Support for Self-Management in Behavioral Health Emerges With Healthcare Reform
SAMHSA Recovery to Practice E-Newsletter, Issue 16; Larry Davidson, Ph.D. 1/30/2014
One of the unanticipated benefits emerging from the integration of behavioral health and primary care is the adoption of a “self-management” approach to prolonged mental health and substance use conditions. While the promotion of patient self-management has been well established in some branches of internal medicine, as a core part of a chronic disease management model, it is a relatively new approach to care in behavioral health and has come about, in part, because of the influence of primary care and, in part, because of the emphasis of the healthcare reforms currently under way across all of health care in the United States. As part of these reforms, the Centers for Medicare & Medicaid Services, as well as private payers, are promoting a shift toward “patient self-management” of all chronic medical conditions.
Consistent with our emphasis on recovery-oriented practices, the promotion of self-care for persons with behavioral health conditions requires encouraging and equipping people to take on more active and informed roles in their own care, both in terms of collaborating with their healthcare practitioners in decision-making and in learning how to manage their own health conditions. To better prepare the behavioral health workforce to adopt these practices, the Centers for Medicare & Medicaid Services have recently released a guide titled Approaches to Supporting Self-Management for Individuals With Serious Mental Illness: A Guide to Resources, Promising Practices, and Tools, which can be accessed on the Web at https://www.resourcesforintegratedcare.com/
sites/default/files/Self-Management%20Guide_0.pdf.
This guide is highly recommended as a resource for practitioners looking to learn more about how to implement self-care promotion and provide self-care support in behavioral health. Not only does the guide clarify that self-care and wellness promotion supports are considered “essential services” to be covered under the Affordable Care Act—and that the goals of self-management support “are closely aligned” with those of recovery-oriented care—but it also provides useful and detailed information about each of the components of self-management support.
These include the following:
- Providing people in recovery and their loved ones with accessible and accurate information regarding their health conditions
- Teaching people how to engage in and sustain self-care and providing them with the encouragement to do so
- Empowering people to become more active in and to take more control of their care and their recovery
- Negotiating any needed changes in health-related behaviors (e.g., diet, exercise, use of alcohol or other drugs)
- Offering training in problem-solving skills so that people can adjust their personal routines and try out alternative strategies in between appointments
- Assisting with the emotional impact of having a behavioral health condition
- Providing regular, sustained follow-up that includes monitoring for and celebrating successes
As overarching principles for the promotion of self-care, this guide identifies the following:
- All patients can engage in and benefit from self-management support.
- Multiple approaches to support self-management are needed.
- Engage clinicians and use a team-based approach to support.
- Use peer supports if they are available.
As the guide recognizes, promoting self-care may be a particularly apt and effective role for peer staff, as they can serve as credible and living role models for the kind of self-care they are hoping to teach to the people they support.
There are two potential areas of difference between self-management support and recovery-oriented care, however, which are worthy of mention. First, this guide assumes, as do most materials on self-management, that mental health and substance use conditions are primarily chronic health care conditions that can, at best, be managed over time. There is no way, yet, for someone with type-1 diabetes to fully recover from diabetes, although there do appear to be people who can recover from asthma. For the most part, the issue of long-term prognosis is not considered that relevant to self-management, except for the fact that the better the condition is managed the fewer complications the person might experience and the longer his or her life may be. In behavioral health, there is strong evidence that many people do recover fully from whatever condition they may once have had, while many others will enter into recovery and continue to see the impact of their behavioral health conditions wane in importance over time.
In adapting the promotion of self-care for persons with behavioral health conditions, the question of long-term outcome is best left open, as it is impossible to predict. Nonetheless, it appears to be useful to promote self-care in persons who experience difficulties associated with mental health and/or substance use conditions as long as those difficulties persist. Should they reach a point at which self-care is no longer required, then all the better. At the same time the provider can respect that some individuals will prefer an idea of continued vigilance against a disease model framework, especially in the tradition of substance use recovery.
Second, self-management resources typically assume that what the person is managing is best understood as a disorder or disease. As we know, this is a highly contentious issue within the recovery community, with many people objecting to being told that they have a disorder or a disease. They may view the difficulties they are experiencing as the result of earlier trauma, or view these difficulties through other lenses, whether they be existential, spiritual, social–political, or cultural. A key challenge in adopting self-care support in behavioral health therefore is in finding a way to honor and respect the person’s own understanding of his or her life situation and offering him or her tools that can be effective in addressing the more distressing aspects of this situation… without insisting that he or she accept our particular understanding of the nature of their difficulties.
We welcome our RTP readers to send in stories of how they or other practitioners have been creative and/or resourceful in finding ways to help people whose own understandings of their situation differed substantially from that of the practitioner. As with much of recovery-oriented practice, this is an area that will require much development if we are ever to succeed in fully promoting the self-care and eventual recovery of all of those we are privileged to serve.
Additional Resource. Battersby M, von Korff M, Schaefer J, Davis C, Ludman E, Greene SA, Parkerton M, & Wagner EH. Twelve evidence-based principles for implementing self-management support in primary care. The Joint Commission Journal on Quality and Safety, 2010, 36(2): 561–70.
Larry is project director for SAMHSA’s Recovery to Practice project. You can contact him at ldavidson@dsgonline.com
http://www.samhsa.gov/recoverytopractice/Index.aspx