PowerPoint Presentation - ASSOCIATION OF DIABETES .ppt

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					 Living Well with
Chronic Conditions
         Also known nationally as the
  Chronic Disease Self-Management Program
        - Developed by Stanford University -
Introductory Note

 • The Utah Approach to CDSMP and Diabetes
   Care: In no way is CDSMP to take the place of
   Diabetes Self-Management Education (DSME)
 • DSME comes first and foremost for a patient with
   diabetes
 • We would like to view CDSMP as
   complementary/supportive to the DSME process
Utah Arthritis Program

 • Leads the administration of the Chronic Disease Self-
   Management Program in Utah
 • Funding sources are the Centers for Disease Control
   and Prevention (CDC) and the Administration on Aging
   (AoA)
 • Work in partnership with the CDC and AoA to address
   the burden of arthritis, and other chronic diseases, in
   Utah
 • Primary objective is to develop partnerships around the
   state to increase access to and use of evidence-based
   programs
CDC Arthritis Funded States
AoA Funded States for CDSMP
Our Broad Goal

                         I love
                        CDSMP
                          and
  To improve the        ADEU!
  quality of life for
  people affected by
  arthritis and other
  chronic conditions.
The Chronic Disease Problem


 Research has shown that an increasing number of
 U.S. families are experiencing high financial burdens
 from medical care expenses, as rapidly rising health
 care costs are passed on to families in the form of
 higher premiums, deductibles, co-payments, and even
 reduced benefits. For people with chronic health
 conditions, such burdens can be a long-term problem
 that threatens their families' financial well-being.

                     Commonwealth Fund (July 23, 2009)
The Chronic Disease Problem

 • Approximately 30% of Utahns have at least one
   chronic condition (similar number for U.S.)
 • Chronic diseases are the most prevalent and
   costly healthcare problems in the U.S.
 • More than two-thirds of all deaths are caused by
   one or more of five chronic conditions: heart
   disease, cancer, stroke, COPD, and diabetes

 Sources: BRFSS, 2007; Centers of Disease Control and Prevention (CDC)
The Chronic Disease Problem

 • Chronic disease not only affects health and quality of
   life, but is also a major driver of healthcare costs…
 • Chronic disease accounts for about 75% of the
   Nation’s aggregate healthcare spending, or about
   $5,300 per person in the U.S. each year
 • In taxpayer-funded programs, treatment of chronic
   disease constitutes an even larger proportion of
   spending:
         • 96 cents per dollar for Medicare
         • 83 cents per dollar for Medicaid

  Source: Centers of Disease Control and Prevention (CDC)
Chronic Disease Rates

  Utah                                                              U.S.
  High Cholesterol 25.9%                                            High Cholesterol 37.6%
  Hypertension 25.4%                                                Hypertension 26.7%
  Arthritis: 24.0%                                                  Arthritis: 26.1%
  Asthma: 7.9%                                                      Asthma: 8.5%
  Diabetes: 6.9%                                                    Diabetes: 8.5%


 Age-adjusted Rates:
 Utah Data: Utah BRFSS 2009
 U.S. Data: National Center for Chronic Disease Prevention and Health Promotion, BRFSS Survey
Prevalence of Arthritis Among
Persons With Other Conditions, Utah




  Source: BRFSS, 2009
Stanford’s CDSMP

• In the past 20 years or so, the Stanford University,
  Patient Education Research Center has developed,
  tested, and evaluated self-management programs for
  people with chronic health problems
• All programs are designed to help people gain self-
  confidence in their ability to control their symptoms
  and how their health problems affect their lives
• Workshops are highly interactive, focusing on building
  skills, sharing experiences and support
Stanford’s CDSMP

• Once a program is developed, it is evaluated for
  effectiveness through a randomized, controlled
  trial, which is 2-4 years in length
• It is ONLY after a program has been shown to
  be safe and effective through these trials that it
  is released for dissemination
• This was the procedure for the Chronic Disease
  Self-Management Program (CDSMP)
Chronic Conditions Represented in
CDSMP Workshops

