7. It is recommended that motivational interviewing be used to counsel patients/families on health behavior change (Hettema, Steele, & Miller, 2005 [M]; Rubak et al, 2005 [M]; Dunn, Deroo, & Rivara, 2001 [M]; Lewin et al., 2001 [M]; Butler et al., 1999 [A]; Monti et al., 1999 [B]; Colby et al., 1998 [B]; Erickson, Gerstle, & Feldstein, 2005 [S]; Miller & Rollnick, 2002 [E]; Rollnick, Mason, & Butler, 1999 [E]).

   Note 1: Motivational interviewing is a patient-centered, directive method of communication used throughout self-management support with the goal of enhancing motivation to change behavior by exploring and resolving ambivalence (Miller & Rollnick, 2002 [E]).

   Note 2: Motivational interviewing is effective in brief encounters and produces better outcomes in management of unhealthy behaviors than traditional advice giving or confrontation when addressing self-management support (Rubak et al., 2005 [M]).

   Note 3: The Elicit-Provide-Elicit method is a motivational interviewing technique to structure the process for counseling patients and families in the context of a brief office visit and is found in Appendix 13 of the original guideline document (Mash & Allen, 2004 [O]; Gance-Cleveland, 2005 [S]; Rollnick, Mason, & Butler 1999 [E]).

8. It is recommended that shared decision making and decision aids (tools) be used regarding intervention options (O'Connor et al., 2003 [M]; Charles et al., 2006 [S]).

   Note 1: See sample generic decision aid tools on the web: http://decisionaid.ohri.ca/AZsearch.php?Topic=Any_decision and http://www.dhmc.org/webpage.cfm?site_id=2&org_id=108&gsec_id=0&sec_id=0&item_id=2486.

   Note 2: Shared decision making is especially beneficial when there is no clear "best" treatment option.

   Note 3: Shared decision aids produce increased confidence, knowledge, and optimism, congruence with treatment, and improved involvement in making choices regarding care options (O'Connor et al., 2003 [M]).

Agree

Agreement on goals that are collaboratively set based on patient's/family's level of importance (priority) and confidence (self efficacy) in their ability to change the behavior.

9. It is recommended that written action plans  including goal setting and barrier management be used to assist patients/families in planning for behavioral change, customizing them to address:
   • Individual needs
   • Patient characteristics
   • Developmental level of the child
   • Patient preferences
   • Available resources

   (Haynes et al., 2005 [M]; Gibson et al., 2004 [M]; Haby et al., 2001 [M]; Toelle & Ram, 2002 [M]; Powell & Gibson, 2003 [M]; Wolf et al., 2003 [M]; Staab et al., 2006 [A]; Local Consensus [E])

   Note 1: There is no consistent evidence that written plans alone produced better patient outcomes than no written plan. However, comprehensive care that includes education, a written self-management plan, and regular review has been shown to improve outcomes. (Gibson et al., 2002 [M]; Toelle & Ram, 2002 [M]).

   Note 2: The "My personal action plan" tool, found in Appendix 14 in the original guideline document, is one that could be used to implement this recommendation. (Local Consensus [E]).

Assist

Assist patients/families to problem solve by identifying personal barriers; strategies; social, environmental, and community support and resources.

10. It is recommended that self-management education and skills building be integrated into the care of all patients/families at the developmentally appropriate level (Gibson et al., 2002 [M]; Wolf et al., 2003 [M]; Fireman et al., 1981 [C]; Task Force on Community Preventive Services. 2002 [S, E]; Betz, 2000 [S]).

    Note 1: Self-management education of patients and families reduces the number of hospitalizations, emergency and unscheduled visits, and missed work and school days. (Gibson et al., 2002 [M])

    Note 2: Patient education alone is not sufficient to promote health behavior (Norris et al., 2006 [M]; Haby et al, 2001 [M]; Bartholomew et al., 1991 [O]).

    Note 3: See Appendix 15 in the original guideline document for possible self-management supports at various developmental stages.

11. It is recommended that self-management education and skills building include tailored health education based on individual patient/family needs, risks, and readiness to change (Norris et al., "The effectiveness," 2002 [M]; Dorr et al., 2006 [D]; Farmer et al., 2004 [O]; Local Consensus [E]).

    Note: In randomized trials of smoking cessation interventions, tailored educational materials had the most significant impact on behavior change (Lancaster & Stead, 2002 [M]).

