C A L I FOR N I A H EALTH C ARE F OU NDATION Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned April 2008 Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned Prepared for California HealthCare Foundation by Susan Baird Kanaan April 2008 About the Foundation The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. For more information about CHCF, visit us online at www.chcf.org. ©2008 California HealthCare Foundation Contents 2 I. Executive Summary 5 II. he Initiative to Integrate Self-Management T Support into Clinical Practice Transforming Health Care to Meet a Growing Public Health Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 A New CHCF Self-Management Initiative Builds on a Previous One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Training in Core Concepts and Techniques . . . . . . . . . . . . . . 7 Monitoring Results and Using Data to Support Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Handling Challenges and Building on Successes . . . . . . . . 10 1 2 III. Summary: Lessons for the Field Self-Management Support . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 System Design and Patient Flow. . . . . . . . . . . . . . . . . . . . . . 12 Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1 4 Appendices A: Grantee Case Studies: Four Projects B: Report Interviews C: Project Staff and Grantees 1 8 Endnotes I. Executive Summary Self-management support is part of a set of strategies to improve chronic disease care and curb the escalating economic and public health impact of chronic illness. Through their daily decisions about diet, exercise, self-measurement, and medications, people with chronic illness play the central role in determining the course of their disease. They need the support of their health care providers to make and sustain changes in these areas. The California HealthCare Foundation (CHCF) has determined that while many health care organizations are interested in helping their patients manage their chronic conditions, they need new organizational capacity, clinical skills, and strategies to be able to do so. The Foundation conducted a two-year initiative in 2006 – 2007, Promoting Effective Self-Management Approaches to Improve Chronic Disease Care, to give health care organizations the training and tools to enable them to support their patients’ growth in self-management. The initiative focused on diabetes, which causes heavy use of health care services and is amenable to self-management strategies. CHCF awarded grants of $65,000 to 10 health care organizations around California, each with a significant number of low-income people among its patients. The grantee organizations were diverse in size, location, and resources, and included community health centers, Federally Qualified Health Centers (FQHCs), a county health department, and a medical practice in a large integrated delivery system. All showed a willingness to make permanent changes to integrate self-management support into care delivery. The initiative had three major components to help grantees develop systems and practices to provide self-management support to their patients: system redesign, staff training, and measurement and feedback. CHCF made resources and experts available to the grantee organizations to support each of these activities. In addition to funding, the grantees received access to consultation on workflow and evaluation, on-site staff training and training tools, and several opportunities for in-person and teleconference meetings with project staff, consultants, and each other. The final project meeting took place in Oakland on November 28, 2007. CHCF also offered two levels of incentive bonuses for grantees that 2  |  C alifornia H ealth C are F oundation fulfilled up to 10 requirements reflecting a high level behavioral change and clinical improvements for of organizational engagement in the process. patients. The project design encouraged grantees to tailor The CHCF initiative produced the following lessons the intervention to local needs and capabilities and for the field: continue to experiment throughout the grant period. Lessons about self-management support: Specially trained nonphysician staff members, such K Core elements of integrating self-management as licensed vocational nurses or community health support into care are motivational interviewing workers, play key roles in self-management support, training, measurement, and feedback. and the sites made different decisions about how to integrate support into the process of care, and which K The self-management support model used in this staff members would play key roles. (The variations initiative can and should be adapted based on are illustrated in the four case descriptions.) organizational resources and priorities. Training was a major component of the initiative. K Patient behavior change and improvements All sites had at least one day-long, on-site training in clinical outcomes take time. Institutional session with an expert in diabetes behavior change is the first step and priority, and lays the change; the number of participating staff members groundwork for other changes. per site ranged from 30 to 200. In addition, K Self-management support is part of a broader follow-up “booster” sessions and a training video set of changes laid out in the Chronic Care were provided. The training provided both key Model, all of which are necessary to improve concepts and hands-on experience in motivational chronic disease care. The dimensions include interviewing, a key clinical technique to help patients self-management