 •   52.7% Arthritis                    •   17.2% Heart Disease
 •   41.0% High Blood Pressure          •   14.3% Asthma
 •   36.6% Chronic Joint Pain           •   13.2% Lung Disease
 •   34.8% Diabetes                     •   12.8% Fibromyalgia
 •   33.2% High Cholesterol             •   8.0% Cancer
 •   27.4% Chronic Pain                 •   7.6% Kidney Disease
 •   23.5% Depression

 Source: Utah Arthritis Program, 2010
Chronic Conditions Represented in
CDSMP Workshops
                                           3.1%
                                           (68)


                                        9.5%
                                        (211)     20.9%     Five or More
                                                  (465)     Four
                                 12.9%
                                 (286)                      Three
                                                            Two
                                  15.7%             20.4%   One
                                  (350)             (454)
                                                            Missing
                                            17.6%           None
                                            (391)




 Source: Utah Arthritis Program, 2011
Living Well with Chronic Conditions
Stanford Model of CDSMP
Living Well with Chronic Conditions
Stanford Model of CDSMP




  Program Description
       – Designed for people who live with any chronic
         condition
       – Based on the symptoms of chronic conditions
       – Participants learn tools that enable them to
         self-manage their symptoms
       – Community or healthcare-based settings
Living Well with Chronic Conditions
Stanford Model of CDSMP




  Patient Engagement Activities
       – Participants learn how to identify problems
       – Participants learn how to act on problems
       – Participants learn how to generate short-term
         action plans
       – Participants learn problem-solving skills related
         to chronic conditions in general
Living Well with Chronic Conditions
Stanford Model of CDSMP



  Program Subject Matter:
       – Dealing with frustration, fatigue, pain and
         isolation
       – Exercise for maintaining and improving
         strength, flexibility and endurance
       – Appropriate use of medication and proper
         nutrition
       – Communicating effectively with family, friends
         and health professionals
       – Evaluating new treatments
Living Well with Chronic Conditions
Stanford Model of CDSMP




 Program Structure
 • Series of 6 sessions, 1 session per week, 2 hours
   per session
 • Held in community settings (including healthcare)
 • Highly scripted curriculum
Living Well with Chronic Conditions
Stanford Model of CDSMP




 Program Structure
 • Designed to be lay-led; 2 leaders facilitate each
   class; at least 1 facilitator also has a chronic
   condition
 • Workshops offered at no charge (free!)
 • Available in Utah in English, Spanish, Tongan
Living Well with Chronic Conditions
Stanford Model of CDSMP


     •   Week 1
          – Difference between acute and           – Healthy eating
            chronic conditions                     – Communication skills
          – Short term distractions                – Problem solving
          – Introduce action plans
                                              •   Week 5
     •   Week 2                                    – Medication usage
          – Dealing with difficult emotions        – Making informed treatment
          – Physical activity and exercise           decisions
                                                   – Depression management
     •   Week 3                                    – Positive thinking
          – Better breathing techniques            – Guided imagery
          – Muscle relaxation
          – Pain and fatigue management       •   Week 6
                                                   – Working with your
     •   Week 4                                      healthcare professional
          – Future plans for healthcare            – Planning for the future
Living Well with Chronic Conditions
Stanford Model of CDSMP


     Improved Outcomes
                                    6 mo.   2 yrs.

