Implementing Practical Interventions to Support ...

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In press, The Joint Commission Journal on Quality and Safety, November, 2003 Implementing Practical Interventions to Support Chronic Illness Self-Management in Health Care Settings: Lessons Learned and Recommendations

Russell E. Glasgow, Ph.D. Kaiser Permanente Colorado Connie L. Davis, R.N., M.N., A.R.N.P. Group Health Cooperative of Puget Sound Martha M. Funnell, M.S., R.N., C.D.E. University of Michigan Arne Beck, Ph.D. Kaiser Permanente Colorado

Corresponding Author: Russell E. Glasgow, Ph.D. Kaiser Permanente Colorado P.O. Box 378066 Denver, CO 80237-8066 Mailing Address: P.O. Box 349 Canon City, CO 81215 Phone: 719-275-6540 Fax: 719-275-5704 e-mail: [email protected]

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Abstract: 157

Text: 3,873

Preparation of this article was supported by grant # 35678 from the Robert Wood Johnson Foundation; grant #HS10123 from the Agency for Health Research and Quality (AHRQ); and grants #DK35524 and P60DK 205721from the National Institute of Diabetes, Digestive and Kidney Diseases.

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Abstract Background: This article summarizes our cumulative experiences working with many different health care organizations to improve the integration of patient self-management support into chronic illness care. Methods: We describe a model for self-management support and education that settings can apply to their unique situations. We discuss effective strategies, as well as approaches that generally do not work, at each of three levels: patient-clinician interactions, the office environment, and the systems/policy/environmental level. Results: The text and tables discuss specific recommendations and lessons learned: key crosscutting concepts are that self-management should be: an integral part of primary care; an ongoing iterative process; patient-centered and use collaborative goal setting and decision making; proactive and include problem-solving, outreach, and systematic follow-up; and proactive and population-based. Conclusions: We summarize our experience and speculate on characteristics of learning organizations that are most successful in incorporating self-management principles into practice. We conclude with recommendations for future research and application, and a list of resources.

Keywords: Chronic disease, disease management, self-care, patient education; systems integration, health systems plans, quality control

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Most health care systems in the U.S. are attempting to address the needs of their members with chronic illness. Given demographic projections that our population will continue to age, and that chronic illness problems are becoming the major health issues facing both developed and developing countries,1 such efforts are well justified. Further, self-management support has been identified as the area of disease management that is least often implemented2 and most challenging to integrate into usual care. There is often confusion among the terms self-management (SM), patient education and self-management support (SMS). In this article, we will use the terms as defined in Barlow, et al.:3 Self-management refers to the individual s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition. Efficacious self-management encompasses ability to monitor one s condition and to effect the cognitive, behavioral, and emotional responses necessary to maintain a satisfactory quality of life. SMS is defined as the process of making and refining multi-level changes in health care systems (and the community) to facilitate patient SM. In contrast, patient education is a broader, older term that is often associated with didactic, knowledge-based interventions for a specific condition. We prefer the term SMS because it emphasizes that the necessary changes involve much more than education.4-7 The evidence supporting the effectiveness of SMS has increased dramatically over the past two decades (www.cochrane.org).3;7-12 In this article, we share our combined experiences of over 60 years of clinical work and research facilitating SM. Our views are heavily influenced by, but not limited to, experience working with over 700 organizations as part of RWJF-sponsored Improving Chronic Illness Care collaborative quality improvement programs (www.improvingchroniccare.org), many in conjunction with the Bureau of Primary Health Care (www.healthdisparities.net). We share a

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bias that a SM model should be feasible across different chronic illnesses, rather than specific to a single condition. We think that there are several principles that can be derived from research evidence and clinical experience and have integrated these principles (e.g., key actions needed for successful SMS) into the model presented below (Figure 1). The purposes of this paper are threefold: 1) to outline a model of SMS that is applicable across different chronic illnesses and health care systems; 2) to present recommendations for assisting health care professionals and practice teams to make changes at the multiple levels required for success; and 3) to provide helpful tips, lessons learned, resources and references. The emphasis will be on strategies that are feasible to apply across a wide range of conditions and settings by health educators, care managers, quality improvement specialists, researchers, program evaluators, and clinician leaders. Successful SMS programs involve changes at multiple levels. For simplification, we have categorized these levels into patient-clinician interactions; office environment changes; and health system, policy, and environmental supports. Since these categories overlap partially in implementation, there is also some overlap among issues discussed in these sections. The remaining sections discuss specific recommendations, and lessons learned in implementing improvement strategies at these various levels. Patient-Clinician Interactionsa Wagner, et al11 have summarized the essential elements of SMS as emphasizing the patient s central role in caring for themselves; assessing patient knowledge, skills, behaviors, confidence and barriers; providing effective behavior change interventions; assuring collaborative care-planning and problem-solving; and providing ongoing follow-up and support a

Clinician is broadly defined to include any trained helper. Most often this is a health professional, but can also be a paraprofessional, or trained community member.

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via peers and professionals.

