Imagine the following doctor-patient conversation:
Doctor: Hello Bill. How are things?
Bill: Well not so good…actually doc they’re terrible. My diabetes has been totally out of control. My blood sugars are always seeming to run very high. And I am not feeling great, in part because I still cannot lose weight. In fact, I’ve actually gained 13 pounds in the last 4 months.
[And maybe, more importantly, imagine the doctor does not interrupt Bill at this point but lets him continue.]
Bill sighs, and continues after a couple second pause:
Bill: But worse than my actual health, my wife thinks it’s all my fault. My son is so worried that he is continually checking up on me. And don’t get me started on my boss. She says I’m not working hard enough. But worst of all, my daughter-in-law is so concerned that I am sick that she won’t let me be alone with my 4-year-old granddaughter. She thinks that I might have a heart attack or be in a coma at any moment. HELP ME!!!! Please.
Doctor: Thinks, but doesnt say, HELP ME!!!! Please
Where should the doctor start?
This story, in many variations, is all too common. Where should the doctor start? How to make a difference in this person’s life? Health is just a means to what Bill really wants – so how does the doctor help him get the health he needs for the life he wants?
The traditional approach to a patient like Bill is to focus on his blood sugar values and to see if adding or modifying medications will improve his glucose control. The doctor might have him talk with a diabetes educator to learn more about diabetes and glucose management, meet with a pharmacist to fine tune his existing medications, and meet with a dietitian to improve his eating. This approach could have some impact, but all too often the gains don’t last.
Controlling Bill’s blood sugar might be the easiest thing to do and the place to start. It is certainly what most doctors and other healthcare providers have been trained to do. A complementary approach, based on decades of research from a variety of fields, is to focus on increasing Bill’s self-efficacy – increasing his confidence and competence to accomplish his goals – while helping him better manage his condition(s). If Bill can have a lasting transformation in his attitude and outlook, he will be better equipped to define his personal priorities, set attainable short-term and long-term goals, and improve not only his medical outcomes but attain his life goals as well.
Better Choices Better Health
The good news is that research proves that this approach works to help patients like Bill. At Canary Health, we have the good fortune to partner with Dr. Kate Lorig and her team – true pioneers and leaders in this field. Dr. Lorig’s work began over 30 years ago at Stanford University where she created the Chronic Disease Self-Management Program (CDSMP). CDSMP is a peer-to-peer, 6-week, in-person, group-based, intervention for adults with one or more chronic conditions. CDSMP has been shown in hundreds of papers from around the world to increase self-efficacy, lessen depression, improve medication adherence, minimize pain, improve important medical outcomes, and lower healthcare costs.
Canary Health’s Better Choices Better Health (BCBH), the digital version of the in-person CDSMP, is proven to engage those who are unable or prefer not to attend in-person workshops. It has the same protocol and curriculum as in-person CDSMP, using a unique digital approach that builds individual and group engagement in self-management.
Each online workshop consists of about 25 adults with at least one chronic condition. BCBH does not require real-time attendance and can be done at the convenience of the user. Two trained peer-facilitators moderate each workshop. Participants are asked to login at least three times weekly for a total of about two hours. Weekly activities include reading content, making and posting an action plan, participating in problem-solving and guided conversations, and posting questions, concerns or accomplishments. Group members comment on posts made by other participants to give wisdom and support. Once the six-week intervention is completed, participants are encouraged to join the online BCBH alumni community to continue to post questions or concerns and to receive and provide support to others. (Go to www.canaryhealth.com to learn more or to https://goo.gl/Av6R5g to see a BCBH demonstration)
Recently published papers (Reference 1,2) from a large study (N =1,232) with Anthem beneficiaries with type 2 diabetes, demonstrated that 12 months after the six-week in-person (N=232) and digital (N=1010) BCBH intervention, the following outcomes were seen:
- Decreased A1C 0.45%; 1.27% if Initial A1C>9% (Reference 1)
- Reduced incidence of depression 27% (Reference 1)
- Improved medication adherence, diet and physical activity (Reference 1)
- Decreased number of, and burden from, co-morbidities (Reference 2)
- Decreased in-patient, Emergency Department, outpatient services, and pharmacy costs (Reference 2)
- Decreased healthcare utilization for co-morbid conditions; minimal change for diabetes-related utilization (Reference 2)
- $815 decrease in healthcare costs in the year post-intervention (Reference 2)
Back to Bill
Now, let’s return to helping Bill and patients like Bill. With the patient in a better frame of mind, and with more confidence that his or her priorities and goals are on the path to success, the next step is to support sustainable behavior change. This is best accomplished when individuals are able to get the support they need from peers and from professionals. Coupled with evidence-based, peer-to-peer support, healthcare professionals can provide expert clinical and treatment advice, augmented by the data and information provided by connected devices or connected medications (such as connected glucometers, scales, spirometers, smart insulin pens/insulin pumps). This approach, called Digital Therapeutics, is demonstrating great promise with a variety of chronic diseases including diabetes.
1 A Diabetes Self-Management Program: 12-Month Outcome Sustainability From a Nonreinforced Pragmatic Trial – Lorig,KL; J Med Internet Res 2016 | vol. 18 | iss. 12 | e322 |
2 Evaluation of a Diabetes Self-Management Program on Type II Diabetes Patients’ Comorbid Illnesses, Healthcare Utilization, and Cost – Turner, RM, et al J Med Internet Res 2018 | vol. 20 | iss. 6 | e207 |
Neal Kaufman MD, MPH
Neal Kaufman, MD, MPH
Dr. Kaufman is Co-founder and Chief Medical Officer at Canary Health, a transformative healthcare company that provides evidence-based, digital self-management programs which arrest the progression of chronic diseases (diabetes prevention and chronic disease self-management). He is an expert on how technology enables lasting behavior change and improves business and health outcomes. During his 40-year career in Los Angeles, Dr. Kaufman has provided medical care to diverse populations, and led efforts to plan, implement, evaluate and evolve health and social services approaches at the individual, family, clinic, community and governmental level. Dr. Kaufman is Adjunct Professor of Medicine & Public Health at UCLA, received his bachelor’s degree from Northwestern University, his M.D. from Chicago Medical School, pediatric training at Children’s Hospital Los Angeles, and his Masters of Public Health from UCLA.