RHP 12 Learning Collaborative
Package One
Debra Flores, Ph.D.
Participants will:
1) Participants will name and describe the different
types of self-management support systems
2) Participants will compare and contrast traditional
patient education and self-management education
3) Participants will compare and contrast traditional
care and collaborative care in chronic illness
4) Participants will have a general understanding of
motivational interviewing
5) Participants will describe the components of
Patient Activation
6) Participants will review patient activation tools
Patient Education
Self-Management Education
Problem Solving and Goal Setting
Behavioral Techniques (Motivational
Peer support (Navigation)
Role Negotiation (Patient Activation)
In the Clinical
In the Acute Care
Post Hospitalization
◦ Select an aim of what the
focus of the education
will involve, i.e. Diabetes,
Hypertension, CHF.
◦ Select the team member
that will be designated to
deliver the education
◦ Create a script with
materials if available to
deliver the education
◦ Deliver the education
◦ Keep a record of the
patients educated
Traditional Patient Education
Self-Management Education
Information and technical skills
about the disease
Problems reflect inadequate control
of the disease
Skills on how to act on problems
Relation of education to the disease
Education is disease-specific and
teaches information and technical
skills related to the disease
What is the theory underlying the
Disease-specific knowledge creates
behavior change, which in turn
produces better clinical outcomes
Education provides problem-solving
skills that are relevant to the
consequences of chronic conditions
in general
Greater patient confidence in
his/her capacity to make lifeimproving changes (self-efficacy)
yields better clinical outcomes
What is the goal?
Compliance with the behavior
changes taught to the patient to
improve clinical outcomes
A health professional
What is taught?
How are problems formulated?
Who is the educator?
The patient identifies problems
he/she experiences that may or may
not be related to the disease
Increased self-efficacy to improve
clinical outcomes
A health professional, peer leader,
or other patients, often in a group
Traditional Care
Collaborative Care
What is the relationship between
patient and health professionals?
Professionals are the experts who
tell patients what to do. Patients
are passive
Shared expertise with active
patients. Professionals are experts
about the disease and patients are
the experts about their lives
Who is the principal caregiver and
problem solver? Who is responsible
for outcomes?
The professional
The patient and professional are
the principal caregivers; they share
responsibility for solving problems
and for outcomes.
What is the goal?
Compliance with instructions.
Noncompliance is a personal deficit
of the patient
The patient sets goals and the
professional helps the patient make
informed choices. Lack of goal
achievement is a problem to be
solved by modifying strategies.
How is the behavior changed?
External motivation
Internal motivation. Patients gain
understanding and confidence to
accomplish new behaviors
How are problems identified
By professional, eg, changing
unhealthy behaviors
By the patient, eg, Pain or inability
to function; and by the professional
How are problems solved?
Professionals solve problems for
Professionals teach problemsolving skills and help patients in
solving problems.
Patient activation is a critical component of
chronic disease management and transitional
Activation- “having the information,
motivation and behavioral skills necessary to
self-manage, chronic illness, collaborate with
health care providers, and access appropriate
Level One
Building knowledge and
Individuals do not feel confident
enough to play an active role in
their own health. They are
predisposed to be passive
recipients of care
Level Two
Building knowledge and
Individuals lack confidence and
understanding of their health or
recommended health regimen.
Level Three
Taking action
Individuals have the key facts and
are beginning to take action but
may lack confidence and the skill
to support their behaviors
Level Four
Maintaining Behaviors
Individuals have adopted new
behaviors but may not be able to
maintain them in the face of
stress or health crisis
Healthy behaviors such
as diet and exercise
Disease selfmanagement such as
adherence to drug
regimens, monitoring
and management of
Medical encounter
Seeking health
Improved adherence to
Increased likelihood to
eat healthier and engage
in physical activity
Increased presence in
workforce and increase
job satisfaction
Decreased likelihood of
ED usage and
readmissions post
Increase engagement
with clinicians
“Self-Management for
Patients with HF” (2013)
Shively & Colleagues
Hospital (N=82, 41
participants in intervention
group & 41 in control
Blood Pressure cuff, weight
scale, & pedometer, selfmanagement DVD and
Education booklet
Patient Activation could be
improved through a
targeted intervention and
the effect was more
pronounced for the
medium-level activation
“Development of the
Patient Activation Measure
(PAM): conceptualizing and
measuring activation in
patients and consumers”
(2004) Hibbard et al
Clinical (N=479 controlled
and randomized trail)
Self-Management tailoring
care plans to activation
Positive impact of tailored
interventions with
improved clinical indicators
such as blood pressure and
counseling in patients with
HF: The Heart Failure
adherence and retention
randomized behavioral
trail” (2010) Powell &
Hospital (N=902)
Efficacy of selfmanagement HF
counseling and education
No remarkable results
“How do people with
different levels of
activation self-manage
their chronic conditions?”
(2009) Dixon, Hibbard &
Outpatient (N=27)
Management of chronic
conditions with different
activation levels
Self-Management support
needs to be tailored for the
different levels of
Measurement for Research
Measurement for Learning and Process
To discover new knowledge
To bring new knowledge into daily
One large "blind" test
Many sequential, observable tests
Control for as many biases as possible
Stabilize the biases from test to test
Gather as much data as possible, "just
in case"
Gather "just enough" data to learn and
complete another cycle
Can take long periods of time to obtain "Small tests of significant changes"
accelerates the rate of improvement
 Self-Efficacy
for Managing
Chronic Disease.pdf
 English Self-Efficacy for
 MOS_adherence_survey.pdf
RAND 36-MOS-Measure of Patient
Spanish Chronic Disease Self-Efficacy.pdf
Spanish Diabetes Self-Efficacy.pdf

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