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Strategies for promoting effective interactions between

clinicians and patients are summarized in Table 1. Self-management by patients is not optional but inevitable12 since clinicians are only present for a fraction of the patient s life and nearly all outcomes are mediated through patient behavior. The philosophy of the care team influences the type of SMS it provides. Clinicians who believe they are in control or responsible for a patient s well being are less able to adopt an approach that acknowledges the central role of the patient in their care. Clinicians are responsible to provide information, evidence-based care, and support, but not to guarantee that patients carry out a prescribed set of activities. While providers are accustomed to being deferred to as the expert, a more effective SMS style is to acknowledge the expertise patients have in living with their condition, and provide the amount of information and level of detail that patients desire.13 Successful communication requires the repeated provision of information in increasing detail when the patient is ready to hear it.14 This may occur over the course of years. Certain strategies and techniques are more useful than others. One approach is to adopt an evidence-based, stand-alone program, such as the Chronic Disease Self-Management Program,15 the Arthritis Self-help course16 or Open Airways (for asthma).17 The advantages of such approaches are that the patient receives consistent professional SMS that does not take up time of office staff. The disadvantages are that often a) the costs of such programs are not reimbursed and b) the communication and linkage back to primary care can be problematic. Group medical appointments have gained in popularity, and the savvy clinician will adopt a model that has been demonstrated effective.18:19 Effective group visits involve patients in setting the agenda, deliver clinical care, and cement the relationship of the patient to their primary care team (as well as to other patients). Group activities, telephone care, and email are all evidence-

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based ways to communicate. Clinicians who use a range of ways to interact with patients, and tailor the approach and modality used to patient preferences, will be more likely to meet the needs of more patients. We have found the framework outlined in Figure 1 to be a useful tool in implementing effective SMS. The key steps have recently been refined to be consistent with the 5As (Assess; Advise; Agree; Assist; Arrange) counseling approach20:21 used to train clinicians in smoking cessation and other types of behavior change counseling. ____________________ Figure 1 ____________________ A well-designed SMS system begins with an assessment of the patient s knowledge, beliefs, and behaviors. This assessment is augmented by the patient s clinical data. Assessment data can also provide useful feedback to the team on the quality of care they are delivering. Next, the clinician advises the patient by providing specific information about health risks and the benefits of change. Specific data about the patient (such as lab values, physical exam findings, or functional status) are used together with knowledge about the patient to frame and present information in ways that patients can understand, and to relate their SM behaviors to their health status. Clinicians must be mindful of the patient s level of understanding and health literacy and numeracy. Many patients do not understand common clinical terms such as acute, and stable, or progressive , and cannot understand a simple graph. Similarly, providing too much information or in a hurried manner does not help patient s learning.22 The key is to relate the patient s SM behavior(s) to their values and clinical outcomes in a way that makes sense to the patient.13

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The next step is agreement. Patients set specific behavior change goals based on their interest and confidence. Goals should be set based on patient priorities and must be clearly specified.23 Too many goals can confuse both patient and clinician. Much has been written about patient-clinician communication skills.13;14;22 Clinicians who cultivate empathic listening do not interrupt patients, but elicit patient beliefs about illness, develop a shared understanding, and negotiate management plans to enhance patient SM skills. Patients are then assisted to develop plans based on their goals. This assistance typically leads to the development of a personal action plan (see center of Figure 1) which describes specifically what the patient wants to do and helps them to anticipate barriers and identify strategies to overcome barriers. Problem-solving is a central component of effective SMS.9;23 Finally, a follow-up plan is arranged. This is frequently accomplished via telephone, or more recently, e-mail. Such follow-up has been demonstrated to be very cost-effective.24;25 All members of the health care team need to be aware of the patient s action plan and reinforce his/her goals. For example, the staff member who takes vital signs can ask patients about the status of their plan. Any staff member trained in action-planning and problem-solving can do follow-up via telephone. _________________ Table 1 _________________ The Office Environment: Changing Practices Most health care practices are based on the traditional model of acute, episodic care.26;27 SMS is usually provided only sporadically as needs arise or through referral to a one-time series of education classes. As a result, SMS is rarely integrated into the medical care provided to the patient.6 Along with adopting new roles and using effective communication strategies to develop

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collaborative relationships with individual patients, practices need to be redesigned to support effective partnerships between clinicians and patients.28 Practice redesign for SMS needs to involve all staff who come into contact with patients. The process for making changes in a practice is very parallel to the 5 A s model used to assist patients in their SM behaviors. The first step is to assess the practice to determine the extent that SMS is being provided, if personnel are being used efficiently for this purpose, and if systems or technology are available to support SM. Assessment strategies and methods include: targeted telephone interviews or focus groups with current and past patients, review of patient records and outcomes, interviews with staff at all levels about current barriers and facilitators for delivery of SMS, and a review of current practice design evaluating efficiency, effectiveness, patient satisfaction and technology. Advice, the second step, involves obtaining recommendations for practice change based upon the assessment information. This advice is customized to fit the given clinical setting, just as advice to individual patients is tailored to their unique needs and situation. The third step is for the practice team to agree upon a common vision of patient-centered care. While this sounds straightforward, embracing this approach involves a major shift for many health care professionals.29 Most have been trained and socialized in clinician-centered practices, where interventions are chosen by clinicians and patients are expected to “comply” with SM recommendations. Many professionals struggle to give up compliance-based approaches even though these are incompatible with collaborative, patient-centered care.30;31 Practices cannot be both clinician-centered and patient-centered. To be effective, practice teams need to achieve clarity and consensus about their vision and the roles each team member will adopt. Table 2 identifies effective and ineffective visions for patient-centered practices. The fourth step is to identify and implement problem-solving strategies to assist the practice in patient-centered SMS. Renders, et al32 reported on 41 studies of practice-based strategies that cumulatively involved more than 200 practices and 48,000 patients. Among the

