Living Healthy: The Chronic Disease SelfManagement Program

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Living Healthy The Chronic Disease
Self-Management Program

• Serena Weisner, MS
• CDSMP Project Coordinator
• NC Division of Aging Adult Services
• May 14, 2009

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Honest doc -- if I had known I was gonna to live
this long, Id have taken better care of myself.
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Prevalence of select chronic conditions, 2003
US Adults Ages 65 and Over
In this age group, Asthma is reported in
1/3 more women than men.
Prevalence estimates from the NHIS
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Asthma and older adults

• A 1997 study found that older patients with
  asthma
• Had more unscheduled visits to their doctors'
  offices and to emergency rooms.
• Were more likely than younger patients to be
  hospitalized for asthma.
• Another 1997 study found that
• The length of hospital stays for asthma increased
  as patients grew older
• Older asthma patients were more likely than
  younger patients to enter convalescent and
  nursing homes after they were discharged from the
  hospital.
• Asthma can be more dangerous in older adults
  because they are more likely to develop
  respiratory failure, even during mild attacks.
• The risk of developing asthma for the first time
  is just as great in adults over age 65 as it is
  in just about any other age group except early
  childhood.
• As baby boomers age, the number of older adults
  affected by asthma is expected to grow
  significantly.

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Treating asthma in the elderly is complicated

• Asthma in seniors is frequently overlooked due to
  the widespread perception of asthma as a
  childhood disorder.
• Normal aging-associated changes in lung structure
  are likely to exaggerate asthma symptoms.
  Difficult to distinguish clearly between asthma
  and COPD, especially in patients who have smoked.
  
• Adverse asthma reactions from medications related
  to polypharmacy are greater in the elderly.
• Desired outcomes may be more difficult to achieve
  in elderly patients with asthma. Normal lung
  function may either be unattainable or be
  attainable only with potentially dangerous, high
  pharmacologic doses. Setting realistic goals for
  therapy is key.
• Getting an annual flu vaccine is particularly
  applicable for asthma patients over age 65 .
• Education and self-management are critical!

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Self-management

• There is no way a patient can avoid managing a
  chronic condition. If he/she does nothing but
  suffer, this is a management style. If the
  patient chooses to be a positive self-manager
  and undergo all the best treatments that health
  care professionals have to offer, along with
  being proactive in his/her day-to-day management,
  this will lead to the healthiest life possible.

Kate Lorig, RN, DPH, et al. Living A Healthy Life
with Chronic Conditions
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Self-management behaviors

• Much of what impacts successful or unsuccessful
  self-management can be found in behaviors.
• Either a person adopts healthy behaviors (e.g.
  exercising, eating healthy, taking meds
  correctly), OR adopts unhealthy behaviors (e.g.
  inactive, poor diet, doesnt take meds)

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What do we know about behaviors?

• Behaviors are complex and specific to the task
  and context. In general, we can say that the more
  intrinsic value the behavior has and the easier
  it is to do, the more likely it will be done.1
• People with different types of chronic illnesses
  have similar issues, needs and goals. 2
• Three major chronic illness management tasks 3
• medical management
• maintaining, changing or creating new meaningful
  behaviors
• dealing with the emotional burden of having a
  chronic condition.

1 Roter, D. L., Hall, J., Merisca, R., Nordstrom,
B., Cretin, D. and B. Svarstad. (1998).
Effectiveness of Interventions to Improve Patient
Compliance. Medical Care, Vol. 36, No. 8
1138-1161. 2 Lorig, K. et al. (1999). Evidence
suggesting that a chronic disease self-management
program can improve health status while reducing
hospitalization a randomized clinical trial.
Medical Care, 37(1) 5-14. 3 Corbin, J. and A.
Strauss. (1988). Unending work and care managing
chronic illness at home. Jossey-Bass Publishers,
San Francisco.
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Illustration of problems that can be impacted by
behaviors for a sample of chronic conditions
Lorig, et al., 2006
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Changing behaviors

• People are generally willing to initiate new
  behaviors or modify existing behaviors that they
  believe address important health concerns.
• They may define 'important' differently than you
  do.
• To many people, the things that are important
  have immediate impact to their lives.
• Clinical rationale for a certain behavior (e.g.
  beginning a walking program) may not be as
  relevant as a personal motive, for example,
  increased energy to take care of the
  grandchildren.
• Program components need to be linked directly to
  what a person says is important to him/her.