support, decision support, set goals, identify and problem-solve about barriers, delivery-system design, clinical information and build confidence in their ability to make needed systems, the organization of health care, and changes. Many grantees considered the intensive alliances with the community. training sessions a turning point for their programs. Lessons about system design and patient flow: Measurement was another essential part of the K For self-management support to be effectively initiative. With technical support from the project’s integrated into care, sites need to rethink their evaluator, the grantees were responsible for tracking team composition and workflow. and reporting data on their patients and provider team members every quarter, and for assessing K Clinical and administrative champions are needed organizational capacity at the beginning and end in each site. of the project. They used a core set of measures K It is possible to integrate self-management support that were tracked across all sites, and were shown into primary care without making physicians their data and comparative data from the other the major agents of the intervention. Doctors’ sites every quarter. Overall, the quarterly data show participation is essential, but they are already positive trends across the indicators. All grantees at their limit. and can play a supportive, rather made positive change in at least six of 21 impact than primary, role. In addition, this approach measures, with the greatest improvements taking cannot be imposed on them; their buy-in must be place in priority areas for this initiative. In addition, secured. all sites made statistically significant changes in 15 of the 16 dimensions of organizational capacity, which K Some questions remain about the roles for project leaders regard as the first step in promoting medical assistants and community health workers Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned  |  3 in self-management support; there is agreement that to be effective team members, they need considerable training and mentoring. Lessons about training: K On-site staff training and hands-on experience for all participating team members, with regular boosters, are key. K Confidence-building is key, for both providers and patients. It is important to celebrate success and focus on what patients can do. Action plans can be very useful, but they must be used in a way that does not undermine the patient’s confidence. Lessons about measurement: K Measurement and reporting are a critical dimension of self-management support for all participants, including the organization, individual providers, and patients. K Many organizations have a steep learning curve in developing appropriate measurement systems and learning to use the data to motivate change. K Feedback to providers is a critical component of closing the measurement loop, so they can understand how to readjust their interventions. 4  |  C alifornia H ealth C are F oundation II. he Initiative to Integrate Self-Management T Support into Clinical Practice Transforming Health Care to Meet a Growing Public Health Challenge The United States now spends three of every four health care dollars treating the 45 percent of the population with chronic disease. This segment of Americans is expected to grow by 1 percent a year in the future, making chronic disease an escalating public health and economic challenge for the nation.1 People with chronic illness play the central role in determining the course of their disease through their daily decisions about diet, exercise, self-measurement, and medications. Because behavior change is inherently difficult, even when serious health outcomes are at stake, people are most likely to make needed changes with support from their health care providers. Because patients’ daily activities are so critical to successful health outcomes, health care providers are having to reshape their own thinking, behaviors, and delivery systems to support healthful behaviors. The Chronic Care Model, the basis for a host of initiatives addressing these issues, identifies self-management support as one of six dimensions of integrated chronic care. The model was developed by Ed Wagner, M.D., director of the MacColl Institute for Healthcare Improvement in Seattle, and his colleagues.2 It has three targets: the health care system, the patient, and the provider. Besides self-management support, the other areas of provider activity are decision support, delivery-system design, use of registries (clinical information systems), organization of health care, and alliances with the community. These activities clearly dovetail with self-management support, as will be seen below. Self-management support transforms the patient-provider relationship into a collaborative partnership and organizes the health care team around the pivotal role of the patient. The process engages patients and providers in a partnership to identify health goals, choose specific actions, acquire needed information, and monitor progress. It incorporates principles of motivational interviewing (in a nutshell, “ask, don’t tell”) and self-directed learning. It uses a team approach, not just because physicians lack the time to provide comprehensive support during the encounter but also because offering it at multiple points in the office visit Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned  |  5 increases its effectiveness. Because these are complex CHCF Senior Program Officer Veenu Aulakh, changes for health care organizations, they typically