Self-Management Support/Education...1. Table 1: Comparison of Traditional Education & Self-Management Education...3

Transcription

1 Patient Self-Management A Discussion Paper December 2007

2 TABLE OF CONTENTS Self-Management Support/Education...1 Table 1: Comparison of Traditional Education & Self-Management Education...3 Empowerment-Based Diabetes Self-Management Education/Support (DSME/S)...3 Motivational Interviewing, Problem Solving, Goal Setting for DSME...4 Table 2: Empowerment-Based Problem Solving Model...5 Resources & References...7 Resources & Tools: Goal-Setting, Problem Solving, Diabetes Self Management...7 Websites for You and Your Clients:...7 References...8 Appendix 1: Goal-Setting Sheet from Hamilton FHT, Canada...9 Appendix 2: Goal-Setting & Tracking Calendar Urban Family Health Team, St. Joseph's Health Centre, Toronto...10

3 Document contributed by: Gita Lakhanpal, MES, OT Reg(Ont), Patient Education Specialist Urban Family Health Team, St. Joseph's Health Centre, Toronto Document created as part of the work of the Diabetes Tool Kit Task Group The Diabetes Tool Kit Task Group is one of four task groups formed as part of the project Interprofessional Clinical Program Development for a Network of Family Health Teams. Project Sponsor: Academic Family Health Team Forum Department of Family and Community Medicine, University of Toronto Project Funder: Primary Health Care and Family Health Teams Health System Accountability and Performance Division Ministry of Health and Long Term Care

4 The objective of this discussion paper is to provide: Basic comparative information on chronic disease self-management and traditional health education as applied to diabetes. Information and resources on problem solving and goal-setting for diabetes self-management. Relevant resources and references to follow-up. A springboard for your FHT to review and adapt for your local organization and community. Self-Management Support/Education Self-management of chronic diseases such as diabetes is promoted in both clinical practice and in the literature. There are a variety of definitions of self-management, and no universally accepted definition. The literature provides a variety of definitions. Some of the related terms include selfmanagement education/support/training, and patient/client empowerment related to chronic disease management. McGowan (2006) reviewed the range of concepts and definitions of self-management which include: Participating in education/treatment to encourage specific health outcomes. Educate and prepare people to monitor and manage chronic health conditions on a daily basis. Practicing specific behaviours and skills. People develop abilities to reduce the physical, emotional impacts of chronic illness, with or without input from health care providers. 1

5 The Chronic Disease Self-Management Program in British Columbia selected the following definition because it includes medical and psychosocial aspects important to self-management and includes a self-management support role of health care providers: 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. Self-management support is defined as the systematic provision of education and supportive interventions by health care staff to increase patients skill and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support. (Adams, Greniner, & Corrigan 2004 as cited in McGowan 2006 pg. 81) This definition of chronic disease management is consistent with the definition of health and health promotion from the Ottawa Charter on Health Promotion (WHO, 1986): Health is a resource for living; a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Health is a positive concept emphasizing social and personal resources, as well as physical capacities Health promotion is the process of enabling people to increase control over, and to improve their health. To reach a state of complete physical, mental and social well-being. Traditional health education usually focuses on teaching technical disease-specific skills, and selfmanagement tends to focus on developing confidence and problem-solving skills to live and cope with a chronic disease. Both types of education are useful to the person diagnosed or at risk for a chronic disease such as diabetes. In a qualitative study, Koch, Jenkin, and Kralik (2002) outline 3 models of self-management: the Medical Model that focuses on adherence; Collaborative Model proposes a partnership between individuals with chronic illness and health care professionals; and the Self-Agency Model that advocates self-determination. The three models outline the continuum between traditional education and self-management education. Table 1 summarizes the two approaches. 2

