CASE ILLUSTRATION 1 (CONTD.)
Alicia Romero’s nurse practitioner asked her to attend a six-session Spanish language diabetes self-management group at her clinic one evening per week, and provided childcare at the clinic to allow parents to attend. At the first session, the 12 participants in the group talked about their challenges in controlling their diabetes, hypertension, and cholesterol. Senora Romero was inspired that everyone faced the same challenges, and toward the end of the meeting, everyone made an action plan to do something realistic to improve their health. Senora Romero’s action plan was to commit to taking all her medications every day. The group divided into buddies, who call each other twice a week to check on the action plans. Senora Romero’s next HbA1c had gone down from 9.5 to 8.2 and her BP was now controlled. She felt good.
Overall, the success of chronic disease management lies in fostering a patient-centered partnership between the patient and health care team. This is particularly important when caring for patients with behavioral health problems and difficult lives. The ultimate goal of this approach is to empower patients to develop the skills and behaviors that will help them self-manage their diseases to achieve better health outcomes. Several clinical trials and systematic reviews have concluded that collaborative care models in which decisions are made jointly between clinicians and patients are significantly more effective in improving clinical outcomes than care in which clinicians tell patients what to do.
Patient-Centered Care for the Clinician
Patient-centered care is a critical concept for effective management of chronic illnesses. The concept includes engaging patients in care planning as well as giving patients tools, skills, and knowledge. It means the health care team and primary clinician elicit and accept the patient’s beliefs and concerns about illness and teache key information and self-management skills in the context of the patient’s family, community, and culture, taking into consideration individual needs. The patient’s concerns are identified and addressed first (Table 39-1). The team and primary care clinician involve the patient directly in negotiating and implementing the treatment plan, making adjustments and providing options that will meet the patient’s goals. Ask: “What do you want to do this week to improve your health?” Working in collaboration with the patient, the primary care clinician and health care team design a treatment program that fits within the context of the patient’s life (Table 39-2). Potential solutions and feasible options are offered and patients are invited to choose those they are willing to accept and pursue or modify. For example, to reduce high cholesterol levels, patients are asked if they would be willing to eat more healthy foods, do more exercise, or regularly take medications. When patients can choose their treatment program, it is more likely they will implement it. The keyword in this context is “collaboration” to work toward goals that are acceptable to both the care team and the patient. Additionally, primary care practitioners should be aware of patients’ culturally based understanding of the disease and its treatment. Every effort should be made to deliver critical information and self-management instruction in the patient’s native language. A patient-centered partnership means that health care providers collaborate with patients to design a treatment program that takes into consideration the patient’s attitudes, beliefs, lifestyle, and culture to promote positive treatment outcomes (Table 39-3).
Table 39-1.Self-management support. ||Download (.pdf) Table 39-1. Self-management support.
|Self-management support is what providers do to assist and encourage patients to be empowered and able to manage their illness. This paradigm shift requires building a partnership—with shared responsibility for making and implementing health-related decisions—between the provider(s) or care management team and the patient. |
Table 39-2.Lessons learned from dialogue. ||Download (.pdf) Table 39-2. Lessons learned from dialogue.
|• The provider allows the patient to set the agenda. |
|• The provider assesses the patient’s levels of importance and confidence and explores what it would take to improve confidence in behavior change. This information also allows the provider to explore the activities patients are interested in pursuing. |
Table 39-3.Key elements to goal setting/action plans. ||Download (.pdf) Table 39-3. Key elements to goal setting/action plans.
|• Collaborative between patient and provider, using tools of motivational interviewing. |
|• Actions are highly specific. |
Clinician behaviors may contribute to better patient self-management, particularly in subpopulations with specific needs. A survey of an ethnically diverse, low-income sample of 956 adult patients with diabetes or asthma in 17 academic outpatient practices revealed a strong relationship between higher patient assessments of provider support and patient self-efficacy for self-care. Within the diabetes subgroup, patients who gave high ratings of provider support were significantly more likely to perform self-management tasks than those with low ratings. The findings provide support for the belief that health care providers can successfully promote patient self-management of chronic illnesses.
Problems of Living with a Chronic Illness
Living with a chronic illness presents the patient with a number of medical, social, emotional, and physical challenges that include adjusting to the natural course or progression of the disease, preventing social isolation, normalizing activities and communication within the boundaries of the illness, preventing exacerbations, controlling chronic symptoms, following complex treatment regimens, and finding the necessary financial and tangible resources to pay for treatments and potential loss of employment. To manage these problems, patients must develop a set of strategies for self-managing the disease and for coping with the problems. Teaching, facilitating, and supporting the patient’s attempts at self-management of the chronic condition is at the core of the patient–clinician–health care team relationship.