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findings of this structured review was that practices providing multiple interventions in which patient education was included or the role of the nurse was enhanced reported more favorable outcomes. Specific strategies for incorporating SMS include:


using a team of professionals within a practice, system or community;33;34




implementing case-management;35-38




using interactive technology to enhance self-management support;39;40




group or cluster visits;18;28




use of standardized instruments or electronic medical records;41

Most practices are currently designed so that care and education are delivered by the physician or nurse practitioner and office nurse, when available. SMS is often viewed as an add-on at the end of the visit. Extra time is spent with the patient, which becomes a significant barrier in most practices as it is costly and challenging to implement. Documentation is often not done, so SMS is not reinforced. To be efficient and cost-effective, SMS needs to be integrated throughout the entire visit and by all staff members.42 Figure 2 illustrates strategies that can be used to redesign practices so that SMS is provided throughout the entire visit without negatively impacting patient flow. _________________ Figure 2 _________________ Office teams also need to arrange follow-up evaluation of results--the final step in practice change. Rapid cycle improvements based on the “Model for Improvement,” which uses Plan-Do-Study Act (PDSA) cycles to rapidly test, implement and spread successful system change is a widely used improvement process via which to test SMS strategeies.34;43;44 One key is to experiment with small changes or steps towards a larger goal, and then evaluate the results as

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part of an ongoing process of practice redesign. This helps practices to avoid the two most common pitfalls of practice redesign. The first is to attempt many major changes at once, fail, give up and go back to the old ways. The second pitfall is to attempt to plan a completely failproof system with a very detailed implementation plan. In spite of all of this planning, an unidentified problem often occurs causing the team to become discouraged and give up.4 We have referred to this as the “PPPP” model (Plan, Plan, Plan, Panic) as contrasted with the rapid cycle PDSA approach. Just as patients need ongoing support to sustain behavior changes, so do practices. It can be hard for professionals to make and sustain changes in professional behaviors without support from other team members. It is important that teams experiment and feel able to try practice changes without the fear of failure. One effective approach is for individuals to conduct personal PDSA cycles and for the practice to create opportunities for staff to discuss their experiences and create new plans as needed. These strategies help teams to sustain new practice patterns and also help them to better understand the needs that patients have for on-going support through firsthand experience. Often the most challenging practice change is to abandon old methods and approaches. It is difficult to adopt new and initially less comfortable ways of interacting with patients. It is easy to adopt a “that won’t work here” or “my patients can’t or won’t” attitude. However, once health care professionals experience positive outcomes using collaborative methods of care, practice redesign logically follows. _________________ Table 2 _________________ Systems, Policy, and Environmental Support for Self-Management

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Philosophy. Patient-clinician interactions occur within the context of and are influenced by increasingly complex health care systems and policies, and the broader context of the social, political, and physical environment. Such influences play a critical role in the success or failure of SMS programs. Organizational factors that support successful SMS programs include the obvious: commitment of financial resources for staff (e.g., care managers) and capital equipment (e.g., electronic medical records, patient tracking and reminder systems); a high degree of clinical integration; facilitating multidisciplinary team SMS at the service delivery level (onestop shopping) and complemented by information systems that provide critical SMS process and outcome data.45 Sometimes less obvious are factors associated with organizational readiness to adopt SMS, including organizational climate and culture and commitment by the organization s leaders.46;47 Commitment by senior leaders might be evidenced by incorporating SMS principles into the organization s mission and vision statements, or by their assistance with identifying and supporting SMS champions at both senior and operational levels. Financial pressures, nursing shortages, and competition in the health care market can all contribute to turbulence46-47 that reduces the ability of organizations to adopt new and innovative practices. An organizational climate that fosters innovation, risk-taking, and team work helps to buffer these negative forces. These characteristics are a hallmark of learning organizations,48 where innovation and nimbleness are encouraged, and knowledge is gained from experiments on an ongoing basis. An organizational climate supportive of SM does not emerge spontaneously. Overreliance on policies and procedures, and analysis paralysis before taking action on new initiatives is often the norm. Similarly, a team orientation, though laudable, is difficult to achieve without effort. Cooperation and collaboration among health care professional groups, clinical

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departments, and even clinics is difficult when budgets for each of these entities are separate, fostering competition for resources. In addition, organizational culture can reinforce perspectives that are antithetical to SMS in both the clinical care and financial realms. The former occurs when the organization holds a clinician-oriented perspective rather than a patient perspective, and the latter when a focus on short-term financial goals takes precedence over a longer-term perspective that is more consonant with SMS activities. Specific techniques and methods. The philosophical issues discussed above can guide systems-level techniques and methods to aid in implementing and sustaining SMS. These include marketing, establishing incentives to adopt SMS activities, cultivating executive support, reorganizing operations and policies to promote a nimble approach, and support to reorganize resources for SMS. Marketing techniques such as academic detailing49 have been shown to be effective in encouraging clinicians to adopt new practices. Because many clinicians, especially physicians, are empirically-minded, a critical component of marketing SMS is to show evidence of its effectiveness and cost-effectiveness in similar settings. Once this educational foundation is established, clinicians must be convinced that adoption of SMS activities are feasible in their setting and will not adversely impact their workload. SMS must be marketed as set of activities that is integral to clinical practice, not a marginalized, optional, stand-alone activity.12 Incentives for SMS come in a variety of forms. Public feedback (e.g., data on promotion of SM behaviors) with rewards for performance help reinforce SMS. Incentives are important in motivating and reinforcing patients adoption of SM practices as well. For example, some health plans waive co-pays for prevention related visits (e.g., mammograms, immunizations). Waiving or reducing co-pays for behavior change counseling can produce the same effect. Other