M.P.H., comments, “For improvements in chronic mean redesigning the delivery system and adopting care to occur, patients must have the knowledge, new ways of thinking and acting to integrate skills, and confidence to manage their own health. self-management support into systems of care. While the chronic care model has been broadly implemented, the least understood component There is strong evidence that self-management of the model is how to best support patients in support improves patients’ health-related behaviors self-management. This initiative was designed to and results in improved clinical outcomes. In a delve deeper into understanding how to integrate 2005 paper and literature review for the California self-management support into practice within the HealthCare Foundation (CHCF), for example, constraints of a busy clinic caring for patients with Thomas Bodenheimer, M.D., and colleagues complex needs.” reported “significant associations between improved information-giving by the physician, more People with diabetes are heavy users of health participatory decision-making, enhanced self-efficacy, care, and the exacerbations of the disease — many healthier behaviors, and better outcomes in patients of them preventable — can be devastating and with diabetes.”3 costly. Thus the foundation focused on diabetes and cardiovascular disease for its second initiative, A New CHCF Self-Management calling this “a continuum of chronic conditions with Initiative Builds on a Previous One clear self-management strategies where we believe CHCF has found that while health care health care systems can have a significant impact organizations are interested in providing when partnering with patients to increase their self-management support, they need concrete self-management skills.”4 strategies and new organizational capacity to do so. This was a major finding of the foundation’s first The many challenges faced by low-income people self-management initiative, Promoting Consumer and their safety-net providers greatly compound Partnerships in Chronic Disease Care, which ended the difficulty of coping with chronic disease. While in 2005. the foundation did not limit the grants to safety- net organizations, it required that the proposed To help organizations integrate self-management interventions be relevant and appropriate to safety- support into primary care services, therefore, CHCF net populations, including people with low levels of launched a new initiative, Promoting Effective health literacy and non-English-speaking and limited Self-Management Approaches to Improve Chronic English-speaking populations. Disease Care, in late 2006. This project, designed in consultation with experts who advised on the Ten health care organizations around the state (see first round, provided structured tools and assistance Appendix) were awarded grants of $65,000 and to enable grantees to support self-management began two-year self-management support projects in and monitor the results for both patients and December 2006. A heterogeneous group, they vary providers. The goals of the initiative were to enhance widely in size and resources, representing diverse organizational capacity, improve understanding of rural and urban settings. They include community self-management support, and produce healthier and health centers, Federally Qualified Health Centers, a more confident patients, as well as more satisfied county health department, and a medical practice in providers and staff. A broader goal was to reduce a large integrated delivery system. Several offered the health care utilization and costs. intervention in multiple clinics. 6  |  C alifornia H ealth C are F oundation All the grantees chose to target patients with intervention and how to integrate it into the process diabetes, many of whom also have co-existing of care. Specially trained nonphysician staff members conditions, such as hypertension. (Forty-four percent played key roles in self-management support at some of people with chronic conditions have two or sites. Several organizations made licensed vocational more of them.) Some sites offered the intervention nurses (LVNs) the main agents, and some identified to all their diabetic patients, while others worked important roles for promotoras (community health with a smaller number, selected on the basis of workers) and/or medical assistants. Physicians played higher risk (HbA1c [blood sugar] level) and/or varied roles in the process in different organizations, greater motivation to manage their diabetes. Most as well. The four case descriptions illustrate some of patients in the initiative have low incomes and are the variations among the grantee programs. either uninsured, underinsured, or enrolled in a government program, such as Medi-Cal. Most have The grantees also were creative about developing limited health literacy; many are Hispanic; and some their own resources for patients and staff to augment speak only Spanish. those provided by the foundation. Monterey’s patient-oriented A1c campaign and Samuel Dixon’s The project had three major components: system self-management mission statement, both described redesign, staff training, and measurement and below, are examples. feedback. CHCF made resources and experts available to the grantees to support each of Training in Core Concepts and these activities. In addition to financial support, Techniques grantees received access to consultation on The centerpiece of the initiative’s training workflow and evaluation, on-site staff training component was a day-long training session, on