Integration of Self-Management Programs into Clinical Settings...Integration of Self-Management Programs into Clinical Settings. Agenda 1. ... COORDINATION AND FACILITATOR COACHING

14 TH ANNUAL SUMMER INSTITUTE

C H A N G E T H E C O N V E R S A T I O N : M A X I M I Z I N G O P P O R T U N I T I E S I N T H E E M E R G I N G H E A L T H C A R E L A N D S C A P E

M E L A N I E M I T R O S , P H D , C E S E X E C U T I V E D I R E C T O R

W W W . A Z L W I . O R G

Integration of Self-Management Programs

into Clinical Settings

Agenda

1. Why Evidence-Based Programs are needed? 2. History of Evidence-based Programs in AZ 3. Learn of the background, structure and purpose

of Healthy Living 4. AZ Data to Date 5. Behavioral Health Programs

2

Arizona Living Well Institute Arizona Living Well Institute

Nationwide Evidence-Based Initiative

y U.S. Administration on Aging funded Initiative 2006 { To transform Aging Services Network to health impacting sites { Brings evidence-based programming to community-based organizations

Ù Stanford University’s CDSMP is the core program

y 2010 American Recovery and Reinvestment Act (ARRA) { Communities Putting Prevention to Work: Chronic Disease Self-

Management Program initiative - $27 million (45 states, District of Columbia and Puerto Rico)

y 2011 NASMHPD Peer Support Specialist Workforce Development Grant

y 2012 ACL-AoA 3rd Round of Self-Management Funding { 22 States to continue to increase reach of EBP to ethnic minority groups

and expand programs available

Arizona Living Well Institute

3

The Business Case for this Work

y Booming Generation (1946-1964) y Chronic conditions account for: { 76% of inpatient hospitalizations* { 88% of all prescriptions filled* { 72% of all physician visits* { 7 out of 10 deaths each year in the US**

y 99% of Medicare spending is on behalf of beneficiaries with at least one chronic condition***

*Johns Hopkins University, 2003

**Centers for Disease Control and Prevention, 2009

***Thorpe & Walker, 2010


4

What Can be Done?

y Increase skills to manage conditions and symptoms

y Learn techniques to help cope with conditions y Gain insights and wisdom from others y Being with others who have similar

challenges can be a powerful motivator


5

Evidence-Based Programs

• A process of planning, implementing, and evaluating programs adapted from tested models or interventions in order to address health issues at an individual level and at a community level

Promising Practice

Best Practice

Evidence-Based Model


Source: Altpeter, M., Schneider, E., Bryant, L. Beattie, B., & Whitelaw, N. (2004).Using the evidence base to promote healthy aging. National Council on the Aging Evidence-based Health Promotion Series, Vol. 1. Washington, DC: National Council on the Aging.

6

W H A T A R E W E P R E P A R I N G F O R ?

L I V I N G W E L L

A R I Z O N A L I V I N G W E L L I N S T I T U T E

H E A L T H Y L I V I N G


The History 7

In Arizona


8

y From 2000-2010 population grew by 24.6% to 6.4 million { US growth was 9.7%

y With a 14% of those over 65 years (882,098) y And 31.7% over 50 years (~2 million)

y Aging baby boomers drove Arizona’s median age up by

1.7 years over the last decade, to 35.9 years old in 2010, according to U.S. Census Bureau data.

y Yet … Active-Adult Lifestyle state

A Different Aging Population


9

y Active aging, resilience, productivity, and aging in a healthy manner

y Voluntarism, voting, and community groups y More likely to vote in national elections y Redefining voluntarism

Healthy Living (CDSMP)

Statewide Work

y Arizona Department of Health Services { Bureau of Tobacco and Chronic Disease

Ù Healthy Aging Ù Diabetes Coalition

{ Division of Behavioral Health Services

y Department of Economic Security { Division of Aging & Adult Services

y Arizona Living Well Institute { Support dissemination of evidence-based programs:

Ù Healthy Living (CDSMP) { Integration & collaboration with other EBPs

Ù EnhanceFitness Ù A Matter of Balance


10


Why the Arizona Living Well Institute?

9 A need for greater coordination and leveraging of resources to create greater impact

9 A systematic approach to data collection and management

9 Coordination of training opportunities throughout the state, including coordination of self-management workshops

9 Educate employers, health care providers and community services organizations about the benefits of self-management programs and evidence-based health promotion programs


11


THE MISSION: TO A DVA NCE EVIDENCE-BA SED PROGRA MS

FOR A RIZONA COMM UNITIES THROUGH STRUCTURED COMMUNICATION, MULTI-LEVEL COORDINATION A ND FA CILITATOR COA CHING.

