsfor Improvement 1. What are we trying to accomplish? (Aim) 2. How will we know that a change is an improvement? (Measures) 3. What changes can we make that willresult in an improvement? (Tests of change)

49. Act Plan Study Do Model for Improvement What are we trying to AIM accomplish? How will we know that a MEASURES change is an improvement? What changes can we make that TESTS OF CHANGE will result in improvement?

50. Example Practice Aim For This Module We want to have 80% of or patients living with chronic disease with document self management goals, within 12 months. OR We want to have 70% of our patients reporting they have a confidence level of >7 out of 10 that they will be able to achieve their self management goal, within 12 months