Patient Self-Management

Self-management is an important aspect of chronic disease management. This approach requires patients to actively participate in their recovery in order to encourage survival, well-being and overall health and reduce the negative impacts of treatments. It involves patients working collaboratively with health professionals and their carers so as to:

• Devise a plan of self-care and monitor it;
• Participate in activities that promote and enhance health, by concentrating on prevention and timely intervention;
• Manage and monitor signs and symptoms;
• Cope with the bearing of the condition on mental health, physical health and social interactions;
• Understand the condition and the options for treatment and management that are available, and participate in decision-making; and
• Develop the confidence and ability to access supports and services.

To facilitate this, it is of value to employ the following supports for patients:

• Provision of tailored information to patients
  • To enhance knowledge and help the patient with behaviour change.
  • Tailor self-management support to the patient’s ability to do so, taking into account skill level and confidence of the patient.
• Promote self-efficacy
  • Involve patients in behaviour change, g. through an action plan.
  • Assist patients to understand the multiple causes of their symptoms to encourage trying new self-management techniques.
  • Maintain a collaborative approach and encourage this with other health professionals involved in care, to aid patients in taking responsibility for their health.

The promotion of behaviour change is central to patient autonomy and success in self-management of their chronic disease. Various techniques can be employed by health professionals to facilitate behaviour change such as:

• Goal setting and planning
  • Help patients to concentrate on a particular issue, set achievable goals and devise a tailored action plan to work towards achievement.
  • Usually, goals are SMART (Specific: simple and focused; Measurable: goal has a measurable outcome; Achievable: the patient must have the ability to achieve; Realistic: the patient is capable of achieving the goal, and during the consultation identify any barriers to doing so; and Timely: define a date and time for achievement of the goal).
• Open questioning
  • Enables patients to discover their issues and devise their own motivation to change.
• Reflective listening
  • Is an active process to mirror the message the patient has just imparted, and further emboldens the patient to articulate their own reasons to change.
• Articulating follow-up requirements
  • Help patients to adhere to planned care strategies, deliver emotional care, and lead behaviour change.
• Problem solving
  • To recognise and analyse issues together with the patient, understand how the issue impacts on their life, work through barriers to change behaviour, and resolve clinical problems, as well as help the patient to do so as well, by effectively using resources and time available.
• Assertiveness
  • Important in handling patients who may be aggressive or defensive, and assists the health professional in approaching challenging issues and tackling people about change.
• Assessing a patient’s willingness to change
  • Will aid a patient to then adhere to the strategies needed to work through the change process.

Motivational interviewing is a technique that promotes a patient’s motivation to change. It is based upon a combined therapeutic relationship where the patient’s autonomy is prioritised, and the health professional identifies the tools required for change. The health professional assumes a supportive approach to facilitate the patient’s journey towards changing their behaviour. The approach of ‘The Five A’s Model of Self-Management Support’ involves the use of essential skills such as reflective listening, goal setting and planning, and open questioning and consists of the following five steps:

1. Assessment – of the patient’s habits, beliefs, knowledge, and the health professional’s review of clinical data.
2. Advise – the health professional aims to improve a patient’s knowledge, provide tailored information, and resolve any misconceptions.
3. Agreement – a collaborative approach with the patient to set specific, achievable goals and develop an ensuing action plan.
4. Assist – help the patient to recognise apprehensions and obstacles to change, and develop strategies to assist in working through these, and achieve these goals.
5. Arrange – follow-up consultation either by phone or in person with the patient to reflect on progress against goals, and reiterate the action plan and goals to be achieved.

Motivational interviewing is successful when the health professional is able to:

• Empower the patient to talk
• Develop self-motivational dot points for the patient
• Handle opposition from the patient
• Inspire the patient to change
• Discuss and devise a plan in collaboration with the patient

The health professional should adopt a patient-centred approach, rather than try to rectify a problem, advise or persuade. The strategy should involve asking the following questions:

1. Why do you want to make this change?
2. How might you go about being successful in changing?
3. What are the three key reasons for you to change?
4. On a scale of 0-10, how important is it for you to make this change?
5. Why have you chosen x rather than a lower number?

After closely listening to the answers, the health professional needs to reflect a concise summary of the information gathered, then ask the patient what they think they will do. Patients should be stimulated to speak their minds in order to help the health professional foster a willingness for change, work through resistance, formulate a plan, develop motivation and take action.

Ogunbayo et al. conducted a study into patient opinions regarding self-care in chronic medical conditions and their reliance on community pharmacies. It was found that healthcare professionals were thought to be passive and incomplete providers of information, and not helpful in effecting behaviour change. Patients reported that sources outside the healthcare realm (i.e. friends, family, carers, the internet) were significant in catering for such voids, in particular with regard to lifestyle measures. Patients’ recognition of community pharmacies as an opportunity for self-care support provision in chronic disease management and, in turn, their utilisation of and perceived need for community pharmacies was found to be minimal, with little cognisance of the potential for the abilities and role of a community pharmacist, with a primary focus on just medication supply. This study demonstrated that community pharmacists should consider patient perception of the lack of contribution to self-care support in chronic conditions, and inter-professional collaboration may be of benefit.

It is clear from widespread documented evidence (beyond the scope of this article) that the clinical pharmacist plays an important role in a multidisciplinary team and can make a significant impact upon patient care, provide a ready resource of drug information and advice for colleagues and patients alike with regard to therapies, monitoring, and toxicity, as well as cost savings and beneficial pharmacoeconomic outcomes. Medications are clearly a vital part of patient therapy, and accordingly, a methodical and careful methodology in assisting patients to manage their medications can simplify matters and positively impact upon therapeutic outcomes. Accordingly, pharmacists can contribute significantly to patient care and represent a dynamic and essential part of the answer to providing care for the growing number of patients in our communities. By applying a systematic, sequential practice combining the fundamental ideologies of pharmaceutical care to each patient’s clinical situation, circumstances and therapeutic goals, then ultimately keeping at the forefront the value for patients, is fundamental to motivating the application of new collaborative initiatives and extended scope of responsibility involving pharmacists in supporting patients on their journey to wellness.