     Self efficacy                  √       √
     Self rated health              √       √
     Disability                     √
     Role activity                  √
     Energy/fatigue                 √       √
     Health distress                √       √
     MD/ER visits                   √       √
     Hospitalization                √

          Lorig, et al 1999, 2001
Living Well with Chronic Conditions
Stanford Model of CDSMP


    Improved Outcomes
                                    1         2        3          4        5
    Self-efficacy                             X        X          X        X
    Self-rated health X                                X
    Fatigue                                   X                   X        X
    Anxiety/Distress                          X                   X        X
    Role limitation   X                                           X
    HRQOL                                                         X
    Pain                                               X
    Exercise          X                                           X        X
    Cog. Symp mgmt                            X                   X        X
     1=Lorig 05, 2=Barlow 05, 3=Goeppinger 07, 4=Kennedy 07, 5=Gitlin 08
Living Well with Chronic Conditions
Stanford Model of CDSMP



         Action Plans
         – Something they     – Action Specific
           want to do
                                – What
         – Achievable
                                – How much
         – Confidence Level
                                – When
         – Problem Solving
                                – How often
Living Well with Chronic Conditions
Stanford Model of CDSMP


    Workshop Resources
    • Resource book: Living a Healthy Life with
      Chronic Conditions
    • CD: Time for Healing
    • Weekly action plans and feedback
    • Groups are small: 10-15 people
        – Share information, interactive learning
          activities, problem-solving, decision-making,
          social support for change
Living Well with Chronic Conditions
Stanford Model of CDSMP


    Infrastructure
    • Master Trainers – 11 in state of Utah as of
      October 2011 (8 English, 2 Spanish)
        – Attend 4 ½ day training at Stanford University
        – Teach classes and train leaders
    • Peer Leaders / Instructors
        – Complete 4-day training taught by 2 Master Trainers in order to
          teach classes
    • Stanford License
        – Each organization teaching this program must purchase a
          license from Stanford
    • Training Material
        – Resource books and CDs for participants and leaders
Living Well with Chronic Conditions
Stanford Model of CDSMP




    What participants are saying. . . .
        – “I know I can self-manage a few problems and make
          life better for me and my husband.”
        – “It gave me some important coping mechanisms.”
        – “This class has helped me get my life in order.”
        – “I recommend this course and handbook to all
          seniors.”
        – “We have set goals, accomplished them and will
          continue to manage our lives better due to this class.”
        Source: Class participants of Wasatch and Summit County courses
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP



  Spanish Program Development

  • Not a translation but an
    independent development in
    Spanish
  • Developed to be culturally
    appropriate
  • Focus groups conducted in
    Spanish
  • Health care professionals working
    with persons with chronic
    conditions
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP



     Spanish Program Development

     • Participants incorporate healthy habits into their
       lives:
         – Healthy eating habits
         – Exercise (physical activity)
         – Cognitive management of symptoms
         – Better communication with health care providers
         – Overall perception of better health
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP


     Week One
    Overview/                    Overview/
     responsibilities             Responsibilities
    Acute/chronic                Acute/chronic
    Using                        Proactive in
     mind/symptoms                 management,
    Action plans                 Importance of food &
                                   exercise
                                  Healthy food
    English
                                  Spanish
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP


     Week Two
    Action plan                  Share
     rpt/problem solve             diaries/problem solve
    Difficult emotions
                                  Formula for a healthy
    Intro to physical             menu
     activity/exercise
    Action plan                  Action plans
                                  Intro to physical
                                   activity/exercise
                                  Exercise practice
    English
                                  Spanish
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP


     Week Three
    Action plan                  Action plan
     report/problem solve          rpt/problem solve
    Better breathing             Prepare a low fat
    Muscle relaxation             menu
    Pain/fatigue                 Managing symptoms
     management                   Muscle relaxation
    Endurance activities         Better breathing
    Action plan                  Action plan

    English                       Spanish
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP


     Week Four
    Action plan                  Action plan rpt/problem
     report/problem solve          solve
    Future plans for health      Reading nutrition labels
     care
    Healthy eating               Finding health care
    Communication skills         Managing depression
    Problem solving              Positive thinking
    Action plan                  Action plan
                                  Spanish
    English
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP


     Week Five
    Action plan                  Action plan
     report/problem solve          report/problem solve
    Medication usage             Communication skills
    Informed treatment           Future plans for healthcare
     decisions                    Increasing physical activity
    Depression management         intensity
    Positive thinking Guided     Medication usage
     imagery                      Working with healthcare
    Action plan                   professional
                                  Action plan