site, and training tools, and several opportunities with William Polonsky, Ph.D., a professional trainer for in-person and teleconference meetings with and expert on diabetes behavior change. Polonsky project staff, consultants, and each other. The also made follow-up visits to some sites, and key staff final project meeting took place in Oakland on had additional “booster session” training that gave November 28, 2007. CHCF also offered two levels them hands-on experience with patient actors.5 The of incentive bonuses for grantees who fulfilled grantees also built their own regular staff training up to 10 requirements, reflecting a high level of sessions into organizational routines. organizational engagement in the process. A basic premise of self-management support is that CHCF designed the project so that grantees could people want to live long and healthy lives, even if tailor the intervention to local needs and capabilities they don’t always do what is best for themselves or and continue to experiment throughout the grant make the changes recommended by their providers. period. At the outset, they had access to a workflow The main reason for the gap, says Polonsky, is consultant to help them analyze workflow and that they encounter barriers that keep them from staff roles and determine the most efficient way making desired changes. Some are practical, such to integrate self-management support into patient as inadequate time or money to follow diet and care — for example, to take advantage of wait times fitness or medication recommendations, and some and make the best use of physicians’ limited time are emotional and attitudinal, such as depression, with patients. doubts about the benefits of the change, or a lack of confidence in one’s ability to change. While all sites used a team approach, they made different decisions about which staff member(s) Polonsky stresses that confidence is a strong would serve as the main agent, or initiator, of the predictor of lasting behavior change. In addition Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned  |  7 to imparting key concepts in his training sessions reporting data on their patients, provider team with the grantees, Polonsky taught them practical members, and organizational capacity. The project’s behavioral techniques, based on the motivational evaluator, Seth Emont, Ph.D., M.S., of White interviewing approach, to help patients set goals, Mountain Research Associates, LLC, advised on data identify barriers, work out solutions, and build collection and compiled and analyzed the data. confidence in their ability to make positive changes. The trainees’ hands-on experience made them more Every quarter between April 2006 and October aware of their habitual ways of working with patients 2007, the grantees surveyed patients about their and enabled them to practice the new approaches. experience and satisfaction and reported the CHCF also supplied grantees with a training video aggregate results to CHCF. They did the same for developed specially for this project. The video, which providers’ satisfaction with self-management support, features Polonsky working with patients, reinforces and they also reported patients’ documented key concepts and illustrates the use of motivational self-management goals and clinical outcomes. interviewing to enhance self-management.6 The grantees used a core set of measures that were tracked across all sites, and they were shown their At the final grantee meeting and in follow-up unblinded data every quarter, with comparisons to interviews, several participants described their other grantees. (Data were collected on 15 sites in all training experience as a turning point for their because two grantees reported on multiple sites.) programs. Many expressed a desire for additional on-site training in the future. Overall, the quarterly data show positive trends across the indicators. All grantees made positive Indeed, training was a major topic of discussion change in at least six of 21 impact measures, with the at the final meeting. The group explored possible greatest improvements taking place in priority areas ways to expand staff training opportunities, such for this initiative. (See more details below.) as through a “train the trainers” program and a professionally developed curriculum. They discussed Organizational Capacity what it would take to create a network of effective In addition to the quarterly surveys, the grantees trainers throughout the state, and how to instill in assessed their institutional capacities at the nonclinical staff members a sense of the limits of beginning and end of the project (February 2006 their knowledge, so they could judge when to answer and November 2007, respectively). The planning patients’ questions and when to refer them to others. and self-evaluation tool for this assessment Some participants said it would be helpful to have has 16 dimensions, divided equally into the financial support to enable medical assistants to complementary categories of patient support and attend classes. The group also talked about frequent organizational support. The first group is composed staff turnover, a common problem for several of elements of service delivery shown to enhance grantees, which only heightens the need for frequent patient self-management in areas such as medication staff training. management, healthy eating, and emotional health. The second group is composed of system Monitoring Results and Using Data to changes that must be made to integrate and sustain Support Improvement self-management