6 Table 1: Comparison of Traditional Education & Self-Management Education Traditional Education Self-Management Education Content How the problem is defined Theoretical Constructs Goal Disease specific and provides information and technical skills related to the disease. Inadequate control of the disease. Disease specific information leads to behaviour change, which then produces better clinical outcomes. Compliance to prescribed behaviour change to improve clinical outcomes. Problem-solving skills to cope, manage and live with impacts of living with a chronic conditions in general. Person with the disease formulates the problem, which may or may not be directly related to the disease. Greater self-efficacy, and increased confidence in the individual (learned through problem-solving skills and support) leads to improved clinical outcomes. Increased self-efficacy for individuals and improved clinical outcomes. Educator Health professional Health professional, peer leader, or people who live with the chronic disease. Adapted from: Bodenheimer, Lorig, Holman & Grumbach (2002) as cited in McGowan Empowerment-Based Diabetes Self-Management Education/Support (DSME/S) Different diabetes group education strategies that are empowerment-based are also consistent with chronic disease self-management education (Tang, Funnell, & Anderson 2006; Funnell, Tang, & Anderson 2007). The authors review the evidence base of the models and programs. Theoretical foundations and strategies of empowerment-based diabetes education include: Autonomy support and autonomy motivation is the primary theoretical framework. Problem-based learning instead of didactic lectures is the primary educational strategy; promotes self-directed learning, reflective skills, and communication skills. Culturally relevant. Designed to meet the needs and situation of the group/population. Five step behavioural change model focussed on goal setting. Encourages the client/patient to engage in behavioural experiments for diabetes management and reflect on the results in their life. See Table 2 in Problem Solving section. 3

7 Researchers of empowerment-based diabetes self-management education state that the model is effective because it supports clients holistic experiences of living with diabetes. The varieties of empowerment-based DSME programs prioritize goal setting within the client s experience and context, instead of being curriculum focused. These are important points because people who live with diabetes do not distinguish between the psychosocial, behavioural, and clinical impacts of diabetes (Tang, Funnell, Anderson 2006; Funnell, Tang, Anderson 2007). This also indicates that attention to the social determinants of health should be considered in planning interventions and selfmanagement education. The empowerment-based DSME is also consistent with research on effective interventions for diabetes care for marginalized populations (Glazier, Kennie, Bajcar, Willson, 2006). Features of diabetes treatment with positive impacts include, cultural tailoring, use of community/lay educators, focus on behaviour-related tasks, and provision of feedback. Didactic teaching or primary focus on diabetes knowledge was associated with negative outcomes (Glazier, Kennie, Bajcar, Willson, 2006). Comparing group versus individual DMSE, studies demonstrate variability in metabolic outcomes. There is some evidence that group-based DMSE is more cost-effective, leads to greater client/patient satisfaction, and may be slightly more effective for lifestyle changes (diet and activity) and quality of life (Tang, Funnell, Anderson 2006; Keers et al 2005;Trento et al 2002). Motivational Interviewing, Problem Solving, Goal Setting for DSME Health behaviour is a result of an individual s feelings, beliefs, and cultural practices. That is why for many people, providing information and education on risks and strategies to improve health is not sufficient. Diabetes distress is described as a range of emotions in response to the complexity of having and coping with a chronic disease; anger, frustration, discouraged, elevated risk for depression (Polonsky et al 2005; Fisher, 2007). Diabetes distress can also impact a person s motivation to engage in self-care and management activities. To support self-management behaviours, it is necessary to explore clients /patients motivation and health beliefs and values. Motivational interviewing (MI) is a client-centred counselling technique designed to help individuals explore and resolve ambivalence about changing their behaviour (Miller & Rollnick, 2002). In MI, clients are encouraged to set the agenda and goals. The basic principles of MI are: 1. Express empathy 2. Avoid argument 3. Support self-efficacy 4. Roll with resistance 5. Develop discrepancy The MI process involves 8 steps: 1. Establishing rapport 2. Setting the agenda 3. Assessing readiness to change 4. Sharpening the focus 5. Identifying ambivalence 6. Eliciting self-motivating statements 7. Handling resistance 8. Shifting the focus 4