12. It is recommended that education on self-management skills building be provided through a range of individual and/or group sessions within a variety of community settings (e.g., homes, schools, churches, camps, and worksites) beyond an office visit (Deakin et al., 2005 [M]; Gibson et al., 2002 [M]; Norris et al., "Increasing," 2002 [M]; Evans et al., 2001 [A]; Resnicow et al., 2001 [A]; Lorig et al., 1999 [A]; Hederos, Janson, & Hedlin, 2005 [B]; Fireman et al., 1981 [C]; Glasgow et al., 2004 [S]).

    Note 1: Group-based training and nurse education improve effective home management (reduces symptoms, exacerbations, school absenteeism, and number of hospitalizations and emergency room visits) (Fireman et al., 1981 [C]).

    Group-based self-management education has been shown to decrease both healthcare costs and resource utilization while improving health outcomes (Deakin et al., 2005 [M]; Hederos, Janson, & Hedlin, 2005 [B])

    Note 2: Heterogeneous patient groups are feasible and beneficial beyond usual care, can improve health outcomes, and may result in more effective use of resources (Lorig et al., 1999 [A]).

    Note 3: Self-management and written health education materials which were administered and brought home from school positively influenced parent's and children's self-management of their child's asthma (Evans et al., 2001 [A]; Evans et al., 1987 [C]).

13. It is recommended that peers (parents, patients, or lay experts) be involved in the delivery of self-management education programs (Chernoff et al., 2002 [A]; Von Korff et al., 1998 [A]; Anderson et al., 1989 [B]; Lorig et al., 1986 [B]; Lorig et al., 2001 [C]; Cohen et al., 1986 [C]; Story, et al. 2002 [O]).

    Note: Peer-led manualized (standardized) education programs for promoting self-management of chronic disease have been found to improve health outcomes, increase patient/family support, while reducing healthcare costs and resource utilization in diverse populations and have been shown to be as effective as those led by healthcare providers (Von Korff et al., 1998 [A], Lorig et al.,1986 [B]; Lorig et al., 2001 [C]; Cohen et al., 1986 [C]).

14. It is recommended that computer-based information packages for patients and/or systematic mailings be used to enhance self-management education (Kroeze, Werkman, & Brug, 2006 [M]; Murray et al., 2005 [M]; Lorig et al. 2004 [A]; Lorig et al., 2002 [A]; Glasgow et al., 1997 [A]; Horan et al., 1990 [B]).

    Note 1: Computerized information packages for patients have been termed Interactive Health Communication Applications (IHCAs) and have been found to:

    • Provide health information (increase knowledge)
    • Enable informed decision making
    • Promote healthy behaviors
    • Promote peer support (increase social support)
    • Manage demand for health services
    • Improve health outcomes

    (Murray et al., 2005 [M]).

    Note 2: Computer-assisted assessment that provides immediate feedback on key barriers to self-management, goal setting, and problem-solving counseling has been found to improve health behavioral change and outcomes (Glasgow et al., 1997 [A]).

    Note 3: Systematic mailings improve role function, decrease disability and improve self efficacy and decrease the human resource cost of delivering this information (Lorig et al., 2004 [A]).

15. It is recommended that the following self-management tools/interventions be incorporated into self-management support:
    • Self monitoring (diaries, journals)
    • Action planning (written action plans)
    • Collaborative problem solving
    • Regular practitioner review/follow up

    (Kroeze, Werkman, & Brug, 2006 [M]; Gibson et al., 2002 [M]; Powell & Gibson, 2003 [M]; Renders et al., 2001 [M]; Lozano et al., 2004 [A]; Von Korff et al., 1998 [A]; Wasson et al., "Patients," 2006 [C]; Wasson et al., "Resource planning," 2006 [O]; Glasgow et al., 2002 [O]).

16. It is recommended that family-to-family support be included as an integral component of care and that "experienced" patients/families be empowered to deliver these interventions (Chernoff et al. 2002 [A]; Ritchie et al. 2000 [A]; Von Korff et al., 1998 [A]; Hederos, Janson, & Hedlin, 2005 [B]; Lorig et al., 1986 [B]; Cohen et al., 1986 [C]; Burroughs et al. 1997 [S]).