support. Another critical dimension of self-management support and this initiative is what Alan Glaseroff, All sites made statistically significant changes in 15 M.D., medical director of Humboldt-Del Norte of the 16 dimensions of organizational capacity. IPA, calls “involving people with their numbers.”7 The greatest institutional gains were in the priority The grantees were responsible for tracking and areas for this initiative. Among the patient-oriented 8  |  C alifornia H ealth C are F oundation measures, the largest changes related to the supports As noted, increasing provider satisfaction was one of for patient involvement, problem-solving skills, and the goals of this initiative. Primary care physicians goal-setting. And related to organizational systems can feel discouraged about the lack of progress with for integrating and sustaining this support, the top their chronically ill patients. An intervention that scores were for education and training, patient input, helps them battle burnout and develop skills for and documentation of self-management support. strengthening patients’ control over their future At the final meeting, Emont called particular is beneficial to them as well as to their patients. attention to this solid evidence of institutional Glaseroff observes that physicians need to learn to let change. “Organizationally and culturally,” he said, go of the notion of noncompliance and appreciate “a shift is taking place.” This new capacity lays the complexities of their patients’ lives, especially the groundwork for greater progress by individual those with low incomes and related disadvantages. patients. “This is about giving people hope, giving them something they can do well at. Over time this will Provider Satisfaction produce results.”8 Every quarter, the core members of the self-management support teams were asked these Cheryl Laymon, director of the Samuel Dixon questions: Family Center, comments that for her clinic’s providers, learning to collect and use data was key. 1.How satisfied are you with how well you and Providers learned to see individual patients as part your staff are helping your patients manage their of a population and to observe trends in their care chronic illness? and outcomes — a new perspective for them. This 2.How satisfied do you think your patients are enabled them to “look past individuals to groups, with how you are helping them manage their stay focused on solutions, and see the progress they’re chronic illness? making.” 3.How satisfied are you with how well you and Patient Indicators your staff are involving patients in their own The patients in the CHCF initiative were asked 11 care? questions every quarter, with four possible answers: 4.How satisfied are you that your patients’ “I do not agree,” “I’m not sure,” “I agree a little,” self-management goals and plans are assessed in or “I agree a lot.” The most significant changes for a standardized manner? patients took place in the third category, lifestyle changes, particularly related to meal plans. 5.How satisfied are you that the self-management tools and protocols your clinic is using are How I feel about taking care of my diabetes: making a difference in your patients’ clinical outcomes? 1.I can tell my doctor what is wrong with me even if my doctor does not ask me. Over the six quarters of data collection, roughly 2.I am sure that I can follow my diabetes care plan. half of the sites had positive trends in providers’ satisfaction with their ability to provide 3.I know what I need to do to take good care of self-management support. The mean percentage my health. of providers answering “extremely satisfied” to 4.What I do can make a big difference in my questions 1, 4 and 5 showed significant progress over health. this period. Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned  |  9 My plan for diabetes care: M.D., describes a positive feedback loop: when the patients see that their doctors are interested in the 5.My doctor and I work together on a plan to help numbers, they get more interested themselves, and control my diabetes. vice versa. 6.My doctor asks for my ideas when we work on my diabetes plan. One of the tools available to CHCF grantees was an 7.My doctor helps me make a diabetes plan I can action plan, “My Diabetes Plan,” which providers follow every day. could use to structure the conversation with patients about goals and steps toward them (see example Making changes in my life: at www.chcf.org). As the project results show, measurable clinical improvements are difficult to 8.Over the past week, I was able to stick with my achieve and, at best, take time. At the final meeting, meal plan. the grantees agreed that it is important to emphasize 9.Over the past week, I was able to stick with my patients’ successes and not “set them up for failure” exercise plan. with overly ambitious goals. Many felt that while the action plans are a useful tool for providing consistent 1 0.(if applicable) Over the past week, I took all of self-management support and collaborative problem- my prescribed medicines when I was supposed solving, clinicians should regard them as facilitating a to. process rather than as an end in themselves. 