    English                       Spanish
Tomando Control de Su Salud
Stanford Model of Spanish CDSMP


     Week Six
    Action plan rpt/problem      Action plan
     solve                         rpt/problem solve
    Working with health          Evaluating home
     care Professional/health      remedies
     care system                  Guided imagery
    Looking back and plan        Sharing
     future                        successes/plan
                                   future
    English                       Celebration

                                  Spanish
Ideas for Linking CDSMP with
Diabetes Education

  • The Utah Approach to CDSMP and Diabetes
    Care: In no way is CDSMP to take the place of
    Diabetes Self-Management Education (DSME)
  • DSME comes first and foremost for a patient with
    diabetes
  • That said, we would like to encourage referrals
    from Diabetes Programs into local CDSMP
    classes for some of the following reasons….
Ideas for Linking CDSMP with
Diabetes Education

  • Self-management support option for post-
    DSME (National DSME Standard #7)
  • Great option for follow up work with patients
    with diabetes (National DSME Standard #8)
  • Supports and complements self-management
    efforts of diabetes educators/healthcare
    providers
  • Continuous quality improvement
    opportunity??
Ideas for Linking CDSMP with
Diabetes Education

 • Powerful evidence-based program for patients
   with co-morbid conditions
    – CDSMP is successful at addressing mental
      health issues as well
 • Excellent self-management option for
   uninsured patients; if you have to turn away
   uninsured patients, please send them to a free
   CDSMP workshop
 • Addresses income issues by offering classes
   at no charge
Ideas for Linking CDSMP with
Diabetes Education

  • Opportunity to connect to community
    resources (perhaps as part of a planned care
    model)
  • Reinforces lifestyle behaviors so that patients
    continue implementing healthy choices such
    as regular physical activity and nutrition
  • Other ideas?
Living Well with Chronic Conditions
Stanford Model of CDSMP


    General Patient and Provider Benefits
    • An evidence-based program such as Living
      Well/CDSMP can capture many chronic
      diseases through this one channel
    • Self-management support option
    • Can improve self-rated health and energy levels
    • Reduced healthcare utilization (ED visits)
    • As the New Jersey program puts it: Feel Better!
Living Well with Chronic Conditions
Stanford Model of CDSMP


   Program Partnerships
   • University of Utah Community Clinics
   • Arthritis Foundation, Utah/Idaho Chapter
   • Area Agencies on Aging/Senior Centers:
       – Weber-Morgan
       – Davis County
       – Salt Lake County
       – Mountainlands (Summit/Wasatch/Utah Counties)
       – Five County (Southwest Utah)
       – Tooele County
       – San Juan County
Living Well with Chronic Conditions
Stanford Model of CDSMP


   Program Partnerships
   • Community-based Organizations:
       – National Tongan American Society
       – Alliance Community Services (Spanish)

   • Local Health Departments:
       – Bear River                – Southwest
       – Central Utah              – Tri County
                                   – Utah County
       – Davis County
                                   – Weber-Morgan
       – Salt Lake Valley
Living Well with Chronic Conditions
Stanford Model of CDSMP


   Program Partnerships
   • Dixie Regional Medical Center in St. George
   • Valley View Medical Center in Cedar City
   • Salt Lake VA Medical Center
   • Valley Mental Health
       – SL County, Park City, Tooele
   • Utah Partnership for Healthy Weight
       – Healthy weight project in Magna
Living Well with Chronic Conditions
Stanford Model of CDSMP



      Resources
      – Stanford University’s site on CDSMP
        http://patienteducation.stanford.edu
       – Utah Arthritis Program (class schedules)
         http://health.utah.gov/arthritis
       – Administration on Aging: www.aoa.gov
       – National Council on Aging:
         http://healthyagingprograms.org
Living Well with Chronic Conditions
Stanford Model of CDSMP