Arizona Living Well Institute 12


Empowerment Systems, Inc.

AZ Living Well Institute

Greater Valley AHEC

Community Outreach Pace +

AZ Coalition for Military

Families

13

www.azlwi.org

Funds to launch the Arizona Living Well Institute were made available by grant funds from St. Luke’s Health Initiatives and the Arizona Department of Health Services through a grant from the Administration on Aging.



Evolution of the Living Well Institute

1. Coordination { Master & Lay Leader Trainings { Strategic Planning Meetings

2. Communication { Statewide to Next door { Regional Collaboratives

3. Coaching o Assessing Agency Readiness o Implementation Coaching o Workshop Fidelity o Follow-up & Continued Mentoring

The 3 C’s

14


EBHPP’s for Older Adults

In Arizona … y Chronic Disease Self-Management Program*

{ In-person in English & Spanish Online, By Mail y Diabetes Self-Management Program*

{ English & Spanish y A Matter of Balance* y Enhance Wellness/Enhance Fitness*


15

Others to Consider… y AF Exercise Program y Active Living Every Day y Care Transitions y Fit and Strong! y Healthy IDEAS y Healthy Moves for Aging Well

y HomeMeds y PEARLS y Stepping On y Tai Chi: Moving for Better

Balance y WRAP

www.ncoa.org/improve-health/center-for-healthy-aging/where-to-find-evidence-based.html

http://www.ncoa.org/improve-health/center-for-healthy-aging/where-to-find-evidence-based.html

















Healthy Living Stanford University’s CDSMP

http://med.stanford.edu/patienteducation/


Healthy Living (CDSMP)

16


http://med.stanford.edu/patienteducation/

Disease

Tense Muscles

Pain

Stress/ Anxiety

Difficult Emotions

Shortness of Breath

Depression

Fatigue

Symptom Cycle

Stanford Chronic Disease Self Management, 2006 17 Arizona Living Well Institute


Workshop Design 18

• 6 weekly sessions that meet 1 day per week for 2.5 hours each

• Introduces tools needed in day-by-day life with chronic conditions

• Practices using self-management skills

• Highly interactive • Focuses on goal setting • Shared experiences,

emphasizes mutual support

www.wittysparks.com/2007/05/26/15-tips-to-manage-yourself-better/

Topics Covered


19

• Action Plans • Feedback/Problem Solving • Getting a Good Night’s Sleep • Managing difficult emotions • Falls Prevention • Physical Activity/Exercise • Nutrition & Food Labels • Weight Management • Mind-Body Connection • Informed Treatment Decisions • Working with Health Care


Understanding Licensing 20

y Stanford University { $500.00 for offering 30 or fewer workshops and 6 Leader

trainings { $1000 for offering 90 or fewer workshop and 12 Leader

trainers { Multiple Program License

y Partnership with a licensed agency { Directly with AZLWI { MOU Required/ Recommended { Licensed agency is responsible for fidelity


T-Trainer - Mentored by

Stanford - Train Master Trainers

Master Trainers - 4 ½ day training led by

2 T-Trainers - Certified through Stanford after

facilitating 2 workshops - Train Leaders – 1 training per year

- May facilitate workshops - May assist in fidelity monitoring

Lay Leaders - 4 day training led by 2 Master Trainers

- Facilitate workshops - Preferably peers with chronic conditions

- May be volunteers or staff, usually not health professionals

Healthy Living (CDSMP) Facilitators

21

Purpose of self-management is to help people gain self confidence in their ability to:

- control their symptoms

- control how their health problems affect their lives

Outcomes?

5 year randomized study, 1000 people

What are the Outcomes?


For more information on CDSMP outcomes, Review of Findings on Chronic Disease Self-Management Program (CDSMP) Outcomes: Physical, Emotional & Health-Related Quality of Life, Healthcare Utilization and Costs, http://patienteducation.stanford.edu/research/Review_Findings_CDSMP_Outcomes1%208%2008.pdf

22



Outcomes

y Increased physical activity y Improved health-status y Improved social/role activities y Better psychological well-being y Decreased days in hospital y Improved self-reported general health y Enhanced partnerships with physicians y Increased energy/reduced fatigue y Reduced health care expenditures For more information on CDSMP outcomes, Review of Findings on Chronic Disease Self-Management Program (CDSMP) Outcomes: Physical, Emotional & Health-Related Quality of Life, Healthcare Utilization and Costs, http://patienteducation.stanford.edu/research/Review_Findings_CDSMP_Outcomes1%208%2008.pdf

National Study of CDSMP (2010-2012)


24

y How does CDSMP affect the lives of participants and society as a whole? { What are the impacts on:

Ù Symptom management and lifestyle behaviors?