1 1.Over the past week, I checked my blood sugar when I was supposed to. Emont and Glaseroff were strong voices for the benefits of using data instruments and data. At the In addition, the grantee organizations tracked final meeting, they reminded the participants of the the patients’ documented goals as well clinical maxim about management and measurement,9 and measures, including HbA1c levels, blood pressure, encouraged the grantees to continue surveying their LDL levels, and body mass index. While there was patients and providers and measuring outcomes. positive change in documented self-management Most participants report that they intend to do so. goals (positive changes occurred in nine of 15 sites), For some, this measurement activity is an explicit the only aggregate clinical indicator to approach part of their broader quality improvement efforts. statistical significance over this relatively short period was a reduction in LDL levels. Handling Challenges and Building on Successes Monterey County’s A1c campaign stands out as an Perhaps the most meaningful sign of the success example of what can be done to involve individual of this initiative is that the grantees intend to patients with their numbers. They created a popular continue providing self-management support to their patient education campaign that teaches about the patients. In addition, some project sites are working significance of A1c levels and uses patients’ data toward extending the intervention to other chronic to motivate them to improve. Educational posters conditions and/or to new parts of their institutions are posted throughout the clinic, and patients or new service areas. In their final meeting, which receive special stickers when their levels are below focused on consolidating lessons learned and 7. Through these strong graphic devices, which sustaining projects in the future, the grantees had are reinforced throughout the process of care, a chance to share experiences and discuss ways to even patients with limited English and literacy build on what they had learned. They also discussed are empowered to track their results and see their common challenges, of which the most frustrating progress. Clinic Medical Director Laura Solorio, is staff turnover. The recommended response is the 10  |  C alifornia H ealth C are F oundation same as it is for creating self-management support by ongoing practicing and mentoring. Participants programs: frequent training. expressed interest in getting copies of his curriculum and observing his training sessions. At this meeting, the group heard two presentations on what might be called “advanced self-management support” — significant team redesign and community outreach efforts that are natural next steps for organizations to take toward sustainable self-management support. The first presenter was Glaseroff, who described the multifaceted diabetes initiative he has led in Humboldt County since 2003. “We’re working to create a community-wide social movement,” he said, “involving patients, health care providers, politicians, and employers around the notion of improving the community’s health.” The use of data that are continually fed back to local clinicians is an integral part of the process, along with training in collaborative primary care strategies. The grantees expressed special interest in his initiative’s Health Education Alliance, which uses an adult learning theory-based curriculum that has been certified by the American Diabetes Association. The Alliance is part of an evolving community- based self-management referral system in Humboldt County that also features a peer-led support group called Peer Outreach Education Team (POET). Bodenheimer reported briefly on his pilot project to introduce a “teamlet” model for working with San Francisco General Hospital’s chronically ill patients. Family practice residents are paired with “coaches” (promotoras or medical assistants) in teamlets that, by covering several aspects of the patient visit, can spend longer than the requisite 12 to 15 minutes with each one. All coaches are culturally concordant with patients. When the coach knows what he or she is doing, he said, the teamlets are successful and the physicians like being part of them. Bodenheimer said his motto is “train to sustain.” He described his staff training work, aimed at bringing about “the key paradigm shift — from directive to collaborative.” He tells staff members, “Stop telling people what to do and start asking.” His training curriculum involves six one-hour sessions, followed Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned  |  11 III. Summary: Lessons for the Field In summary, the CHCF initiative Promoting Effective Self-Management Approaches to Improve Chronic Disease Care produced the following lessons for the field: Self-Management Support K Core elements of integrating self-management support into care are motivational interviewing training, measurement, and feedback. K The self-management support model used in this initiative can and should be adapted based upon organizational resources and priorities. K Patient behavior change and improvements in clinical outcomes take time. Institutional change is the first step and priority, and lays the groundwork for other changes. K Self-management support is part of a broader set of changes laid out in the Chronic Care Model, all of which are necessary to improve chronic disease care. The dimensions include self-management support, decision support, delivery-system design, clinical information systems, the organization of health care, and alliances with the community. System Design and Patient Flow K For self-management support to be effectively integrated into care, sites need to rethink their team composition and workflow. K Clinical and administrative champions are needed in each site. K It is possible to integrate self-management support into primary care without making physicians the major agents of the intervention. Doctors’ participation is essential, but they are already at their limit and can play a supportive role. In addition, this approach cannot be imposed on them; their buy-in must be secured. K Some questions remain about the appropriate roles for medical assistants and community health workers; there is agreement they need considerable training and mentoring to be effective team members. 