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Self-Management in pcmh

Self-Management in pcmh. Promoting empowerment in chronic illness. Patient self-management Definitions. Definition #1 – Self-management is how patient manages aspects of their chronic disease (s).

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Self-Management in pcmh

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  1. Self-Management in pcmh Promoting empowerment in chronic illness

  2. Patient self-management Definitions • Definition #1 – Self-management is how patient manages aspects of their chronic disease (s). • Definition # 2 – Learning and practicing the skills necessary to carry on an active and emotionally satisfying life in the face of chronic illness.

  3. Self-management tasks • Managing the elements of their chronic disease: medication adherence, diet, exercise, treatments, self-testing and record keeping. • Maintaining their roles and functions in life. • Dealing with the emotional demands of their lives.

  4. The case for self-management support • The role of the PCMH team is to provide motivating support and education needed by chronically ill patient needs . This includes • Timely, accurate, understandable information • Involvement in collaborative decision making • Goal setting and problem solving • Help managing psychosocial needs

  5. NCQA 2011 Certification Guidelines for PCMH • PCMH 4A: Support Self-Care Process- MUST PASS • Requires practice to develop and document self-management plans/goals (CRITICAL FACTOR) in at least 50% of patients/families. • Documents self-management abilities for at least 50% of patients/families. • Provides self-management tools to record self-care results for at least 50% percent of patients/families. • Counsels at least 50% of patients/families to adopt healthy behaviors. • Provides educational resources or refers at least 50 % of patients/families to assist in self-management. • Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients/families.

  6. Patient teaching vs. Self-management support • Patient EducationSelf-Management Support • Information and skills are taught Skills to solve patient-identified problems are taught • Usually disease specific Assumes that confidence yields better outcomes • Goal is compliance Goal is increased self confidence • Healthcare professionals are the teacher Teachers can be professionals or peers Gives information Provides tools Gets patient involved in day-to-day decisions

  7. Stages of change model • Development of self-management skills means change to the patient’s life. • Recognizing where patient is on the continuum of change is critical to effective support • The stages of changes as 1st proposed by Prochaska and DiClemente in 1983: • Precontemplation (not ready to change) • Contemplation (thinking of changing) • Preparation (ready to change) • Action (Making the change) • Maintenance (Staying on track) **Added to the theory since then, is # 6 Relapse (falling of the wagon!)

  8. Other Skills and tools needed • Open-ended and exploratory questioning- frame your communication so a simple “yes, no or I don’t know” are not possible answers. • Reflective listening – encourages patient communication. Patient can’t/won’t talk if staff member is “telling” them what to do. • Depression Assessment – soon to be done practice wide. • Health literacy assessment – Don’t assume people understand what they are told by the PCP or yourself. Use the Teach-Back technique. • Engaging family members, caregivers and other signifigant social supports – should be with patient’s agreement. Be careful of self-appointed family members who want to become the “diabetic police”! • Goal setting, prioritizing and planning of care- use of motivational interviewing technique's and work toward the patient’s strengths and health belief system. • Effective team membership and participation- required by NCQA. Be proactive. • Document all of the above in the EHR

  9. self- Management and goal setting • Step 1 - Problem identification • Impact of illness • Identify specific symptoms and signs of illness • Identify factors leading to preservation and promotion of a healthy lifestyle Step 2 – Identifying barriers to self-management • Motivation • Knowledge of condition • Knowledge of symptom management • Comorbidities • Health beliefs • Self efficacy • Social context

  10. Self Management and goal setting • Step 3 – Planning (setting of goals) – SMART • Specific • Measurable • Achievable • Realistic • Timely • Goals should focus on medication adherence, smoking cessation, self-monitoring • (i.e. glucose logs), diet, exercise, foot care, managing comorbidities and continuing • to live a participative lifestyle. Once goals are set , patient should get copy and they • should be shared with team via EHR.

  11. Brief Negotiation Roadmap • Developed in 2002 by Kaiser Permanente and two psychologists, Miller and Rollnick • Needed a tool for practitioners to use in day-to-day patient interactions to promote healthy behavior changes. • Systematic way to efficiently and effectively discuss these changes with the patient/family. • Basic tenet of brief negotiations is that everyone has the potential for positive change. • Structure is a brief collaborative interaction to discuss health care changes.

  12. Further Learning ONline • http://www.kphealtheducation.org/

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