After attending a workshop on self-management run by the Ministry of Health last week, I thought it might be useful to look at some of the areas studied in other countries before New Zealand runs headlong into thinking that self-management is both inexpensive and easy. Not that I am in any way saying that self-management is the wrong approach for managing chronic health conditions, just that it’s not quite a panacea for all ills within the health system!
Yesterday I touched on the need for effective follow-up because at each encounter with the health system, a person with chronic pain is likely to be faced with a choice: either to continue with the chronic model, or to slip into an acute model of management. My point is that new skills are difficult to maintain – I mean, self management is more challenging than taking a pill in any case because they require internal locus of control, changes to everyday habits, and ongoing perseverance to use them even during challenging times. Give a person a quick and simple answer – and you can bet that’s the one they’ll choose over having to work really hard day in and day out!
Back to today’s study. This is a study of the role of the nurse care manager and primary care physician. Now I don’t really think it’s a matter of who is delivering the services: in this case it’s nurses vs doctors. Maybe it’s much more about other factors such as face-to-face time and accessibility – so I’m going to review this paper in this light. Matthias, Blair, Nyland, Huffman, Stubbs, Damush and Kroenke (hereafter known as ‘the authors’!) conducted four focus groups within the Indiana University Medical Group Primary Care Clinics and Ri8chard L Roudebush Veterans Administration Medical Center General Medicine clinics. Participants had been part of the SCAMP trial, which was looking at a stepped care model for primary care patients with musculoskeletal pain and depression.
The SCAMP study is itself an interesting approach to helping people cope with the double burden of depression and chronic pain – stepped care patients had 12 weeks of antidepressant medication plus six sessions of pain self management over 12 weeks, the control group were simply informed they had depressive symptoms and they should seek advice about treatment.
The four focus groups had between 3 – 6 participants in them, with two groups being women, and two groups male only. In this study, the focus group participants were only those who had received the stepped care approach. The groups were moderated by an external facilitator, and a simple open-ended semistructured discussion was conducted. Members of the research group were also present to code responses.
Although the questions were not specifically about the relationships that people had formed with the care manager or GP, the groups are reported to have raised this relationship often during the course of the discussion. Typically the participants were less than happy with the pain management they had received from their GP, and much more satisfied with the pain management provided during the self management programme.
Now, the key differences between the two approaches are summed up as these:
- continuity of care
In other words, the self management arm of this study provided participants with some of the very things that provide people with a sense of being understood, being listened to, and – oh yes, take time to do.
This is, I guess, why I’m somewhat dubious that a self management approach will be a cost-saving way to manage chronic conditions. Unless the facilitators of these self management programmes are paid less than the current care providers (mainly GPs), what is reduced in terms of medications, investigations and fees for passive treatments are likely to be spent on enabling each patient to be seen for longer – both longer within a session, and over a longer period of time.
Follow-up, maintaining an interest in how the person is managing, problem-solving and really understanding how a slip-up in using new behaviours occurs takes a lot of time and a lot of really good listening skills. It demands that the facilitators continue to hold the chronic management model as an effective approach (or it’s common for the person to return to a passive or acute model), especially when people find it challenging. Sometimes people who make a slip-up in using new skills have no idea why they’ve used the old approach, sometimes they defend their use of an old approach simply because it’s easy and it works.
In other words, although in this study it was nurses who facilitated the self management, and doctors who provided the standard care, I wonder if it’s really about who delivers it. Maybe it’s more about time, commitment to the self management model, and knowledge of how behaviours change (or don’t as the case may be!). I think it could be easy to think that self management is a quick solution to the ongoing problem of chronic health management when in fact, it’s a whole new way of viewing health and wellbeing, and it is not easy. It does require good training in how to carry it out effectively – and support for those providing the care in the community.
I really do hope the wave of interest in self management is supported – because while it’s the patients who will need the ongoing followup to maintain their behaviour change, it’s the health care providers who will need to be supported to do a good job.
Matthias, M., Bair, M., Nyland, K., Huffman, M., Stubbs, D., Damush, T., & Kroenke, K. (2009). Self-Management Support and Communication from Nurse Care Managers Compared with Primary Care Physicians: A Focus Group Study of Patients with Chronic Musculoskeletal Pain Pain Management Nursing DOI: 10.1016/j.pmn.2008.12.003