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incentives to adopt SM include integrating SMS activities into primary care practice (e.g., providing prompts for behavior change counseling or referral via an electronic medical record). Finally, consistent with the notion that one manages what one measures, incorporating SMS activities into individual, departmental, clinic, and organizational performance criteria may be necessary to sustain SMS. In the resource-constrained environment that health care organizations face, caution must be exercised in selecting new programs or activities. Asking teams to add SMS activities to their already heavy workloads can create a perverse incentive for SMS adoption. Adding resources, typically clinical staff, is the easiest approach to support SMS. However, this option is often unavailable when operating budgets must be neutral. The more difficult, but promising approach, involves careful assessment and redesign of staff roles to incorporate SMS within existing budgets. This entails evaluating whether SMS activities can substitute for other routine but low value activities (e.g., having nurses spend more time counseling patients by phone or in person, rather than putting patients in exam rooms). The growing sophistication of information systems (electronic medical records, disease registries) provides another opportunity for more easily incorporating SMS. Clinician prompts, SMS guidelines, automated tailoring and printing or emailing of patient education materials are examples of techniques that exploit information technology to support SMS39;40 and may actually save clinician time and create more informed patient-clinician visits. Finally, linkages to and collaboration with other community organizations and resources is an important key to success. Patients live, work, and recreate in social and physical environments outside of the health care system. Strategic analyses and support of opportunities to provide contextual support for SM are critical for long-term results.

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_________________ Table 3 _________________

Summary and Conclusions There is no magic bullet or strategy that works in all situations or settings. There are, however, some cross-cutting principles that are helpful in teaching and implementing systemsbased chronic illness SMS efforts. These principles (Table 4) work best if tailored to the local setting and tested in an iterative trial and error approach, rather than employed in an automatic manner with the expectation of complete success without refinement. The first principle is that there are many parallels among change efforts at the individual, office environment, and broader contextual levels. Empowerment approaches that provide information, tools and resources, but allow the patient--or staff--to make the important decisions and to tailor improvement efforts are applicable at all levels. Rather than expecting improvement to be immediate, dramatic and permanent, more realistic expectations are that improvement will be gradual, refinements will be necessary and that slips are to be expected, but can be managed and problem-solved.50 The second principle is that behavior change--either of individuals or of systems--does not occur in a vacuum, but rather in a complex web of interconnecting social, economic and technical influences. Addressing these contextual factors leads to better solutions and often enlistment of natural support mechanisms or networks of others with similar goals. The intervention style we recommend is more structured and directive at the beginning, but much less so over time as patients--or teams--gain experience, success, and confidence. It is important not to be totally non-directive or to give the impression that anything works as well as anything

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else. 14 However, the level of structure should gradually be faded as patients--and staff--acquire greater expertise. They often become wonderful role models for each other--trading ideas, strategies, and stories about how challenges were overcome.4 _________________ Table 4 _________________

The last three principles come from working with clinicians who sort of get it, but do not make fundamental changes or sustain changes over time. Today, there are few clinicians who would say that they are not patient-centered or managers who would say that they do not use participatory decision-making methods. However, there are important differences between abstract understanding of a change concept such as being population-based, and putting such tenets into practice. This is why didactic presentations are generally insufficient to promote behavior change: actual rehearsal, practice and successful real-world implementation of new skills are generally necessary to produce significant or lasting change--be it of patients or clinicians.51;52 An important tool to assess how one is doing is to involve ongoing measurement of key improvement indicators; ideally including both process and outcome indices. Finally, it is important to keep one s focus on the denominator of all patients, clinicians, clinics, etc., in one s system and not to rest on initial success with early adopters.

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The ultimate test of a

SMS system is if change efforts attract and produce sustained change among the vast majority of members--and especially those who could most benefit from improvement efforts (but are often least likely to participate initially). One system that has implemented many of the above recommendations is the Bureau of Primary Health Care s network of community and migrant health centers across the U.S.

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(www.healthdisparities.net). Following participation of 5 community health center teams in an initial chronic illness improvement collaborative,4;34 they have spread this care model using a train-the-trainers strategy to over 500 health care centers across the country. Beginning from an initial focus on one or two chronic illnesses, these health centers have created their own regional collaboratives on diabetes, depression, heart failure, asthma, and more recently cancer screening and prevention (www.healthdisparities.net). Throughout this process, the community health centers have consistently emphasized the use of the rapid cycle PDSA change methodology, and a focus on SMS programs that are patient-centered; proactive; and populationbased. A large part of our optimism regarding the potential of modern SMS improvement efforts results from the successes of these clinics--which often have the most challenged and disadvantaged patients and the fewest per capita resources. We conclude with a brief listing of resources. These are not the only helpful tools--the availability of such books, journal articles, websites, and training programs is constantly changing. They are some of the most widely available, general SMS resources that we have found useful in our work with a large number of different health care systems, teams, and illnesses.

