A Forum on Disease Management Sustaining the Shift Catalyzing the Change Singapore, November 9 10, 2007

1. A Forum on Disease ManagementSustaining the Shift & Catalyzing the ChangeSingapore, November 9 & 10, 2007 The Global Self-Management Movement: Where is this bringing us? Patrick McGowan, PhD University of Victoria British Columbia, Canada

5. SM Precipitating Factors Emerging prevalence of chronic conditions Nature of chronic conditions Aging population Burden on individuals and families Current health care system not sustainable Consumerism Costs through illness and disability

15. Role of Health Care Providers Self-management support is what health caregivers do to assist and encourage patients to become good self-managers. U.S. Institute of Medicine definition: �the systematic provision of education and supportive interventions to increase patients� skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem solving support.� IOM. Priority Areas for National Action: Transforming Health Care Quality. Washington DC: National Academies Press, 2003, p 52.

19. Delivery of Self-Management In groups led by health professionals and lay persons By health professionals in clinical practice Interactive technology Over the telephone

20. Group Self-Management Programs Programs have multiple interventions Have not undergone rigorous evaluation Lack of theoretical base External validity concerns Result: No one universally accepted �gold standard� group program

46. Expert Patient Programme The trial shows that a lay-led self-care group support programme improves patient self-efficacy and self-reported energy Although it does not have a significant effect on routine health service utilization over 6 months, overall it is associated with improvements in health related quality of life at no increased cost, and is likely to be cost effective. The programme may be a useful addition to current provision for long-term conditions. Kennedy et al., 2007

47. Effectiveness Small to moderate effect sizes. http://patienteducation.stanford.edu/programs/cdsmp.html

48. Self-Management Delivered by Health Professionals The Flinder�s Model Motivational Interviewing The 5A�s Planned Visits

52. Motivational Interviewing Motivational interviewing is a directive, client- centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. (Rollnick & Miller, 1995)

53. a hehavioural counselling approach originated with alcohol-addiction steps involve: assessing patients� readiness to change (based on importance and confidence), using interview techniques to help patients increase their willingness to change, and if motivated, engaging patients in goal setting Few controlled studies evaluating efficacy of MI in health problems (Britt et al, 2004; Burke et al, 2003) Effectiveness of MI in enhancing physical activity and managing chronic illness inconclusive at this time (Bodenheimer & Grumbach, 2007)

54. The 5 A�s The �5As� model of behavior change counseling is an evidence-based approach appropriate for a broad range of different behaviors and health conditions, and is feasible to apply in primary care. (Fiore et al., 2000; Glasgow et al., 2001a; Glasgow et al., 2002; Serdula et al., 2003; Glasgow et al., 2004b; Goldstein et al., 2004; The Quality Indicator Study Group, 1995).

55. The 5A�s are as follows: assessing patient level of behavior, beliefs and motivation; advising the patient based upon personal health risks; agreeing with the patient on a realistic set of goals; assisting to anticipate barriers and develop a specific action plan; and arranging follow-up support (Moen et al., 1999; Glasgow et al., 2002; Berwick, 2003; Glasgow et al., 2003).

64. Where is this bringing us? A 70 year-old male with several chronic diseases (e.g., diabetes, heart failure, myocardial infarction, hypertension and osteoporosis), and non-specific health conditions of pain, impaired mobility, and disordered sleep. Consequence: Plethora of disease management guidelines; up to 15 prescription medications.

65. A promising approach to address the difficulties associated with co-morbidities may be the development of an �Integrated, Individually Tailored� model of care which incorporates the strategies and supports of self-management.

66. Essential Elements of Self-Management Both people are Experts Two-way information exchange Both state preferences Consensus to decide treatment Collaborative relationship Environment

67. A Choice of Paradigms Disease-Oriented Model Versus Integrated, Individually Tailored Model (Tinetti & Fried, 2004)

68. Clinical Decision Making Clinical decision making is focused primarily on the diagnosis, prevention , treatment of individual diseases. Clinical decision making is focused primarily on the priorities and preferences of individual patients.

69. Cause Discrete pathology is believed to cause disease; psychological, social, cultural, environmental and other factors are secondary factors, not primarily determinants of disease. Health conditions are believed to result from the complex interplay of genetic, environmental, psychological, social, and other factors.

70. Treatment Treatment is targeted at the pathophysiologic mechanisms thought to cause the disease(s). Treatment is targeted at the modifiable factors contributing to the health conditions impeding the patient�s health goals.

71. Symptoms Symptoms and impairments are best addressed by diagnosing and treating �causative� factors. Symptoms and impairments are the primary foci of treatment even if they cannot be ascribed to a disease cause.

72. Clinical Outcomes Relevant clinical outcomes are determined by the disease(s). Relevant clinical outcomes are determined by individual patient preference.

73. Survival Survival is the usual primary focus of disease prevention and treatment. Survival is one of several competing goals.