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Also known nationally as the Chronic Disease Self-Management Program - Developed by Stanford University -

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Title: Also known nationally as the Chronic Disease Self-Management Program - Developed by Stanford University -


1
Also known nationally as the Chronic Disease
Self-Management Program- Developed by Stanford
University -
Living Well with Chronic Conditions
2
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/suppo
    rtive to the DSME process

3
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

4
CDC Arthritis Funded States
5
AoA Funded States for CDSMP
6
Our Broad Goal
I love CDSMP and ADEU!
  • To improve the quality of life for people
    affected by arthritis and other chronic
    conditions.

7
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)

8
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)
9
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
    Nations 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)
10
Chronic Disease Rates
U.S. High Cholesterol 37.6 Hypertension
26.7 Arthritis 26.1 Asthma 8.5 Diabetes
8.5
Utah High Cholesterol 25.9 Hypertension
25.4 Arthritis 24.0 Asthma 7.9 Diabetes 6.9
Age-adjusted Rates Utah Data Utah BRFSS
2009 U.S. Data National Center for Chronic
Disease Prevention and Health Promotion, BRFSS
Survey
11
Prevalence of Arthritis Among Persons With Other
Conditions, Utah
Source BRFSS, 2009
12
Stanfords 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

13
Stanfords 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)

14
Chronic Conditions Represented in CDSMP Workshops
  • 52.7 Arthritis
  • 41.0 High Blood Pressure
  • 36.6 Chronic Joint Pain
  • 34.8 Diabetes
  • 33.2 High Cholesterol
  • 27.4 Chronic Pain
  • 23.5 Depression
  • 17.2 Heart Disease
  • 14.3 Asthma
  • 13.2 Lung Disease
  • 12.8 Fibromyalgia
  • 8.0 Cancer
  • 7.6 Kidney Disease

Source Utah Arthritis Program, 2010
15
Chronic Conditions Represented in CDSMP Workshops
Source Utah Arthritis Program, 2011
16
Living Well with Chronic ConditionsStanford
Model of CDSMP
17
Living Well with Chronic ConditionsStanford
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

18
Living Well with Chronic ConditionsStanford
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

19
Living Well with Chronic ConditionsStanford
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

20
Living Well with Chronic ConditionsStanford
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

21
Living Well with Chronic ConditionsStanford
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

22
Living Well with Chronic ConditionsStanford
Model of CDSMP
  • Week 1
  • Difference between acute and chronic conditions
  • Short term distractions
  • Introduce action plans
  • Week 2
  • Dealing with difficult emotions
  • Physical activity and exercise
  • Week 3
  • Better breathing techniques
  • Muscle relaxation
  • Pain and fatigue management
  • Week 4
  • Future plans for healthcare
  • Healthy eating
  • Communication skills
  • Problem solving
  • Week 5
  • Medication usage
  • Making informed treatment decisions
  • Depression management
  • Positive thinking
  • Guided imagery
  • Week 6
  • Working with your healthcare professional
  • Planning for the future

23
Living Well with Chronic ConditionsStanford
Model of CDSMP
  • Improved Outcomes
  • 6 mo. 2 yrs.
  • Self efficacy v v
  • Self rated health v v
  • Disability v
  • Role activity v
  • Energy/fatigue v v
  • Health distress v v
  • MD/ER visits v v
  • Hospitalization v
  • Lorig, et al 1999, 2001

24
Living Well with Chronic ConditionsStanford
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/Distres
s X X X Role limitation X X HRQOL
X Pain X Exercise X X X Cog. Symp
mgmt X X X
1Lorig 05, 2Barlow 05, 3Goeppinger 07,
4Kennedy 07, 5Gitlin 08
25
Living Well with Chronic ConditionsStanford
Model of CDSMP
  • Action Plans
  • Something they want to do
  • Achievable
  • Confidence Level
  • Problem Solving
  • Action Specific
  • What
  • How much
  • When
  • How often

26
Living Well with Chronic ConditionsStanford
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

27
Living Well with Chronic ConditionsStanford
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

28
Living Well with Chronic ConditionsStanford
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
29
Tomando Control de Su SaludStanford 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

30
Tomando Control de Su SaludStanford 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

31
Tomando Control de Su SaludStanford Model of
Spanish CDSMP
Week One
  • Overview/
  • responsibilities
  • Acute/chronic
  • Using mind/symptoms
  • Action plans
  • English
  • Overview/
  • Responsibilities
  • Acute/chronic
  • Proactive in management,
  • Importance of food exercise
  • Healthy food
  • Spanish

32
Tomando Control de Su SaludStanford Model of
Spanish CDSMP
Week Two
  • Action plan rpt/problem solve
  • Difficult emotions
  • Intro to physical activity/exercise
  • Action plan
  • English
  • Share diaries/problem solve
  • Formula for a healthy menu
  • Action plans
  • Intro to physical activity/exercise
  • Exercise practice
  • Spanish

33
Tomando Control de Su SaludStanford Model of
Spanish CDSMP
Week Three
  • Action plan report/problem solve
  • Better breathing
  • Muscle relaxation
  • Pain/fatigue management
  • Endurance activities
  • Action plan
  • English
  • Action plan rpt/problem solve
  • Prepare a low fat menu
  • Managing symptoms
  • Muscle relaxation
  • Better breathing
  • Action plan
  • Spanish

34
Tomando Control de Su SaludStanford Model of
Spanish CDSMP
Week Four
  • Action plan rpt/problem solve
  • Reading nutrition labels
  • Finding health care
  • Managing depression
  • Positive thinking
  • Action plan
  • Spanish
  • Action plan report/problem solve
  • Future plans for health care
  • Healthy eating
  • Communication skills
  • Problem solving
  • Action plan
  • English