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Annotated Bibliography of Recommended Resources Books: The Art of Empowerment: Stories and Strategies for Diabetes Educators Authors: B. Anderson, M. Funnell American Diabetes Association (2000) Alexandria, VA This book is written to help educators create partnerships with patients through stories and questions for reflection. Based on extensive experience and research in the area of patient empowerment, the book is designed to be used for self-study by individuals or groups of educators and is published by the American Diabetes Association (www.diabetes.org). The information is relevant for working with patients having other chronic illnesses besides diabetes. Health Behavior Change: A Guide for Clinicians Authors: S. Rollnick, P. Mason, C. Butler Churchill Livingston (1999) New York A readable explanation and examples of the use of patient-centered motivational interviewing strategies in health care. This brief intervention and counseling approach is being applied in a wide variety of health behavior change areas and different health conditions. Edgeware: Insights from Complexity Science for Health Care Leaders Editors: B. Zimmerman, C. Lindberg, P. Plsek VHA, Inc. (2001) Irving, TX A readable and provocative explication of the principles and ways to utilize complexity theory for organization improvement. Journal Articles: Barlow J, Wright C, Sheasby J, et al: Self-management approaches for people with chronic conditions: A review. Patient Education and Counseling 2002:177-187. This review article provides an overview of the types of self-management interventions used and their effectiveness for different chronic conditions. It summarizes the results of randomized trials and contains implications for practice as well as a good definition of self-management and a nice reference list. Funnell MM, Anderson RM. Changing office practice and health care systems to facilitate diabetes self-management. Current Diabetes Reports 2003 3(2):127-133. A user-friendly discussion of the philosophy, approach, and strategies for conducting miniexperiments to change the delivery of care to make chronic illness care more patient-centered.

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Glasgow RE, Funnell MM, et al: Self-management aspects of the Improving Chronic Illness Care Breakthrough series: Design and implementation with diabetes and heart failure teams. Annals of Behavioral Medicine 2002; 24:80-87. This paper describes efforts to integrate self-management support into routine medical care by diabetes and congestive heart failure teams in the Chronic Illness Care Breakthrough Series. The experiences and strategies used by 21 health care teams are reported. Lorig KR, Sobel DS, Stewart AL, Brown BW, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization. Medical Care 1999;37:5-14. A real-world report of the experience in implementing the authors chronic disease selfmanagement program in many different settings throughout many different Kaiser Permanente managed care organizations and with professional and lay group leaders.

Websites: www.improvingchroniccare.org Website of the Robert Wood Johnson Foundation supported Improving Chronic Illness Care program. Contains information on the applications of the Chronic Care Model of Wagner and colleagues. www.cochrane.org Website of the Cochrane Collatoration, an international project devoted to conducting and maintaining updated reviews of the evidence in many different areas of health care. Also contains reviews of self-management and behavior change evidence on topics such as physical activity, healthy eating, and smoking cessation.

www.healthdisparities.net Website of the Bureau of Primary Health Care and the Institute for Health Care Improvement s collaborative effort among community and migrant health centers to improve access to and quality of care for chronic illness among underserved and minority patients. Contains many examples of low-literacy self-management tools and improvement activities.

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References 1. World Health Organization. Non-communicable diseases and mental health division. Innovative care for chronic conditions: Building blocks for action. 2002. Geneva, World Health Organization. 2. Glasgow RE, Strycker LA: Level of preventive practices for diabetes management: patient, physician, and office correlates in two primary care samples. Am J Prev Med 19:914, 2000. 3. Barlow JH, Wright C, Sheasby J, et al: Self-management approaches for people with chronic conditions: A review. Patient Educ Couns 48:177-187, 2002. 4. Glasgow RE, Funnell MM, Bonomi AE, et al: Self-management aspects of the improving chronic illness care Breakthrough Series: Implementation with diabetes and heart failure teams. Ann Behav Med 24:80-87, 2002. 5. Clark NM, Becker MH, Lorig K, et al: Self-management of chronic disease by older adults: A review and questions for research. J Aging Health 3:3-27, 1991. 6. Funnell MM, Anderson RM. Changing office practice and health care systems to facilitate diabetes self-management. Curr Diabetes Rep 3(2):127-133, 2003. 7. Norris SL, Engelgau MM, Narayan KM: Effectiveness of self-management training in type 2 diabetes: Systematic review of randomized controlled trials. Diabetes Care 24:561-587, 2001. 8. Lorig KR, Sobel DS, Stewart AL, et al: Evidence suggesting that a chronic disease selfmanagement program can improve health status while reducing hospitalization. Med Care 37:5-14, 1999. 9. Center for the Advancement of Health. Essential elements of self-management interventions. 2002. Washington, D.C. 10. The Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Eng J Med 346:393-403, 2002. 11. Wagner EH, Austin BT, Davis C, et al: Improving chronic illness care: Translating evidence into action. Health Affairs 20:64-78, 2001.