12  |  C alifornia H ealth C are F oundation Training K For all participating team members, on-site staff training and hands-on experience, with regular boosters, are key. K Confidence-building is key, for both providers and patients. It is important to celebrate success and focus on what patients can do. Action plans can be very useful, but they must be used in a way that does not undermine confidence. Measurement K Measurement and reporting are a critical dimension of self-management support for all participants, including the organization, individual providers, and patients. K Many organizations have a steep learning curve in developing appropriate measurement systems and learning to use the data to motivate change. K Feedback to providers is a critical component of closing the measurement loop, so they can understand how to readjust their interventions. Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned  |  13 Appendix A: Grantee Case Studies: Four Projects Southern California Permanente Medical Monterey County Health Department (Salinas) Group (Riverside) As a Federally Qualified Health Center (FQHC), this Kaiser Riverside has five Population Care Nurse grantee serves the low-income population of the Salinas Clinics serving the large and heterogeneous Riverside area, working in collaboration with the Community area. The 270,000 Kaiser members in this area have Health Department. More than half of its patients varied levels of income and literacy as well as diverse speak only Spanish, and all of its medical assistants ethnic backgrounds. Approximately 18,000 have are bilingual. Two of its seven clinics participated in diabetes. Self-management support and action planning the CHCF self-management support project — Alisal are integrated into Kaiser Permanente’s Diabetes Family Practice, located in East Salinas, and Laurel Roadmap, the national framework for diabetes care Internal Medicine, based on the campus of the county for all Kaiser members. In Riverside, Project Manager hospital. Sixty-five percent of the patients of the Laurel Jeanie Taylor, R.N., says that diabetic patients are Internal Medicine Clinic have diabetes. The diabetes introduced to action planning by registered nurses educator is the main agent of the self-management (RNs) in their roles as clinicians, health educators, support intervention, but everyone in the clinic has and case managers. Licensed vocational nurses (LVNs) been educated in self-management support and plays then make follow-up phone calls to provide health a role. The most distinctive innovation of Monterey care coaching. Focus group discussions with patients County’s project is its A1c program, which uses posters have shown that the follow-up calls help them stay to draw patients’ attention to their A1c levels and focused on their action plans and on track with colorful stickers to reward them when they keep it medications, lab tests, and so on. This is manifested in below 7. They plan to continue the A1c program. In the self-management support initiative’s data: patients’ addition, they are looking for ways to use goals and confidence levels and progress toward goals increased report cards to help patients feel successful, and they following the phone calls. Surveys of staff by Kaiser’s want to develop mini-group visits for peer support. Care Management Institute (CMI) also found that The medical director also is working with the county’s the organization’s RNs value the action planning tool public health nurses to help them incorporate more as a guide for their conversations with patients, and self-management support into their work with that the self-management support process has spurred chronically ill patients. Monterey County participates professional growth for LVNs. Kaiser Riverside plans in the Center for Disease Control’s (CDC) Steps to a to continue using the self-management support model Healthier U.S. initiative. Project leaders reported on with diabetic patients in its five Riverside clinics, and their self-management support program during a recent will also apply the model to other chronic conditions, CDC site visit, and they also have reported on it to starting with heart failure. In addition, Kaiser’s CMI other community health providers. and Inter-Regional Nursing Council are helping to integrate action planning nationally by sharing the value of incorporating it into care models. The CHCF initiative’s action planning tool is now in use in Kaiser Permanente facilities in Ohio, the Northwest, Georgia, Colorado, and Hawaii, as well as in Riverside. 