Care Coordination and Supporting Patient Self-Management
Chronic disease management is a dilemma felt acutely in primary care settings. Even with the advancement of medical knowledge and treatment opportunities, most office visits are too limited by time constraints to effectively manage chronic illness; management of disease is also exacerbated by the list of issues — an average of 7.1 problems per visit that patients need to address. The problem, however, is not the patient. According to Holman and Lorig (2004), our current health care system was originally designed to meet the needs presented by acute disease, and it did not shift or change when chronic illness became the central health care issue of this era. This means that the ebb and flow of the current patient visit model is designed to treat a problem as a linear issue with patients dependent on the skill and knowledge of a health care professional to cure them; they see the provider, receive a course of treatment, take the treatment (as recommended, of course), and check back in with the provider after a week or two, with the expectation that the problem is resolved. A conspicuous difference between acute illness and chronically ill patients is that disease management does not happen during office visits; it happens in the day-to-day decisions patients make about about their health, with the end goal being about disease regulation and control rather than cure.
Emerging studies state that a more collaborative approach to care is paving the way to achieving efficacy in chronic disease management. Research in collaborative care suggests that the patient and health professional must share responsibility and knowledge in the process of treatment. A well-implemented care coordination model is an opportunity for primary care settings to provide a synergistic approach to health care by supporting patient self-management in addition to population management. Implied in this approach is an improvement in overall care delivery, sustainable and consistent health outcomes, and a reduction in healthcare costs. A care coordinator plays a vital role in seeking out and identifying high-risk patients or patients with long term chronic illness in order to engage them in more robust health coaching; the end goal is to support patients in managing their own disease by eliciting behavior changes and removing obstacles to treatment.
Patient Self- Management: Eliciting Change Behavior
Motivational interviewing (MI) is an evidenced-based approach to patient teaching/health coaching that has proven to be effective in evoking barriers to treatment recommendations, as well as helping patients identify their own desires for change. MI, developed 30 years ago by Dr. William Miller (University of New Mexico), had its beginnings in the addiction/substance abuse arena. It is an emerging tactic now being used in preventative health settings, specifically for patients with chronic conditions (read more about motivational interviewing and clinical health coach programs we like). The key components of MI revolve around the concept that meeting health care goals ultimately depends on the patient’s intrinsic motivation. In a multi-center, randomized controlled trial with Type 1 diabetics, 66 teenagers between the ages of 14-17 were selected to participate in motivational interviewing intervention sessions for a year. Each session needed to include some or all of the following aspects: awareness building, alternatives, problem solving, making choices, goal setting, and avoidance of confrontation. Both of the interventionists selected had a background in nursing. Their focus in the motivational interviewing sessions was to help the teens articulate their conflicting beliefs about behavioral change, and elicit a cost and benefit analysis of making the change against social, emotional, and financial factors. The result of the 12 month study showed that MI can be an effective method of working with diabetic teens in producing long-term improvements in glycemic control, psychological well-being, and quality of life as demonstrated by improved A1C levels, higher life satisfaction, and less anxiety/worry about their disease.
Patient Self-Management: Identifying Barriers
According to the National Council for Behavioral Health, “an estimated 60 percent of adults in the United States have experienced an adverse life event at least once in their lives.” Ongoing research on trauma exposure indicates that these events can have a significant and persistent impact on physical and mental health outcomes. Trauma also affects how a person approaches a helpful relationship, and can dictate how someone may engage or disengage in social or health care services.
Between 1995-1997, the Centers for Disease Control (CDC) and Kaiser Permanente did a study on 17,337 Kaiser Health Maintenance Organization (HMO) members in Southern California. The study, called the Adverse Childhood Experiences study (ACE), provided participants confidential surveys regarding childhood experiences during routine physicals. The surveys were designed to collect information on child abuse, neglect and other psychosocial and behavioral factors that were challenging for the participant. The study revealed that adverse childhood experiences (ACE) were common; about two-thirds of the study participants reported at least one ACE. More importantly, the study found a direct link between the number of adverse childhood experiences and adult onset chronic disease and conditions such as alcoholism/alcohol abuse, chronic obstructive pulmonary disease (COPD), smoking, liver disease, mental illness, and ischemic heart disease. For example, a person with an ACE score of 7 (i.e. 7 adverse events) with no evidence of risk-taking behaviors had a 30-70% increased risk of developing ischemic heart disease as an adult. A person with an ACE score of 4 or higher was two to four times more likely to develop depression, hypertension and diabetes. As the number of ACEs increased so did the likelihood of cancer, chronic lung disease, and liver disease.
Most patients with a history of trauma do not seek mental health services, but instead seek help in primary care settings, often presenting with physical symptoms. In the process of seeking help, patients can sometimes feel triggered when accessing medical care. Experiencing a lack of control, a sense of vulnerability and helplessness or powerlessness in trying to navigate a complicated health care system, insurance authorizations, referrals, or even long wait times can compound a trauma history, resulting in re-traumatization. This can lead to irritable/resistant behavior, violence, missed appointments, and disengagement from care, at times leaving the health care provider with the impression that the patient is “resistant” or “non-compliant.” Research suggests that patients don’t mind being asked about trauma history in primary care settings, as long as it’s in a safe, supportive environment. An integrated care coordination model should develop and/or adopt trauma sensitive screenings and approaches in order to identify barriers in treatment goals and minimize risk for re-traumatization, therefore enhancing patient-provider rapport and patient outcomes.
Read more about Care Coordination in the fourth article in the series, Care Coordination: Managing your Populations coming in late March.
Trauma-informed Medical Care: Patient Response to a Primary Care Provider Communication Training: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5051697/
Patient Self-Management: A Key to Effectiveness and Efficiency in Care of Chronic Disease: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497631/pdf/15158102.pdf
Patient Self Management: Chronic Disease in Primary Care: https://pdfs.semanticscholar.org/f510/213819a7d4ea1c0e3441d7c1e657731dbd73.pdf
Toward a Theory of Motivational Interveiwing:
Channon, et., al. A Multicenter Randomize Controlled Trial of Motivational Interviewing in Teenagers with Diabetes: http://care.diabetesjournals.org/content/30/6/1390
Trauma-informed Primary Care: Fostering Resilience and Recovery: https://www.thenationalcouncil.org/consulting-areas-of-expertise/trauma-informed-primary-care/
About the CDC-Kaiser ACE Study: https://www.cdc.gov/violenceprevention/acestudy/about.html
Larkin, et., al. The Health and Social Consequences of Adverse Childhood Experiences (ACE) Across the Lifespan: An Introduction to Prevention and Intervention in the Community: https://www.iowaaces360.org/uploads/1/0/9/2/10925571/compiled_articles_final.pdf