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12. Bodenheimer TS, Lorig K, Holman H, et al: Patient self-management of chronic disease in primary care. JAMA 288:2469-2475, 2002. 13. Anderson RM, Funnell MM: The art of empowerment: Stories and strategies for diabetes educators. Alexandria, VA, American Diabetes Association, 2000. 14. Rollnick S, Mason P, Butler C: Health behavior change: A guide for clinicians. New York, Churchill Livingstone, 1999. 15. Lorig K, Holman H, Sobel D, et al: Living a healthy life with chronic conditions. Palo Alto, CA, Bull Publishing, 2000. 16. Lorig K, Holman H: Arthritis self-management studies: A twelve-year review. Health Educ Q 20:17-28, 1993. 17. Evans D, Clark NM, Feldman CH, et al: A school health education program for children with asthma aged 8-11 years. Health Educ Q 14:267-279, 1987. 18. Beck A, Scott J, Williams P, et al: A randomized trial of group outpatient visits for chronically ill older HMO members: The cooperative health care clinic. JAGS 45:543-549, 1997. 19. Sadur CN, Moline N, Costa M, et al: Diabetes management in a health maintenance organization: Efficacy of care management using cluster visits. Diabetes Care 22:20112017, 1999. 20. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: Clinical practice guideline. June. 2000. Rockville, MD, U.S. Department of Health and Human Services, Public Health Service. 21. Whitlock EP, Orleans CT, Pender N, et al: Evaluating primary care behavioral counseling interventions: An evidence-based approach. Am J Prev Med 22:267-284, 2002. 22. Goldstein MR, DePue J: Models for provider-patient interaction: Applications to health behavior change, in Shumaker S, Schron EB, McBee WL (Eds): The handbook of health behavior change. New York, Springer, 1998, pp 85-113.

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23. Nezu AM, Nezu CM: Clinical decision making in behavior therapy: A problem-solving perspective. Champaign, IL, Research Press, 1989. 24. Wasson J, Gaudette C, Whaley F, et al: Telephone care as a substitute for routine clinic follow-up. JAMA 267:1788-1793, 1992. 25. Piette JD, Weinberger M, McPhee SJ: The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care (a randomized controlled trial). Med Care 38:218-230, 2000. 26. Hiss RG: Barriers to care in non-insulin-dependent diabetes mellitus, The Michigan experience. Ann Intern Med 124(1):146-148, 1996. 27. Glasgow RE, Hiss RG, Anderson RM, et al: Report of Health Care Delivery Work Group: Behavioral research related to the establishment of a chronic disease model for diabetes care. Diabetes Care 24:124-130, 2001. 28. Wagner EH, Grothaus LC, Sandhu N, et al: Chronic care clinics for diabetes in primary care: A system-wide randomized trial. Diabetes Care 24:695-700, 2001. 29. Anderson RM: Patient empowerment and the traditional medical model. Diabetes Care 18:412-415, 1995. 30. Glasgow RE, Anderson RM: In diabetes care, moving from compliance to adherence is not enough: Something entirely different is needed. Diabetes Care 22:2090-2092, 1999. 31. Funnell MM, Anderson RM: The problem with compliance in diabetes. JAMA 284:1709, 2000. 32. Renders CM, Valk GD, Griffin SM, et al: Interventions to improve the management of diabetes in primary care, outpatient, and community settings: A systematic review. Diabetes Care 24:1821-1833, 2001. 33. National Diabetes Education Program. Team care: Comprehensive lifetime management for diabetes. 2001. Bethesda, MD, National Institutes of Health; Centers for Disease Control and Prevention.

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34. Wagner EH, Glasgow RE, Davis C, et al: Quality improvement in chronic illness care: A collaborative approach. Journal of Joint Commission on Health Care Quality 27:63-80, 2001. 35. Aubert RE, Herman WH, Waters J, et al: Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Ann Intern Med 129:605-612, 1998. 36. Norris SL, Lau J, Smith SJ, et al: Self-management education for adults with type 2 diabetes: A meta-analysis on the effect on glycemic control. Diabetes Care 25:1159-1171, 2002. 37. Norris SL, Nichols PJ, Caspersen CJ, et al: The effectiveness of disease and case management for people with diabetes. A systematic review. Am J Prev Med 22:15-38, 2002. 38. Hiss RG, Greenfield S: Forum Three: Changes in the U.S. health care system that would facilitate improved care for non-insulin-dependent diabetes mellitus. Ann Intern Med 124(1):180-183, 1996. 39. Piette J: Enhancing support via interactive technologies. Current Diabetes Reports 2:160165, 2002. 40. Glasgow RE, Bull SS: Making a difference with interactive technology: Considerations in using and evaluating computerized aids for diabetes self-management education. Diabetes Spectrum 14:99-106, 2001. 41. McDiarmid T, Chambliss ML, Koval PB, et al: Improving office-based preventive care for diabetes. The beneficial results of a patient questionnaire and a flow chart. North Carolina Medical Journal 62:8-13, 2001. 42. Glasgow RE, Eakin EG: Medical office-based interventions. In: Snoek FJ, Skinner CS (Eds): Psychological aspects of diabetes care. London, John Wiley and Sons, Ltd., 2000, pp 142-168. 43. Von Korff M, Gruman J, Schaefer J, et al: Collaborative management of chronic illness. Ann Intern Med 19:1097-1102, 1997.