35
Tomando Control de Su SaludStanford Model of
Spanish CDSMP
Week Five
  • Action plan
  • report/problem solve
  • Communication skills
  • Future plans for healthcare
  • Increasing physical activity
  • intensity
  • Medication usage
  • Working with healthcare
  • professional 
  • Action plan
  • Spanish
  • Action plan
  • report/problem solve
  • Medication usage
  • Informed treatment
  • decisions
  • Depression management
  • Positive thinking Guided
  • imagery
  • Action plan
  • English

36
Tomando Control de Su SaludStanford Model of
Spanish CDSMP
Week Six
  • Action plan rpt/problem solve
  • Working with health care Professional/health care
    system
  • Looking back and plan future
  • English
  • Action plan rpt/problem solve
  • Evaluating home remedies
  • Guided imagery
  • Sharing successes/plan future
  • Celebration
  • Spanish

37
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.

38
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??

39
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

40
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?

41
Living Well with Chronic ConditionsStanford
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!

42
Living Well with Chronic ConditionsStanford
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

43
Living Well with Chronic ConditionsStanford
Model of CDSMP
  • Program Partnerships
  • Community-based Organizations
  • National Tongan American Society
  • Alliance Community Services (Spanish)
  • Local Health Departments
  • Bear River
  • Central Utah
  • Davis County
  • Salt Lake Valley
  • Southwest
  • Tri County
  • Utah County
  • Weber-Morgan

44
Living Well with Chronic ConditionsStanford
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

45
Living Well with Chronic ConditionsStanford
Model of CDSMP
  • Resources
  • Stanford Universitys 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//healthyagingprog
    rams.org

46
Living Well with Chronic ConditionsStanford
Model of CDSMP
  • Contact Information
  • Utah Arthritis Program www.health.utah.gov/arthri
    tis (for class schedules)
  • Rebecca Castleton rcastlet_at_utah.gov
  • 801-538-9340
  • Christine Weiss cweiss_at_utah.gov
  • 801-538-9458

47
Help Your Clients Quit Tobacco
  • Marci Nelson, B.S., CHES
  • Tobacco Prevention and Control Program
  • Utah Department of Health
  • marcinelson_at_utah.gov
  • http//www.tobaccofreeutah.org/healthcare.html
  • (801) 538-7002

48
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

49
Tobacco Use in UtahThe 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

50
Tobacco Health Effects
  • Short-term
  • Respiratory illness
  • Decreased lung capacity
  • High blood pressure cholesterol
  • Nervousness
  • Mouth problems
  • Reduced taste smell
  • Long-term
  • Heart disease
  • Stroke
  • Lung function
  • Cancers
  • Ulcer
  • Infertility

Responsible for more than 400,000 premature
deaths each year in the U.S.
51
Health Effects of Secondhand Smoke
  • Stillbirth miscarriage
  • Premature Birth
  • Cleft palates and lips
  • Sudden Infant Death
  • Infertility
  • Tooth Decay
  • Cancer
  • Bronchitis pneumonia
  • Asthma
  • Upper Respiratory Tract Disease
  • Ear Infections
  • Coughs

Secondhand smoke affects loved ones is a
powerful motivator to quit!
52
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

53
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.

54
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

55
Brief Counseling ASK, ADVISE, REFER
ASK
about tobacco USE
ADVISE
tobacco users to QUIT
REFER
to other resources
ASSIST
Patient receives assistance, with follow-up
counseling arranged, from other resources such as
the Utah Tobacco Quit Line
ARRANGE
56
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.

57
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).

58
What if they are not willing?
Offer a motivational intervention, the 5 R's
Relevance Risks Rewards Roadblocks Repetition
59
The 5 Rs
  • 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.

60
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)

61
Utah Tobacco Quit Line
  • Toll free 1.800.QUIT.NOW
  • - Spanish 1.877.629.1585
  • - TTY 1-877-777-6534
  • Monday-Sunday, 600 am to 1100 pm
  • FREE
  • For adults and youth
  • Services available in English, Spanish and
    translation in 140 other languages

62
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

63
  • Fax Referral System

Would you like the Utah Tobacco Quit Line to
help you quit?
64
  • 3 Simple Steps
  • Personalize your forms online at
    www.tobaccofreeutah.org/utqlprofax.html
  • 2. 2 As and R with client. For those ready to
    quit give them the form to fill out. Verify
    signature!
  • 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.

65
  • http//utahquitnet.com
  • Quitting guide
  • Medication guide
  • Expert counseling
  • Personalized quit plan
  • 24 hour community support
  • Online NRT purchase

Lifetime membership!
66
  • 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
67
Tobacco Dependencea 2-Part Problem
Tobacco Dependence
Physiological
Behavioral
Treatment should address the physiological and
the behavioral aspects of dependence.
68
Smoking Cessation Medications
  • Nicotine polacrilex gum
  • Nicorette (OTC)
  • Generic nicotine gum (OTC)
  • Nicotine lozenge
  • Commit (OTC)
  • Generic nicotine lozenge (OTC)
  • Nicotine transdermal patch
  • Nicoderm CQ (OTC)
  • Nicotrol (OTC)
  • Generic nicotine patches (OTC, Rx)
  • Nicotine nasal spray
  • Nicotrol NS (Rx)
  • Nicotine inhaler
  • Nicotrol (Rx)
  • Bupropion SR (Zyban)
  • Varenicline (Chantix)

These are the only medications that are
FDA-approved for smoking cessation.
69
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!

70
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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