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Self-Regulation & Chronic Illness Management

Titis Kurniawan, MNS

Overview
Chronic Illness Acute care model for Chronic Illness Behaviors/Life style & chronic Illness Self-Regulation & behavior changes

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Chronic Illness
Chronic Illness Facts CDC surveys:
70% death in US caused by chronic diseases (cardiovascular disease, cerebrovascular disease, cancer and COPD) 65 & older 85% have at least 1 chronic illness

Indonesia
Highest causes of death 2012; cardiac problem, TBC, vascular problem (stroke), PPOK, newborn, hypertension, & DM (WHO, 2013) 60 & older 18,27 million (7,5%) 50% have health problem (BPS, 2012) Higher illness of Hajj; Hypertension, DM, cardiovascular problem, pulmonary, arthritis, etc (MOHRI, 2012)

Nature of Chronic Illness

Multiple & vary/changing causes Non specific onset, gradual & indefinite Uncertainty prognosis unpredictable Cure & technology not main treatment Complications Broad impacts Bio-psycho-sociospiritual-financial-family Patients center approach

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Type of Chronic Illness

Life-threatening diseases; fast growing cancers, stroke or heart attacks. Manageable diseases; diabetes, hypertension, osteoarthritis, chronic sinusitis Progressively disabling diseases; Parkinsons, lupus, RA and multiple sclerosis Others; fibromyalgia and chronic fatigue syndrome

Symptom Cycle
Disease Fatigue Tense muscles

Vicious Cycle
Depression Stress/Anxiety

Anger/Frustration/Fear

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Coping Skills
Denying or minimizing Seeking information Learning to provide ones own medical care Setting concrete, limited goals Recruiting support Considering possible future events Gaining a manageable perspective

Long-term Adaptation
Adaptation making changes to adjust to life circumstances Quality of life fulfillment, purpose, personal control, relationships, activities, personal and intellectual growth, material possessions

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Acute Care Model for Chronic Illness

Health Services Activities series:
Screening, Admission, A single point-in-time assessment, A short course of minimally individualized treatment Discharge and brief aftercare, followed by termination of the service relationship

Focus; symptom elimination for a single primary problem Professional center approach A professional expert directs and dominates decision-making throughout this process. Long-term care viewed as self-sustainable without professional assistance Evaluation Relapse single point in time follow up individual failure/non-compliance/non-adherence

..Acute Care Model for Chronic Illness

Research Findings
50% drop out (Hubbard, Flynn, Craddock, & Fletcher, 2001) & 40% not complete the treatment (Watkins, Pincus, Tanielian, & Lloyd, 2003) High relapse rate 50-60% relapse among patients with drug/alcohol addiction, (50-70%) Hypertension and (50 to 70%) asthma (Stocker, 2006) Effective treatment effective when combined information system, organizational, patientoriented, & provider oriented. DM outcomes (HbA1c, Blood glucose level, LDL) achieved only when the patients-oriented applied (Renders
et al, Diabetes Care, 2001)

Low treatment compliance

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..Addiction/Chronic Illness
Compliance Rate
Addiction Alcohol Opioid Cocaine Nicotine Insulin Dependent Diabetes Medication Diet and Foot Care Hypertension Medication Diet Asthma Medication 30-50% 30-50% 30-50% 30-50%

Relapse Rate
50% 40% 45% 70%

<50% <50% <30% <30% <30%

30-50% 30-50% 50-60% 50-60% 60-80%

(O'Brien & McLellan, 1996)

Differences Between Acute and Chronic Care Roles

ACUTE CHRONIC Select and Teacher/coach conduct therapy and partner

Role of Professional

Role of Patient
Lorig 2000

Follow orders

Partner/ Daily manager

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..Acute Care Model for Chronic Illness

Conclusion
Acute care model not meet the expectation Acute model not effective for chronic illness Need new approach;
Post-treatment continuing care services - continuing care over a continuum of care for life Non single Evaluation approach Encourage patients self-management Professional health care assistance aftercare period Involvement of families & intimate