14  |  C alifornia H ealth C are F oundation Northeast Valley Health Corporation Samuel Dixon Family Health Centers (northeast Los Angeles County) (Santa Clarita Valley, Los Angeles County) Northeast Valley is a nonprofit FQHC whose patients Samuel Dixon operates community health centers are predominantly Hispanic, low income, and in two sites, one rural and one in the city of Santa medically indigent. Many speak only Spanish. There Clarita. Although 93 percent of patients who use are about 1,600 people with diabetes in its four adult the health centers are employed, they have have low medicine clinics. In its two smaller clinics, all diabetic incomes and are either underinsured or uninsured. patients are entered into the disease registry and case All staff members are bilingual, as most patients are managed by the Family Medicine Care Coordinator, Hispanic. This is a small, nimble program with just while only high-risk patients (with A1c levels of three providers and an executive director. As a not-for- 9 or greater) are entered into the registry and case profit organization, Samuel Dixon has a governing managed. All providers and care coordinators use the board, and its members have been educated about My Diabetes Plan. At the outset, the organization self-management along with others in the organization. worked with an expert consultant to analyze workflow To provide self-management support, this small and redesign care delivery. Family medicine care staff uses a team model: The physician is the clinical coordinators (usually LVNs) became the main leader, the physician’s assistant plays a key role, and agents of the self-management support intervention, the medical assistant provides backup. The director and were given special training for the job. Clinic reports that their day-long training with Polonsky physicians, who also received training, were enthusiastic was a turning point for them in understanding how about having a standardized process for supporting to support patients in self-management. During the self-management, and surveys showed early positive project, Samuel Dixon’s lead staff wrote a full-page results for both patients and providers. However, about “Self-Management Mission Statement: A Philosophy of eight months into the project, Northeast Valley lost Patient Care” that concludes, “We encourage our staff all of its care coordinators, typifying the staff turnover to actively seek out barriers and work with our patients problem that plagues many safety-net providers. After a to develop action plans that support the patient as the dip in survey results, Northeast’s patients and providers head of the healthcare team.” The organization plans to are again showing progress in self-management. The continue supporting self-management for patients with organization plans to continue the intervention in diabetes and other chronic conditions, and providing the future, and it may increase the role of medical appropriate training and refreshers for staff members. assistants if it can find the resources to adequately They are considering having providers use the CHCF train and mentor them. Leaders also plan to support initiative’s patient satisfaction survey, with its emphasis self-management for patients with other conditions, on goals, as a tool in their interactions with all their such as asthma and hypertension, and to continue to patients. evaluate the impact of the intervention. Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned  |  15 Appendix B: Report Interviews Veenu Aulakh, M.P.H. Senior Program Officer California HealthCare Foundation Oakland, CA Thomas Bodenheimer, M.D. Adjunct Professor, Dept. of Family and Community Medicine, University of California San Francisco, CA Seth Emont, Ph.D., M.S. Principal White Mountain Research Associates, LLC Danbury, NH Alan Glaseroff, M.D. Medical Director Humboldt-Del Norte IPA Eureka, CA Cheryl Laymon Executive Director Samuel Dixon Family Health Centers Val Verde, CA William Polonsky, Ph.D., C.D.E. President Behavioral Diabetes Institute San Diego, CA Debra Rosen, R.N., M.P.H. Program Director, Chronic Disease Programs Northeast Valley Health Corporation San Fernando, CA Laura Solorio, M.D. Medical Director Clinic Services Division Monterey County Health Department Salinas, CA Jeanie Taylor, R.N., M.S.N., C.D.E. Nursing Project Coordinator Care Management Department Southern California Permanente Medical Group Riverside, CA 16  |  C alifornia H ealth C are F oundation Appendix C: Grantees Arroyo Vista Family Health Center, Los Angeles, CA Brookside Community Health Center San Pablo, CA LifeLong Medical Care Berkeley, CA Monterey County Health Department Salinas, CA NorthEast Valley Health Center Los Angeles, CA Petaluma Health Center Petaluma, CA Samuel Dixon Family Health Center Val Verde, CA Solano Coalition for Better Health Solano County, CA South Bay Family Healthcare Center Torrance, CA Southern California Permanente Medical Group Riverside, CA Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned  |  17 Endnotes 1. Improving Chronic Illness Care, “The Chronic Care Model,” 2007. www.improvingchroniccare.org 2. Ibid. 3. Bodenheimer T., K. MacGregor and D. Sharifi C. Helping Patients Manage Their Chronic Conditions. California HealthCare Foundation, June 2005, page 17. www.chcf.org/topics/chronicdisease/index.cfm?itemID=111768 4. California HealthCare Foundation Request for Proposals, “Promoting Effective Self-Management Approaches to Improve Chronic Disease Care.” September 2005, page 2. 5. That is, actors specially trained to portray patients. 6. California HealthCare Foundation, Patient Self-Management training video. www.chcf.org/topics/chronicdisease/index.cfm?itemID=124673 7. Dr. Glaseroff, a Humboldt County physician who participated in the first self-management support initiative, was a speaker at the November 2007 final meeting and an interviewee for this report. The quotation is from his comments at the final meeting. 8. Interview with Dr. Alan Glasseroff, January 8, 2008. 9. “What gets measured is what gets managed.” 18  |  C alifornia H ealth C are F oundation C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org