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44. Langley GJ, Nolan KM, Nolan TW, et al: The improvement guide: A practical approach to enhancing organizational performance. San Francisco, Jossey-Bass, 1996. 45. Beck A, Selby J, Roblin D, et al. Clinical integration at the service delivery level. 2001. Center for Health Management Research. 46. Axelrod R, Cohen MD: Harnessing complexity: Organizational implications of a scientific frontier. New York, Simon & Schuster, 2000. 47. Zimmerman B, Lindberg C, Plsek P: Edgeware: Insights from complexity science for health care leaders. Irving, TX, VHA, Inc., 2001. 48. Senge PM: The fifth discipline: The art and practice of the learning organization. New York, Currency Doubleday, 1994. 49. Tu K, Davis D: Can we alter physician behavior by educational methods? Lessons learned from studies of the management and follow-up of hypertension. J Contin Educ Health Prof 22:11-22, 2002. 50. Marlatt GA, Gordon JR: Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York, Guilford Press, 1985. 51. Bandura A: Self-efficacy: The exercise of control. New York, W.H. Freeman, 1997. 52. Glanz K, Lewis FM, Rimer BK: Health behavior and health education: Theory, research and practice. San Francisco, John Wiley & Sons, 2002. 53. Rogers EM: Diffusion of innovations. New York, Free Press, 1995. 54. Berwick DM: A primer on leading the improvement of systems. BMJ 312:619-622, 1996.

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Table 1. Patient-Clinician Interaction Level Tips What Works

What Does Not Work

Philosophy Patient-centered, acknowledging patient expertise in their own life Responsibility TO patients

Clinician knows best, care based on clinician needs Responsible FOR patients

Self-directed, iterative, and ongoing support

One-time educational sessions

Strategies and Techniques Evidence-based programs that patients can choose to participate in Group interactions following tested models Various SMS methods (group, individual, electronic, telephonic, in person) ASSESS Brief standardized assessments with feedback to both patient and team on progress/status Assessment of patients view of progress and how behaviors relate to risks/benefits, goal attainment, and values ADVISE Personalized feedback on lab values, exam findings or functional status related to risks/benefits and ways behaviors can affect outcomes Participatory decision-making with patient determined level of involvement Learner directed, tailored to person and environment Problem-based learning Listening to patients AGREE Collaborative goal setting based on patient priorities and data review Action planning for specific behavior changes ASSIST Problem-solving based approach; linked to patient social environment and identified barriers ARRANGE Follow-up (in person, phone or email)

One-time referral Groups without clear clinical care or behavior change support Only one program or approach

Trying to do behavior change work without any assessment or baseline information Assuming patient shares same goals, values, and understanding of condition as the professional

Rushed or overly complicated feedback that patient cannot understand or does not appear to be relevant to patient Clinician imposed interaction style Imposed regimen or didactic curriculum Didactic, standardized recommendations Lecturing to patients Clinician imposed goals; taking on too many goals at once Vague recommendations (e.g., lose weight; exercise more) Telling patient what to do, lack of awareness of personal, cultural and community context Failure to follow-up

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Table 2. Office Environment SMS Practices What Works Philosophy Patient-centered Shared responsibility by all staff Shared vision/philosophy Culture of caring Respect for individual needs and response to illness and cultural influences Belief in patient responsibility for decisions, behaviors and outcomes Treating whole patient and their social context and focus on patient quality of life Strategies and Techniques Action plan congruent with clinic flow/philosophy On-going care and self-management support Documentation including a problem list, selfmanagement plan, education provided and patient-selected goals Proactive with regular recall and review of health status and needed tests Tracking systems for meeting standards of care guidelines or performance indices Effective use of pre- or post-clinician visit time for assessment, goal review, SM assessment, and support, and preparing patient to discuss concerns/questions with clinician Use of validated and culturally appropriate assessments and tools Use visit time to support/review selfmanagement Enhanced role of RN and other staff for followup and case-management Focused follow-up (e.g., all team focus on diet with patient rather than diet, exercise and monitoring) Enhanced use of interactive technology for documentation and follow-up

What Doesn t Work

Practice-centered Clinician responsible for all aspects/outcomes Different team members working from different visions/philosophies Business culture/ administration/accounting-centered care Disease-focused Belief that health professionals know best and are responsible to influence decisions, behaviors and outcomes Attempting to treat specific organs or diseases without context

Friction between practice constraints and action plan One-time, episodic care for self-management New plan created at the start of each visit with no follow-up on previous plan Reactive and symptom-driven Relying on clinician memory Using only time allotted with the clinician for care and self-management support

Clinician determined questions for each patient at each visit Focus on physical assessment/medical care only Clinician trying to do it all Trying to change everything at once

Paper--or person--dependent systems

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Use community resources for care, social, psychological and educational needs Use of rapid cycle quality improvement approaches such as PDSA45 Innovative practice designs (e.g., group medical visits) Patient-centered environment (e.g., waiting time spent in interaction with other team, materials available for reading etc.) Involving all staff in planning for practice designs that support SM and create supportive environments

Trying to meet all patient needs in the practice setting Working on perfect plan, nay-saying (e.g., that will never work here, insurance won t reimburse us) Traditional, inflexible practice design SMS only conducted in formal pre-planned setting and not conducive for self-management support Clinician/administrator driven practice

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Table 3. Systems, Policy, and Environmental Support for Self-Management What Works

What Does Not Work

Philosophy Commitment by leaders demonstrated by resource allocation (money, time) and by publicizing the message broadly and repeatedly (town hall meetings, face time with clinic staff); making goals part of organizational mission or vision statements Willingness to take risks, experiment, and to fail without punishment