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Changing behaviors contd

• Time to practice new behaviors
• Tools and resources needed
• Monitor progress
• Follow up activities
• Self-efficacy (i.e. self-confidence)
• Social influence when possible, engage
  companions/significant others.
• Engage the target population /or trusted opinion
  leaders in program delivery

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Health promotion and behavior change strategies
work for older adults

• Longer life
• Reduced disability
• Later onset
• Fewer years of disability prior to death
• Fewer falls
• Improved mental health
• Positive effect on depressive symptoms
• Possible delays in loss of cognitive function
• Lower health care costs
• www.healthyagingprograms.org/content.asp?sectionid
  85ElementID304

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The aging services network

• THEN
• Meals/nutrition services
• Elder rights
• Home health care
• Adult day/day health care
• Caregiver assistance
• Housing
• Exercise programs
• Health programs

• NOW
• Evidence-based health
• promotion and disease
• prevention programs
• Funders increasingly demand that programming be
  based on solid evidence, agency leaders want to
  concentrate limited resources on proven programs,
  and older adults themselves are looking for
  programs that have been proven to work.

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Evidence-based health promotion

• Usual question Does what we are doing work?
• Evidence-based question Can we do what is known
  to work?
• What do we know works?
• About whom do we know it?
• How can we tell if we are doing it right?

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Advantages of an evidence-based approach

• Increases the likelihood of positive outcomes
• Makes it easier to justify funding
• Helps to establish partnerships esp. with health
  care
• Leads to efficient use of resources
• Facilitates the spread of programs
• Facilitates the use of common performance
  measures
• Supports continuous quality improvement

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Chronic Disease Self-Management Program (CDSMP)

• Format Train the Trainer
• Lay Leader Led
• 2 ½ hours session 1x/wk 6 weeks
• Program goal To enable participants to build
  self-confidence to assume a major role
  maintaining their health and managing their
  chronic health conditions.

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Reasoning behind the programs design and
elements

• People with chronic conditions have similar
  concerns and problems.
• People with chronic conditions must deal not only
  with their disease(s), but also with the impact
  on their lives and emotions.
• Lay people with chronic conditions, when given a
  detailed leader's manual, can lead the CDSMP as
  effectively, if not more effectively, than health
  professionals.
• The process or the way the CDSMP is taught is as
  important, if not more important, than the
  subject matter that is taught.

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Essential program components and activities

• The CDSMP focuses on
• Problems common to individuals suffering from
  various chronic diseases.
• Strategies such as goal setting, behavior
  modeling, problem-solving techniques, and
  decision making.
• Learning and utilizing new behaviors!
• Individuals are taught to control their symptoms
  through
• Relaxation techniques
• Changing their diets
• Managing pain and fatigue
• Using medications correctly
• Exercise
• Communication with health providers

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Research shows that CDSMP participants

• Increased their levels of physical activity.
• Developed better coping strategies and symptom
  management.
• Showed better communication with their
  physicians.
• Improved their self-rated health.
• Increased their social/role activities.
• Decreased health distress levels.
• Had more energy and less fatigue.
• Experienced decreased disability.
• Had lower numbers of physician visits and
  hospitalizations.

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National Support

• US Administration on Aging (AoA)
• Over 5 million invested in 24 states
• (3-year grants) All are doing CDSMP
• Other federal agencies
• CDC
• AHRQ
• CMS
• Dozens of private funders, including
• Atlantic Philanthropies
• John A. Hartford Foundation
• Robert Wood Johnson Foundation
• Archstone Foundation

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CDSMP in North Carolina Living Healthy

• 3-year demonstration grant from AoA
• Joint partner are the NC Division of Public
  Health and the NC Division of Aging Adult
  Services
• Currently in 7 Area Agency on Aging Regions
• Regional Coordinators
• Working to target hard-to-reach, underserved
  adults 60, and offer the program in a wide
  variety of settings.
• Also seeking to develop partnerships to offer the
  program to younger populations.

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Living Healthy Project Map
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Partnering is crucial to success

• Goal To sustain CDSMP beyond the AoA grant
• Requires
• Continued commitment from a wide variety of
  partners
• Stable infrastructure that is consistent across
  partners
• Incorporating CDSMP into existing systems and
  initiatives
• Partnering and more partnering
• DAAS DPH
• AARP
• NC Cooperative Extension
• Local Aging and Public Health networks
• CCNC
• AHECs

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Future Policies

• NC DAAS Requires use of 35 of OAA Title IIID
  funds (health promotion/disease prevention) to
  support evidence-based programs
• AoA Hoping that demonstration grants will lead
  to OAA appropriations
• Ultimate goal Obtain recurring state
  appropriations to support the continued
  dissemination and implementation of CDSMP/Living
  Healthy for all populations, not just older
  adults!

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• Vision without action is merely a dream.
  Action without vision just passes the time.
  Vision with action can change the world."
• - Joel Barker -

For more information about Living Healthy,
please contact Serena Weisner, MS CDSMP
Project Coordinator [phone], Ext.
246 serena.weisner_at_ncmail.net