  Contact Information

  • Utah Arthritis Program: www.health.utah.gov/arthritis
    (for class schedules)
  • Rebecca Castleton: rcastlet@utah.gov;
    801-538-9340
  • Christine Weiss: cweiss@utah.gov;
    801-538-9458
 Help Your Clients
  Quit Tobacco

          Marci Nelson, B.S., CHES
   Tobacco Prevention and Control Program
          Utah Department of Health
            marcinelson@utah.gov
http://www.tobaccofreeutah.org/healthcare.html
                (801) 538-7002
                 Objectives
 Discuss the risks of tobacco use especially the
  effects of smoking on diabetes

 Present a brief intervention to quit
 Discuss procedures for implementation
 Supply information on free tobacco cessation
  services
               Tobacco Use in Utah:
                  The Problem

 More than 200,000 Utahns use tobacco
 More than 1,330 die annually from their
  smoking
 Nearly 17,150 children exposed to secondhand
  smoke in their homes
 $663 million each year in smoking-attributable
  medical and lost productivity costs

 Source: Tobacco Prevention and Control in Utah Tenth Annual Report - August 2010
   Tobacco Health Effects

       Long-term                        Short-term
           Heart disease                    Respiratory illness
           Stroke                           Decreased lung capacity
           Lung function                    High blood pressure &
           Cancers                           cholesterol
           Ulcer                            Nervousness
           Infertility                      Mouth problems
                                             Reduced taste & smell


Responsible for more than 400,000 premature deaths each year in the U.S.
Health Effects of Secondhand Smoke
   Stillbirth; miscarriage      Cancer
   Premature Birth              Bronchitis;
   Cleft palates and lips        pneumonia
   Sudden Infant Death          Asthma
   Infertility                  Upper Respiratory
   Tooth Decay                   Tract Disease
                                 Ear Infections
                                 Coughs

Secondhand smoke affects loved ones & is a powerful
               motivator to quit!
 Effect of Smoking on Diabetes

 Tobacco raises  blood sugar levels
 Tobacco use increases the risk of heart attack
  or stroke
 Increased chance of getting gum disease and
  may suffer tooth loss
 Tobacco use can make foot ulcers, foot
  infections, and blood vessel disease in the legs
  worse
       WHY SHOULD CLINICIANS
        ADDRESS TOBACCO?
 Tobacco users  expect to be encouraged to quit by
  health professionals.
     • 72% of Utahns saw a healthcare provider in the last year
 Screening for  tobacco use and providing tobacco
  cessation counseling are positively associated with
  patient satisfaction (Barzilai et al., 2001).
 Advice from a healthcare provider can double the
  chances of successful quitting.
Clinical Practice Guideline for Treating
    Tobacco Use and Dependence

   Update released May 2008
   Sponsored by the Agency for
    Healthcare Research and Quality of the
    U.S. Public Heath Service with
      Centers for Disease Control and

       Prevention
      National Cancer Institute

      National Institute for Drug Addiction

      National Heart, Lung, & Blood

       Institute
      Robert Wood Johnson Foundation
   Brief Counseling:
 ASK, ADVISE, REFER
 ASK                                  about tobacco USE


ADVISE                               tobacco users to QUIT


REFER                                 to other resources



 Patient receives assistance, with        ASSIST
  follow-up counseling arranged,
     from other resources such as
    the Utah Tobacco Quit Line          ARRANGE
     Step 1: ASK                            1 min
Ask EVERY patient about tobacco use status at
EVERY visit.
•   Current
•   Former
•   Never
    This occurs most consistently when there are systems
    in place, such as question on intake form, chart
    stickers, or electronic prompts on electronic medical
    records. Chart stickers are available.
    Step 2: Advise                                1 min
Clinicians should urge all tobacco users to quit.
Even brief advice to quit by a clinician results in greater
quit rates. Smokers cite a clinician's advice to quit as an
important motivator for attempting to stop smoking.

