Engaging Patients in Chronic Disease Management

Of every dollar spent on healthcare in the U.S., more than 75 cents goes toward treating chronic diseases. Nearly 92 percent of older adults have at least one chronic condition and 77 percent have more than two, according to the Centers for Disease Control and Prevention (CDC). Bending the cost curve and improving care and health outcomes will require putting patients at the center of managing their disease. Researchers have been studying cost-effective strategies for improved chronic disease management, including targeted physician training for better patient-physician interactions at the point of care, patient self-management education and health IT tools. Stanford: in person & Online Learning Successful chronic disease self-management requires a holistic approach in which patients learn action planning, problem solving and decision-making skills head on, says Kate Lorig, RN, DrPh, professor at Stanford University School of Medicine and director of the Stanford Patient Education Research Center. In the 1990s, Lorig founded Stanford’s Chronic Disease Self-Management Program, a pioneering self-management program tailored to adults with diabetes, arthritis, high blood pressure, heart disease, emphysema, multiple sclerosis and depression, among others. Currently, more than 1,000 organizations worldwide have acquired a license to teach this program, according to Lorig. The National Council of Aging also administers the program at its popular www.restartliving.org [1] website. Available in person at community and health organizations and more recently online, the six-session, two-and-a-half hour workshop is taught by trained leaders—many of whom have a chronic disease themselves. People with different chronic health problems attend together. Subjects covered include: • Techniques to deal with problems such as frustration, fatigue, pain and isolation; • Appropriate exercise for maintaining and improving strength, flexibility and endurance; • Appropriate use of medications; • Communicating effectively with family, friends and health professionals; • Nutrition; • Decision making; and How to evaluate new treatments. • The program has undergone two major updates in 2006 and 2013. The key to the success of Stanford’s program is equipping patients to set and accomplish their own goals, says Lorig. “People find it works. They work very hard to accomplish what they want, with the whole idea of systematically using processes to feel more confident. It’s about empowering people in a systematic way.” Empowering People Works Numerous studies have positively linked Stanford’s Chronic Disease Self-Management Program to better care, outcomes and lower costs. Specifically, a national study of the program—published in November 2013 in Medical Care—concluded that it achieved the triple aim. Researchers surveyed 1,170 older adult participants from 22 organizations in 17 states and studied their healthcare utilization at baseline, and then 6 months and 12 months after the program. The study ultimately found that participation in the program significantly reduced emergency room visits by 5 percent at both the 6-month and 12-month assessments as well as hospitalizations by 3 percent at 6 months. This equated to a potential net savings of $364 per participant and a national savings of $3.3 billion if 5 percent of adults with one or more chronic conditions were reached, according to the study. “Given that older adults with chronic condition consume 75 percent of healthcare expenditures, these findings are encouraging,” the authors wrote. Another study looking at 761 patients with diabetes who participated in the online version found improvements in A1C levels, patient activation and self-efficacy. The program works because it does not tell people what to do, Lorig says. “We are problem centered. We ask people, ‘what is your problem that you would like to solve?’ and then help them set up ways of going about it. We are very experiential and we really want people to do self-experiments.” Health IT tools like apps can help a patient better manage their illness, but only up to a point, says Lorig. Technology tools tend to do one of two things: Capture data and give patients feedback, or capture data and give feedback to the doctors. “Those are useful in and of themselves,” she says, “but for patients to truly self-manage their conditions, they need knowledge and confidence to deal with emotional and physical symptoms.” As for patient engagement, Lorig calls that “window dressing.” While she supports greater patient access to data and stronger roles in healthcare decision-making, she is also a little skeptical. “If patients have access to health data, it doesn’t do them any good if they don’t know what to do with it,” she says. However, if patients understand what their data mean and how their behavior impacts these measurements (e.g., the effect on blood glucose after exercising or eating) then the data serve a useful purpose. Adherence in Older Adults Asthma is typically associated with children, but adults with the disease actually outnumber children 18.9 million to 7.1 million, according to the CDC. This perception is one reason why asthma is overlooked in the geriatric population, and subsequently hinders efforts to teach self-management techniques, according to Alan Baptist, MD, assistant professor of internal medicine at the University of Michigan. He is actively involved in the university’s Center for Managing Chronic Disease. Self-management of asthma is more specialized and best conducted in conjunction with treatment. However, “For people who develop it later in life, it’s difficult to get asthma education at all.” Baptist led a successful self-regulation intervention that improved asthma control, quality of life and healthcare utilization in older adults that, like Stanford’s program, taught participants how to overcome specific barriers related to their disease and set goals to overcome them. The intervention consisted of a health educator leading three group meetings and conducting three individual one-on-one phone calls. This approach works because it gets patients focused on managing their disease to handle real-life scenarios: like wanting to go on a walk with their grandchildren or go to a friend’s house without concern of having an episode. Doctors often focus on inhaler use, frequency of symptoms and interrupted sleep, but patients are worried about broader issues, Baptist says. “Overcoming obstacles must be about how they would define them, not necessarily the way physicians define them,” he says. Following these positive results, Baptist embarked on another intervention, but this time it is tailored to African-American adults ages 18 to 30 suffering from asthma. Given the busy schedules of this age group, “We looked at how to deliver the program in a format more appropriate and decided to digitize the entire process.” The Center for Managing Chronic disease, thus, worked with the University of Michigan’s School of Information, which built an intervention tool from the ground up. A separate website portal was developed so enrolled participants can access the program, which is available both on computers and mobile devices. The pilot is automated with no health educator, but prompts participants through the same goal-setting curriculum. Patient-Physician Communication Another Center for Managing Chronic Disease intervention looked to patient-physician communication to improve patient self-management of asthma. This intervention involved training physicians on recommended guidelines of care, called the Physician Asthma Care Education program, and communicating effectively with patients with asthma within the context of clinical visits, says Minal R. Patel, PhD, MPH, assistant professor of health behavior and health education at the University of Michigan. These two-hour trainings took place twice, two weeks apart. This intervention reduced urgent care visits and improved patient satisfaction. Physicians did not spend more clinical time with their patients, but merely implemented better communication techniques—such as asking more pointed open-ended questions, Patel says. Patel also is working on a culturally tailored version of the Physician Asthma Care Education program that relays culturally-sensitive communication techniques. “It taught physicians how to work cross-culturally,” she says, in particular how to ask questions so patients can communicate their beliefs about asthma. In cases, physicians would work with a translator or a third party who knows the patient well to better facilitate the conversation. “With people managing multiple chronic diseases, the individual, his or her family, the provider and the community all have to communicate, but I’m not sure we’re quite there yet,” she says. “Technology has the potential to facilitate that.” Outlook Chronic disease self-management programs are showing promise. But, even with the well-studied Stanford program, challenges remain in two areas: letting people know that programs exist and lack of a payment system supporting them. Stanford’s programs are paid for by a patchwork of sources: federal or foundation grants, employers and health systems. Lorig argues for a systematic, one-payment mechanism and a national network so anyone can find a class within six weeks. Those are the missing pieces, she adds. But, if providers continue to reap gains from such programs, expect solutions. Topic Category: Clinical Practice [2] ________________________________________ Source URL: http://www.clinical-innovation.com/topics/clinical-practice/engaging-patients-chronic-disease-management Links: [1] http://www.restartliving.org [2] http://www.clinical-innovation.com/topics/clinical-practice TSH Editors Note: Great recap and we appreciate the opportunity to share. BB