8 MI is consistent with chronic disease management and diabetes self-management education literature that supports behaviour change, and goal setting with attention to the client s values and specific context. The empowerment-based diabetes self-management education and support (DMSE & DSMS) outlines a similar problem-solving model (See Table 2). Though the model is used for group education, it may be useful for individual self-management counselling and case management. The authors also provide an outline for weekly problem-based group sessions (Tang, Funnell, Anderson 2006; Funnell, Tang, Anderson 2007). Table 2: Empowerment-Based Problem Solving Model Step 1: Explore the problem or issue (past) What is the hardest thing about caring for diabetes for you? Please tell me more about that. Are there some specific examples you can give me? Step 2: Clarify feelings and meaning (present) What are your thoughts about this? Are you feeling (insert feelings) because (insert meaning)? Step 3: Develop a plan (future) What do you want? How would this situation have to change for you to feel better about it? Where would you like to be regarding this situation in (specific time: eg. 1 month, 3 months, 1 year)? What are your options? What are barriers for you? Who could help you? What are the costs and benefits for each of your choices? What would happen if you do not do anything about it? How important is it, on a scale of 1 to 10, for you to do something about this? Let s develop a plan. Step 4: Commit to action (future) Are you willing to do what you need to do to solve this issue? What are some steps you could take? What are you going to do? When are you going to do it? How will you know if you have succeeded? What is one thing you will do when you leave here today? Step 5: Experience and evaluate the plan. How did it go? (future) What did you learn? What barriers did you encounter? What, if anything, would you do different next time? What will you do when you leave here today? From: Tang, Funnell, Anderson 2006; Funnell, Tang, Anderson

9 What these two models/strategies share is a focus on the client setting the goals, and the health care professional refrains from advice giving. Both models also promote the development of problemsolving skills. To address diabetes distress, and promote self-efficacy, it is also important to assist the client to breakdown goals into achievable steps. It is also important not to use a cookie-cutter approach. Often our clients demonstrate problem solving ability in other areas of their life. As health care professionals, we can assist the client to transfer these skills to diabetes management. Health care providers must be prepared that the client s goals may not directly relate to clinical/metabolic outcomes. For example, the client may feel anxiety and fear about glucose-self monitoring; the client will require support and education about anxiety management. Another example is that the client may feel isolated in managing diabetes, and state that their goal is to inform family and friends they have diabetes. Working with the client on self-identified goals, will encourage self-efficacy. In turn, this can encourage the client to take on other self-management/selfcare goals (diet, exercise, medication). 6

10 Resources & References Resources & Tools: Goal-Setting, Problem Solving, Diabetes Self Management 1. Dr Nick Kates Hamilton FHT ( Appendix 1) 2. Goals and Tracking Calendar SJHS FHT (Appendix 2) 3. Wellness Module 4: Problem-Solving Available as PDF download BC Partners for Mental Health & Addictions Information Websites for You and Your Clients: 1. Canadian Diabetes Associations Education material for clients, lifestyle change and prevention information, research articles, local community resources. 2. Diabetes Self Management : Articles on self-management; recipes; community blog. 3. American Diabetes Association Education material for clients, lifestyle change and prevention information, research articles, local community resources. 7

11 References Funnell, M., Tang, T., Anderson, R. (2007). From DSME to DSMS: Developing Empowerment- Based Diabetes Self-Management Support. Diabetes Spectrum 20(4), Glazier, R., Bajacar, J., Kennie, N., Willson, K. (2006), A systematic review of interventions to improve diabetes care in socially disadvantaged populations. Diabetes Care 29(7), Keer, J., Groen, H., Sluiter, W., Bouman, J., Links, T. (2005). Cost and benefits of a multidisciplinary intensive diabetes education programme. Journal of Evaluation in Clinical Practice 11(3), Koch, T., Jenkin, P., Kralik, D. (2004). Chronic illness self-management: locating the self. Journal of Advanced Nursing 48(5), McGown, P. (2007). The Chronic Disease Self-Management Program in British Columbia (79-90), In: Emerging Approaches to Chronic Disease Management in Primary Health Care, Ed John Dorland & Mary Ann McColl; Montreal & Kingston: School of Policy Studies, Queen s University. Miller, W.R., Rollinck, S. (2002). Motivational Interviewing: Preparing people for change. New York, NY: Guilford Press. Polonaky, Q., Fisher, L., Earles, J., Dudl, J., Lees, J., Mulian, J., Jackson, R. (2005). Assessing Psychosocial Distress in Diabetes: Development of the Diabetes Distress Scale. Diabetes Care 28(3), Tang, T., Funnell, M., & Anderson, R. (2006). Group education strategies for diabetes selfmanagement. Diabetes Spectrum 19 (2), World Health Organization. (1986). Ottawa Charter for Health Promotion. WHO: Copenhagen. Available at: 8

12 Appendix 1: Goal-Setting Sheet from Hamilton FHT, Canada 9

13 Appendix 2: Goal-Setting & Tracking Calendar Urban Family Health Team, St. Joseph's Health Centre, Toronto This calendar is printed on legal size paper and brought to each appointment with the Patient Education Specialist. 10