The partnership paradigm is based on acknowledging the expertise of both the clinician and team in understanding the disease, its psychological and physical impact on patients, and therapeutic interventions; and patients’ expertise about their own lives. The new paradigm of clinician/team–patient partnership supports interactions that are primarily based on the patient’s agenda, not the clinicians.’ It purports a belief that increased self-efficacy for self-care tasks facilitates behavior change that education alone cannot accomplish. In the patient-centered approach, enhanced self-efficacy is the goal rather than adherence to clinician advice. Finally, mutually agreed upon decisions are made together by the patient and clinician. Self-management support encourages patients to become more actively engaged to adopt health behaviors and develop necessary skills.
Self-Management Support Strategies
Research has demonstrated that activated patients are more likely to adopt healthy behaviors and thus have improved clinical outcomes. Several strategies to activate patients are discussed here.
Collaborative Agenda Setting
In traditional clinical encounters, the visit is guided by the chief complaint provided by the patient and the agenda is established by the clinician. In the collaborative paradigm, the agenda is negotiated between the clinician and the patient.
Information Giving Using Ask-Tell-Ask
One technique that has been used in providing patients with information is based upon the “elicit-respond-elicit” motivational interviewing technique first described by Miller and Rollnick (see Chapter 19). This method is more popularly called “ask-tell-ask,” a strategy based on adult learning theory in which individuals learn best when provided with information that they are interested in learning. Rather than giving patients a didactic lecture on diabetes, the nurse or health educator asks “What do you know about diabetes?” and “What would you like to know about diabetes?” and gives patients the information they want to know, after which they ask again whether the patient understands or has other questions. In addition, rather than telling patients that they must exercise and change their diet, the health care team member asks patients what they are willing to do to improve their health. For many health professionals who are used to telling patients what to do, this shift to collaborative interactions and shared decision making is a challenge.
Information Giving: Closing the Loop (Teach Back Method)
A simple but much overlooked strategy is asking the patient to restate instructions provided by the practitioner. It is known that 50% of patients leave a medical visit without understanding or remembering what the clinician said. “Closing the loop” or “teach back” assesses a patient’s understanding of the information provided by the practitioner. Rather than asking, “Did you understand how to take your medication?” which does not assess understanding, closing the loop involves asking, “Just to make sure I was clear, how will you be taking that new medicine?” Teach-back or check-back is a relatively simple strategy that has been associated with improved outcomes in patients with diabetes; yet few clinicians actually close the loop in practice.
Behavior Change Action Plans
Traditionally, clinicians tell patients that they must eat healthier foods, exercise, and take all their medications without their input to the treatment recommendations. Motivational interviewing studies suggest that telling patients what they are supposed to do generates resistance on the part of the patients and is thereby ineffective in encouraging behavior change. Keys to motivational interviewing technique include: (1) assessing readiness to change by determining the relationship between level of importance and level of confidence for change and (2) encouraging patients themselves to talk about a behavior change they are willing to entertain. To assess level of confidence and importance, a 0–10 scale or a picture graph can be used (Figure 39-2). Once individuals are motivated to change a behavior, they can set goals for themselves, and then agree to a specific action plan that begins the process of meeting the patient-generated goals.
Self-Efficacy Scale indicating confidence in ability to make a change in behavior (diet, exercise, etc.).
Action plans are developed through collaboration between the clinician or health care team member and the patient. The action plan is very specific with identified behaviors, a start date, and frequency. For example, a patient may wish to walk 3 days per week (Monday, Wednesday, and Friday) at lunchtime, for 20 minutes, beginning next Monday. Another example may include reducing candy bar consumption to 1 per day from 3 per day and eating one piece of fruit daily.
The primary purpose of action plans is to achieve behavior change through a series of successes. Self-efficacy is defined as an individual’s level of confidence in performing a specific behavior or activity. If self- efficacy is high, the behavior is likely to be performed. Thus, enhancing self-efficacy is of primary importance in achieving long-term behavior change. Therefore, the action plan should be simple and achievable. If the patient has a low level of confidence in achieving the action plan, the team member can suggest a more achievable goal to insure success. Additionally, if self-efficacy is low, this provides an opportunity for the clinician to explore barriers to change and to develop specific strategies to promote success. In a randomized controlled trial, patients with diabetes who made action plans had significant lowering of HbA1c compared with patients who were given patient education without action plans. The key to success in implementing action plans is to engage the patients by eliciting their input and to increase their self-confidence to act.