    Note 1: Family-to-family support has been shown to decrease anxiety and worry in caring for children with chronic health conditions (Ireys et al., 2001 [S]).

    Note 2: Examples of family support interventions may include family-to-family networking, parent mentoring, web-based communication, patient/family newsletter, and/or parent advisory teams.

17. It is recommended that children, adolescents, and their families be referred to trained professionals to implement any of the following interventions:
    • Family therapy
    • Stress management
    • Coping skills training
    • Relaxation and cognitive behavioral therapy
    • Behavioral incentives

    (Yorke, Fleming, & Shuldham, 2005 [M]; Eccleston et al., 2003 [M]; Lemanek, Kamps, & Chung, 2001 [M]; Kashikar-Zuck et al., 2005 [B]; Burkhart et al., 2002 [B]; Degotardi et al., 2005 [C])

    Note 1: These techniques have been shown to be effective in the management of patients with chronic pain, headache, and asthma (Yorke, Fleming, & Shuldham, 2005 [M]; Eccleston et al., 2003 [M]).

    Note 2: Intense family therapy has been shown to improve outcomes in adolescents with poorly controlled insulin-dependent diabetes (Ellis et al., 2005 [B]).

    Note 3: Behavioral Family Systems Therapy (BFST) has been shown to improve diabetic outcomes, parent and adolescent relationships, and treatment adherence (Wysocki et al., 2000 [A]; Wysocki et al., "Effects," 2006 [A]; Wysocki et al., "Behavioral assessment," 2006 [S]).

    Note 4: Behavioral incentives (e.g., praise, stickers, special activities, toys, games, gift certificates, or monetary rewards) have been shown to improve treatment adherence in children with chronic illness (Lemanek, Kamps, & Chung, 2001 [M]).

Arrange

Determine and arrange for a specific follow-up plan.

18. It is recommended that self-management interactions and re-assessments occur on a regular, structured basis (Haynes et al., 2005 [M]; Gibson et al., 2002 [M]; Powell & Gibson, 2003 [M]; Renders et al., 2001 [M]; Hauser et al., 1990 [C]; Jacobson et al., 1990 [C]; Hauser et al., 1986 [C]; Jacobson et al.,  1987 [O]).

    Note 1: Available evidence does not well define the optimal level of intensity or frequency for these interactions. In one meta-analysis of adults with type 2 diabetes, increased contact time between educator and patient was the only significant predictor of improved glycemic control (Norris et al., "Self-management," 2002 [M]).

    Note 2: Evidence indicates that decreased intensity or frequency of clinical review may negatively impact the effectiveness of self-management (Powell & Gibson, 2003 [M]).

    Note 3: Frequent contacts (email, phone, office visit) between provider and patient/family are an effective method of enhancing adherence. More complex interventions do not necessarily produce better outcomes (Haynes et al., 2005 [M]).

Definitions:

Cincinnati Children's Hospital and Medical Center Grading Scale

M: Meta-analysis
A: Randomized controlled trial: large sample (n >100)
B: Randomized controlled trial: small sample (n <100)
C: Prospective trial or large case series
D: Retrospective analysis
O: Other evidence
S: Review article
E: Expert opinion or consensus
F: Basic laboratory research
Q: Decision analysis

References open in a new window

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Children's Hospital Medical Center Health Policy and Clinical Effectiveness Department at HPCEInfo@chmcc.org.

• Chronic care: self management. Guideline highlights. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2007 Feb 20. 1 p. Electronic copies: Available in Portable Document Format (PDF) from the Cincinnati Children's Hospital Medical Center Web site.
• Evidence-cased care guideline development and update process. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006. 35 p. Electronic copies: Available in Portable Document Format (PDF) from the Cincinnati Children's Hospital Medical Center Web site.

Additionally, a variety of implementation tools, including a sample algorithm for initiating self-management, samples of assessment tools, criteria to assess the validity of an assessment tool, and a self-management personal action plan are available in the appendices of the original guideline document.

Copies of Cincinnati Children's Hospital Medical Center (CCHMC) Evidence-Based Clinical Practice Guidelines (EBCG) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of CCHMC's EBCG include the following:

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• Copies may be provided to patients and the clinicians who manage their care.

Notification of CCHMC at HPCEInfo@cchmc.org for any EBCG adopted, adapted, implemented or hyperlinked to by a given organization and/or user, is appreciated.

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