ÙBetter care? Ù Improved health? ÙReduced health care

costs?

y Study Participants { Baseline (n=1,170) { 12 month (n=825)

y Measures { Symptom management

and lifestyle behaviors { Better Care { Better Health { Lower Health Care Cost

Whitelaw, N., Lorig, K., Smith, M. L., & Ory, M. G. (March 19, 2013). National Study of Chronic Disease Self-Management Programs (CDSMP). Retrieved April 2, 2013, from www.ncoa.org/cha

Does CDSMP Facilitate the IHI Triple Aim Goals?


25

y The best care for the whole population at the lowest cost.

1. Better Care: { improving the experience of care

2. Better Health: { improving population health

3. Lower Cost: { reducing per capita health care costs

*Berwick et al. (2008). The Triple Aim: Care, Health,

And Cost. Health Affairs.

CDSMP: Better Care


26

Notes. † These statistics control for covariates gender, age, race/ethnicity, education, number of chronic conditions.

y Ï Indicates that larger scores are better for this measure y Ð Indicates that smaller scores are better for this measure. y **p<0.01, *p<.05

Baseline Mean

12-Month Mean

% Improvement †

Communication with MD (0-5) Ï 2.6 2.9 9%** Medication Compliance (0-1) Ð 0.25 0.21 12%** Health Literacy (Confidence filling out medical forms) (0-4) Ï 3 3.1 4%**

CDSMP: Better Health


27

Notes. † These statistics control for covariates gender, age, race/ethnicity, education, number of chronic conditions.


Baseline Mean

12-Month Mean

% Improvement ᵻ

Self-assessed Health (1-5) Ð 3.2 3 5% **

PHQ Depression (0-3) Ð 6.6 5.1 21% **

Quality of Life (0-10) Ï 6.5 7 6% **

Unhealthy Physical Days (0-30) Ð 8.7 7.2 15% **

Unhealthy Mental Days (0-30) Ð 6.7 5.6 12% **

CDSMP: Lower Health Care Cost


28

Notes. † Odds Ratio or Mean Ratio after controlling for covariates gender, age, race/ethnicity, education, number of chronic conditions


Baseline 12-Month Adjusted Ratios ᵻ

Percentage with ER Visit in Past 6 Months Ð 18% 13% 0.68**

Number of ER Visits among those with any ER Visit 1.5 1.4 1.00

Percentage Hospitalized in the Past 6 Months Ð 14% 14% 1.01

Number of Hospitalizations among those with any Hospitalization 1.4 1.4 1.00

Estimated Cost Savings Related to

Reduced ER Visits & Hospitalization


29

y Preliminary Results: { ~$740 per person savings in ER and

hospital utilization { ~$390 per person net savings after

considering program costs at $350 per participant

y Reaching even 10% of Americans with one or more chronic conditions would save ~$4.2 billion!

• Healthy Living will NOT interfere with other programs - it will complement other programs!

• Healthy Living is not a support group.

o Even though participants share experiences and support each other, it is a workshop where you learn and try new skills, and increase your ability to manage your health.

• To be most effective, it is important for participants

to be present and contribute in all sessions.

What Else Do I Need to Know?


30


W O R K S H O P

P A R T I C I P A N T

F E E D B A C K


31

Evaluation Tools

Evaluation Tools


32

y Workshop & Training Registration { www.azlwi.org { Mentoring Process

y Workshop Cover Sheet { Date { Time { Location { Facilitators { Substitutes { Session Zero

y Participant Survey { Pre { Post

y Feedback Questionnaire { Program { Facilitators { Meeting Space

y Fidelity Process { Workshops { Trainings


33

Participant Level Data

2 0 0 7 - 2 0 1 3

Workshop Participants


y Number of Participants and Completers Ï over last 6 years y Completion rate Ï from 50% in 2007 to average of 71% since 2010