Chronic Care Model

Community
Resources and Policies SelfManagement Support

Health System
Health Care Organization Clinical Information Systems

Delivery System Design

Decision Support

Informed, Activated Patient

Productive Interactions

Prepared, Proactive Practice Team

Improved Outcomes

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Behaviors/Lifestyle & Chronic Illness

Improper/unhealthy behaviors/Life style Most of chronic illness causes Behavioral change/adjustment main treatment strategies Behavioral change challenges
Behaviors daily activities Need long-term process Change Stressed Internal & external motivation needed Need conducive & supportive environment

one of the

Self-Regulation
Basic Assumption
Client is...an active problem solver... interested in improving his/her health Client is a person whose behavior attempts ...to close the perceived gap between his or her current status and a goal, or ideal state. Client has some skills beneficence for their illness Client is the expert of their illness Client partner of professional health care in the treatment management Healthcare professional facilitator

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Self-Regulation

The Elements of Self-Regulation

Self-Monitoring Self-Evaluation Self-Reinforcement (Kanfer and Galick-Buys (1991)

The Element of Self-Regulation

Self-Monitoring
Client individual intentionally monitors/ observes his/her own certain behaviors Identify & record frequency, intensity, duration of some behaviors/activities related to their current condition

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The Element of Self-Regulation

Self-Evaluation
Client compare their own behaviors to the standard/expected behaviors Expected/standard of behaviors provided by the professional health care Identify the gap;
The exist behaviors suitable with their current condition maintenance The exist behaviors need modification to be suitable with their current condition The exist behaviors worsening their current condition should be terminated

The Elements of Self-Regulation

Self-Reinforcement
Client providing emotional or cognitive responses regarding the evaluation stage Form of responses feedback or feedforward and further makes decision to improve, modify or just maintain the current behaviors properly Activities;
set the behaviors must be managed goal setting behavioral adjustment planning

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The Elements of Self-Regulation

Therapeutic Contract (Kanfer and Galick-Buys (1991)
The agreement statement between clients and facilitator regarding the certain behaviors that would be improved and the consequences for the accomplishment and non-accomplishment Other references action planning therapeutic contract = goal setting &

Benefit providing the measurable outcomes that facilitate the objective evaluation of patient achievement during implementing the behavioral improvement process Standard;
Specific Behaviors Detail & Clear Criterion of achievement measurable/observable Include the positive reinforcement Reinforcement conducted as soon as possible

The Elements of Self-Regulation

Self-Efficacy
The beliefs regarding one's capabilities of successfully completing tasks or goals (Locke & Latham, 2002) Measured as three basic scale:
Self-efficacy magnitude measures the difficulty level (e.g. easy, moderate, and hard) an individual feels is required to perform a certain task (Van der Bijl & Shortridge-Baggett, 2002). Self-efficacy strength refers to the amount of confidence an individual has about performing successfully at diverse levels of difficulty (Van der Bijl & Shortridge-Baggett, 2002). Generality of self-efficacy refers to the "degree to which the expectation is generalized across situations (Lunenburg, 2011).

Bodenheimer et al., (2007); self-efficacy scale 7 (0 10) as cut point indication client will successfully perform the expected action s

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The Elements of Self-Regulation

Clients activities: - Set the goal - Set the action plan - Identify any challenge/ potential barrier - Identify any support/ resources to manage the difficulties - Training - Implement the action plan

Clients activities: - Intentionally observe/ contemplation certain behaviors - Record intensity, frequency, duration of activities/behaviors

Clients activities: - Compare current behaviors with the standards - Judge/decide; maintain, modify, or eliminate current behaviors

Self-Reinforcement
Facilitators activities: - Regularly follow up - Providing counseling - Providing reinforcement - Facilitating client to re-planning, develop further action plan

Self-Evaluation
Facilitators activities: - Providing adequate information related expected/behaviors standard related to patients condition

Self-Monitoring
Facilitators activities: - Facilitate/Guide/asking question regarding clients current activities

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