Multidisciplinary team mentality instead of protecting one s turf mentality Incorporating patient SMS philosophy into practice Champions at the executive and operational levels, including mid-level supervisor Organizational readiness to adopt practices supportive of SMS Long-term financial, clinical, and quality gain perspective instead of short-term financial gain emphasis Partnership approach to community resources and organizations Strategies and Techniques Marketing change: academic detailing, getting buy-in for importance of SMS activities and their incorporation into practice, not as a marginalized stand-alone activity; showing evidence that SMS is effective Incentives for SMS and behavior change counseling: Public feedback (e.g., unblinded clinician performance data) with rewards for good performance; building in structural incentives to adopt SMS, e.g., waiving or reducing co-pays for behavior change

Leaders not walking the talk (lip service but no back up)

Being beholden to existing bureaucratic procedures that stifle innovation and nimbleness. Insisting on planning to death and having every last detail of a perfect system specified BEFORE trying anything new Lack of organizational readiness to adopt SMS practices (e.g., financial pressures (having a bad year with losses, staff shortages, etc.) Reluctance to change clinician or system-oriented perspective to incorporate patient perspective Silo mentality (e.g., protect my budget without regard to organizational bottom line) Not invented here mentality (e.g., just because they developed an effective SMS program at clinic doesn t mean it will work at another) Short-term financial gain or cannot make ANY added expenditures now perspective

Competitive, secretive or elitist relationship with other entities and community programs

Multiple competing priorities for the organization s resources (e.g., how to fund disease managers for CHF and support SMS activities)

Misaligned or perverse incentives for clinicians and patients to engage in SMS activities ( Each system is perfectly designed to get exactly the results it produces. 54

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counseling, integrating SMS into routine primary care practice (e.g., providing behavior change counseling referral prompts for PCPs via electronic medical records; incorporating SMS into department, clinic, and organizational performance criteria so that one manages what one measures ) Executive level support for adoption of SMS Learning organization: Nimble approach incorporating implementation, feedback, and modification loops; de-bureaucratizing Support to reorganize resources, not to add to already overburdened staff load (e.g., someone needs to backfill for clinical or support staff who are trying new approaches to SMS (otherwise adoption is seen as thankless and punishing) Data sharing and continual improvement approach to community organizations Organization being a good citizen and collaborating to create community supports for SM (walking trails)

Lack of concrete or visible executive level support for SMS Lack of support from senior leaders to change ineffective practice routines or overlybureaucratic policies that stifle adoption of SMS Trying to just add more and more onto already overburdened staff (just trying to work harder) without fundamental reorganization Top down, hierarchical approach that does not involve the stakeholders/ those directly impacted by changes Referral only to community programs without feedback Organization participating in community programs only when clearly in short-term financial interests

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Table 4. Recommendations that Apply across SMS Levels

1. Key elements of successful SMS are similar across different levels of change (patientclinician; office environment; and system/policy/environment) - Identify meaningful, specific, measurable and realistic improvement goals in a collaborative and client-centered manner - Identify potential barriers to success and problem-solve solutions - Induce an attitude of this will succeed in time; an expectation that gradual refinement is necessary--do not expect the perfect solution the first time 2. Attend to the surrounding social, technical, economic and environmental context in which the change effort is embedded; look especially for resources and support networks 3. Rely more on participant ideas and experiences over time, and fade the amount of direction and support provided 4. Attend to differences between saying, knowing, and doing 5. Keep everyone s eyes on the prize (measure quality and outcomes and provide regular feedback and recognition/incentives) 6. Keep the focus on the denominator; it is easy to attend only to those participants in front of one and forget about the larger population--including those not yet participating

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ASSESS: Beliefs, Behavior & Knowledge

ARRANGE: Specify plan for follow-up (e.g., visits, phone calls, mailed reminders)

1. 2. 3. 4.

Personal Action Plan List specific goals in behavioral terms List barriers and strategies to address barriers. Specify Follow-up Plan Share plan with practice team and patient s social support

ASSIST: Identify personal barriers, strategies, problem -solving techniques and social/environmental support

Figure 1. Five A s Model of Self-management Support Adapted with permission from Glasgow, et al, 20024

ADVISE: Provide specific information about health risks and benefits of change

AGREE: Collaboratively set goals based on patient s interest and confidence in their ability to change the behavior.

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Prior to Visit Mailed reminder re: goal set last visit, self-monitoring records (e.g., diet, exercise), recommended laboratory tests

Waiting Room Patient completes self-management form or computer-based assessment Surrounded by information on disease management and community programs

Examination Room and Vital Signs Nurse gives feedback on changes since last visit (weight, blood pressure, lipids, disease-specific indices) Inquires about self-management goal since last visit Nurse checks self-management form and asks which area is currently of most concern (circles area for physician; reinforces patient interest; educates on importance of self-care)

Physical Examination (Physician or Nurse Practitioner) Refer to self-management form and discuss area of most concern to patient Message: I see you would most like to discuss.... Diabetes is serious and your behavior is important in managing it Reinforce patient s willingness to change behavior and refer to nurse, health educator, or centralized education resources for specific plan

Nurse, Educator, Dietician Follow-up Review and clarify goals for behavior change in one area of self-care Develop specific, realistic, measurable action plan Have patient identify barriers to goal and assist in problem-solving Plan for continued support: refer to education or support group; community resources; telephone call between visits, etc. Record goal (with copy for patient) and plan for follow-up at subsequent contacts

Figure 2. Sequential Example of Self-Management Support Integrated into Primary Care