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

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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

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CDC Arthritis Funded States
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AoA Funded States for CDSMP
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Our Broad Goal
I love CDSMP and ADEU!

• To improve the quality of life for people
  affected by arthritis and other chronic
  conditions.

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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)

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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)
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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)
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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
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Prevalence of Arthritis Among Persons With Other
Conditions, Utah
Source BRFSS, 2009
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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

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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)

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

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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

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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

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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

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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

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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

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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

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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
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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

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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

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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

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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
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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

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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

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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

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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

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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

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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

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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

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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

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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??

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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

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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?

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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!

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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

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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

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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

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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

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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

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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
• [phone]

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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

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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

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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.
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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!
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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

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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.

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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

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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
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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.

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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).

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

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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)

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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

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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

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• Fax Referral System

Would you like the Utah Tobacco Quit Line to
help you quit?
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• 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.

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• http//utahquitnet.com

• Quitting guide
• Medication guide
• Expert counseling

• Personalized quit plan
• 24 hour community support
• Online NRT purchase

Lifetime membership!
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• 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!

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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