{ Completers defined as attending at least 4 of 6 workshop sessions

34

0200400600800

100012001400

2007 2008 2009 2010 2011 2012 June2013

139 252 298 317

882

1317

555


Summary by Year for Arizona

35

2010 2011 2012 2013

Gender (% female) 78% 76% 72% 73%

Age (years) 70 62 60 59

Race/Ethnicity

Non-Hispanic White 89% 84% 76% 83%

African American 3% 6% 5% 6%

Latino/Hispanic 11% 16% 24% 17%

Asian/Pacific islander 1% 2% 1% 2%

American Indian/Alaska Native 1% 2% 6% 15%

2+ Chronic Conditions 69% 70% 67% 65%

Number of Workshops 23 72 120 56

Workshop Participants 320 882 1317 555 Workshop Completion Rate (4+ sessions) 67% 76% 71% 70%

Reported Chronic Condition Rates


36

0

10

20

30

40

50

60

Perc

ent R

epor

ting

Con

diti

on, %

2007 2008 2009 2010 2011 2012 2013

Age Demographics by Year


37

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2007 2008 2009 2010 2011 2012 2013

unknown80+70-7960-69below 60

F A C I L I T A T O R S

W O R K S H O P S


38

Organizational Level Data


2-MT

13-LL

23-LL 2-MT

15-LL 9-MT

Spanish

Master Trainer T-Trainer

Lay Leader

Spanish Available

1-TT

April 1, 2010 June 30, 2013

39

Facilitator Growth

2007-2010 2013


y 3 Counties y 3 Host Organizations { Community Health Center

Ù Mariposa Community Health Center, Inc.

{ Area Agency on Aging Ù Pima Council on Aging

{ Local Health Department Ù Yavapai County

Community Health Services

y 15 Counties y 48 Host Organizations

with over 110 Partners { Area Agencies on Aging { Behavioral Health { Health Insurance Plans { Community Health Centers { Local Health Departments { Non-Profits { Veterans Administration

Host Organization Growth 40

Workshop Growth by County


41

County 2007-2009

2010-2011 2012

2013 (TD) Total

Apache 1 2 3 Cochise 2 2 3 7

Coconino 11 10 4 25 Graham 1 3 1 5

Greenlee 1 1 1 3 La Paz 1 5 1 7

Maricopa 34 50* 20* 99 Mohave 2 2 2 6 Navajo 2 1 5 8

Pima 11 17 30 16 74 Pinal 3 1 2 6

Santa Cruz 7 1 1 9 Yavapai 6 15 12 5 38

Yuma 1 1 2 Total in AZ 24 92 120 56 292

Workshop Types


42

18 22

69

107

56

6 1 3

12

1 5 2 4

0

20

40

60

80

100

2007-2009 2010 2011 2012 2013

Num

ber

of W

orks

hops

CDSMPTCSBCBHASMPDSMP

43

Programs in Behavioral Health


Where it’s Happening 44

y Stanford { HARP Program

y New Zealand y Oregon y Michigan y Arizona! { RBHA { Provider Organizations { VA Health Care System


Behavioral Health Outcomes 45

Jackson Co. MH Project y Demographics { 27 Participants { Age range 21-62 { Average of 3 chronic conditions per participant { Retention rate 40%

y Outcomes { 19% drop in fatigue { 35% drop in shortness of breath { 18% drop in pain levels { Number of doctor visits dropped by 26%

y Limitations


For more information: Arlene Logan, LCSW, Regional Coordinator for Living Well, [email protected]

mailto:[email protected]

Structure of Behavioral Health A

DH

S

DBHS

RBHAs

NARBHA RAs

Magellan NPOs

Cenpatico Provider Org.

CPSA Provider Org.

TRBHAs

Gila River

Navajo

Pascua Yaqui

White Mountain

Colorado River


46

Implementation Models 47

y Target Participants { SMI, Behavioral Health, Combination

y Partnerships with other clinics or county health departments

y Facilitators { Peers { Other behavioral health Professionals { Combination

y Evaluation


Behavioral Health Workshops


48

y 40 workshops hosted since 2011 y 371 participants { 283 completers { 76% completion rate

y Reported Depression Rate of 67% y NARBHA RA’s (Sept 2011-Dec 2012) { Increased confidence in doing things { Decreased interference in daily activities { Decreased health distress { Increased physical activity

Workshops Held at NARBHA’s RAs September 2011 - December 2012

Stanford Average

NARBHA Pre-

Workshop

NARBHA Post-

Workshop

Confidence Managing Chronic Disease (6 Items) 10 is "Totally Confident" 5.17 5.52 6.45