Advice should be:
• clear
• strong
• personalized

Specific to the individual 's own situation
(e.g. oral health condition, family status, costs of tobacco).
What if they are not willing?
                 Offer a motivational
              intervention, the “5 R's”
                    Relevance
                      Risks
                     Rewards
                    Roadblocks
                    Repetition
                The “5 R’s”
Relevance: Why is quitting important to their own
  personal situation?

Risks: Outline the risks of continued tobacco use.
Rewards: Outline the benefits of quitting.
Roadblocks: What are the barriers preventing this
  person from quitting? What are some solutions to
  these barriers?

Repetition: Repeat this discussion frequently, until
  the person is ready to quit.
Step 3: Refer                                   1 min
Referral options:
   A doctor, nurse, pharmacist, or other clinician, for
    additional counseling
   The Utah Tobacco Quit Line
   Utah QuitNet
   Text to Quit
   Local Services
    - Ending Nicotine Dependence (youth)
    - First Step (pregnant women)
      Utah Tobacco Quit Line
 Toll free: 1.800.QUIT.NOW
      - Spanish: 1.877.629.1585
      - TTY: 1-877-777-6534
 Monday-Sunday, 6:00 am to 11:00 pm
 FREE
 For adults and youth
 Services available in English, Spanish and
  translation in 140 other languages
      Utah Tobacco Quit Line

• Professional counseling sessions by
  telephone – up to five 40-minute sessions
• Individualized Quit Plan
• NRT upon qualification (patch, gum or
  lozenge)
• Tailored resources for Utah residents

             1.800.QUIT.NOW
Fax Referral System

“Would you like
the Utah Tobacco
Quit Line to help
    you quit?”
   3 Simple Steps
1. Personalize your forms
   online at:
   www.tobaccofreeutah.org
   /utqlprofax.html

2. 2 A’s and R with client.
   For those ready to quit
   give them the form to fill
   out. Verify signature!

3. Fax form in to the Utah
   Tobacco Quit Line:
   1-800-483-3076

  *The Quit Line will fax you to inform
   you of services your patient received.
             http://utahquitnet.com


 Quitting guide      Personalized quit plan
 Medication guide  24 hour community support
 Expert counseling  Online NRT purchase



         Lifetime membership!
   Text messaging service that offers Utahns daily
    quit tips to help them get through the quitting
    process
       Users text READY to 53535 to receive two quit tips
        per day via cell phone for 21 days.
         • Users will be asked to answer simple questions regarding
           age, gender and zip code.
   New research suggests that motivational text
    messages more than double the odds that
    smokers will be able to kick the habit.
                                      Source: The Lancet, news release, June 29, 2011
        Tobacco Dependence:
          a 2-Part Problem

                 Tobacco Dependence

    Physiological                        Behavioral

The addiction to nicotine         The habit of using tobacco
             Treatment                          Treatment



Medications for cessation         Behavior change program

       Treatment should address the physiological and
            the behavioral aspects of dependence.
       Smoking Cessation Medications
Nicotine polacrilex gum                    Nicotine nasal spray
      Nicorette (OTC)                            Nicotrol NS (Rx)
      Generic nicotine gum (OTC)
                                           Nicotine inhaler
Nicotine lozenge                                  Nicotrol (Rx)
      Commit (OTC)
      Generic nicotine lozenge (OTC)      Bupropion SR (Zyban)

Nicotine transdermal patch                 Varenicline (Chantix)
      Nicoderm CQ (OTC)
      Nicotrol (OTC)
      Generic nicotine patches (OTC, Rx)
                 These are the only medications that are
                   FDA-approved for smoking cessation.
      What About A Relapse?
Viewed as a learning experience
Not a sign of personal or clinician failure
Continue to provide encouragement

   It takes an average of 7 quit attempts to
         successfully quit using tobacco!
                Make a Commitment
Address tobacco use
      with all patients.

At a minimum,
      make a commitment to incorporate brief tobacco
      interventions as part of routine patient care.

Ask, Advise, and Refer.




             For more information, contact:
      Tobacco Free Resource Line: 1-877-220-3466 or
    http://www.tobaccofreeutah.org/healthcare1.html

				
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