Symptoms - Health Distress (4 Items) 0 is "none of the time" 2.04 2.50 2.37

Symptoms - Fatigue (1 Item) 0 is "no fatigue" 4.89 5.65 5.55

Symptoms - Pain (1 Item) 0 is "no pain" 4.36 6.04 5.75

From NARBHA, V. Wilson 2/8/2013 NARBHA CDSMP Outcome Measures ~ Veronica Wilson Master Trainer

49

Feedback from Facilitators 50

y Focus on Behavioral health or Physical health y Time frames { 2 ½ hours, 6 consecutive weeks

y Triggers y Recruitment { Small Workshops

y Attrition rates { 2 ½ hours, 6 consecutive weeks

y Facilitator Turnover


Possible Solutions and Adaptions 51

y Collaboration y Follow-up (for recruitment issues) y Facilitator “Refreshers” prior to workshop y Careful Consideration when choosing facilitators y Extra “Support” person Consult with Stanford prior: y Support groups

y Oregon

y Longer breaks



The Benefits 52

Benefits Beyond the Program


53

y Strategic Growth { Technical Assistance { Regional Collaboratives { County Coalitions

y Improved Retention { Facilitators { Participants

y Stay up to Date { Updates { Meet & Retreats { Refresher Trainings

y Improved Problem Solving { Local Mentors { Statewide Webinars

y Leverage Funding Opportunities { Partners supporting

Partners

CMS Innovation Grant Application


54

y HEALTH CARE INNOVATION AWARDS ROUND TWO, FUNDING OPPORTUNITY CMS-1C1-14-001

y Empowerment Systems, Inc. (EmSys) proposes to enhance the AZ Healthy Living Initiative { a comprehensive membership system of evidence-based

wellness programs that are promoted, paid and integrated with primary and behavioral health outpatient providers of service for enrolled Medicaid and Medicare patients living with or at risk of developing chronic conditions.

{ In order to sustain and expand impact, AZLWI will further develop, support and promote a structured provider membership system to ensure quality evidence-based wellness services are provided at affordable prices.

• Community Navigators • Medical/Behavioral

Health Providers • Self-Referral

Referrals • Integrated, Point of Care Screening for Chronic Disease Risk Factors • Evidence-based Self-

Management Workshops • Assistance completing health

& human service applications (e.g. AHCCCS) • Referral to potential Medical

Home • Referral to other needed

services (e.g. ASHLine, etc.)

Services • Response to referral

source of services provided to include: • Participation in Self-

Management Workshop • Other completed

referrals/services

Outcomes

Integrated Closed Loop Referral Process

56

Moving Forward with Action


What is your Action Plan? 57

Things to Consider: y What is you agency’s plan for programs in 2013? y Number of workshops y Target population y Will you train facilitators? { Leaders or Master Trainers?

y What is your target completer/ retention rate? { Facilitators { Participants

y Potential partners


Find out who your friends are…


58

Systems Change & Sustainability

y Making a Difference in the lives of adults with ongoing health conditions and individuals with disabilities { Changing the course of chronic conditions & injury { Changing systems “The way we do business.”

y Working from an Evidence-based Perspective { Drawing from the evidence { Contributing to new evidence

y Working Collaboratively to “Move the Dial” { Creating an inclusive, far reaching agenda for healthy living for all ages in all

communities { Creating conditions for sustained improvement in health in caregivers and

care recipients


59


So how do we get to “Healthy Aging”?

y Develop a Mantra: ¾ It’s never too late to start & it’s always too early to quit!

y Invest in health ¾ Regular Exercise ¾ Good Nutrition ¾ Self Management of Stress & Chronic Conditions ¾ Engagement in family and community, volunteering

y Protect health ¾ Immunizations ¾ Early detection of health conditions ¾ Fall Prevention


60

Participant Comments


61

y I feel that this class has been of great benefit to me which will stay with me in times of difficulty or when I feel myself slipping back toward depression or isolation from people. I will put forth an extra positive effort to continue the breathing techniques and especially the exercises learned or reinforced in a continued plan to control my painful condition in the best possible way without being dependent upon prescription drugs. Rebecca – Arizona City

y We had experienced, or learned different parts of this program before, but no part alone was life changing. But with this program structure, I am a different person than I was just six-weeks ago and hope to stay motivated! MDC - Goodyear

Questions?


Melanie Mitros, PhD Director

AZ Living Well Institute [email protected]

(480) 982-3118 or (877) 982-3118

www.azlwi.org

62

mailto:[email protected]

http://www.azlwi.org/

Documents

Integration of Self-Management Programs into Clinical Settings...Integration of Self-Management Programs into Clinical Settings. Agenda 1. ... COORDINATION AND FACILITATOR COACHING