Abstract
In this article, I advocate the expansion of self-management support from chronic to acute care as a means of increasing the value of services and highlighting the value of occupational therapy. Like people with chronic conditions, clients with acute conditions (1) need to participate in their own care, (2) require support for participation, (3) engage in care outside of traditional medical behaviors, and (4) benefit from a focus of care that extends beyond discrete episodes. Self-management support can facilitate adherence, promote holistic conceptualizations of health, and address long-term outcomes and costs. Given that self-management support aligns with occupational therapy’s philosophical roots, expansion of self-management support to acute care highlights the profession’s contribution to health promotion in this practice area.
Self-management support (SMS) refers to the fostering of people’s knowledge, beliefs, and skills to enable active engagement in their own health (Institute of Medicine [IOM], 2003; Packer, 2013). SMS is a model of care that philosophically aligns with occupational therapy’s humanistic, capability-focused perspective of health (Stern, 2018). SMS also makes an important contribution to the discourse surrounding value of health care services, defined as “the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes” (Porter & Lee, 2013, p. 52). The IOM (2003) identified self-management as a priority area with relevance to multiple populations, yet discussion of SMS is chiefly restricted to the management of chronic conditions with no emphasis on their acute counterpart. Expansion of SMS to acute care may increase the value of services and highlight the value of occupational therapy in health promotion.
Chronic conditions, such as diabetes and arthritis, present with long-term functional limitations, multifactorial nonreversible causes, and a need for ongoing medical care. In contrast, acute conditions, such as musculoskeletal trauma, present with remediable impairments and a discrete episode of medical intervention. Although the focus of chronic care is usually on maintenance or prevention, that of acute care is generally curative in nature (World Health Organization [WHO], 2003).
The traditional health care model stems from acute care. Its fragmentation, rewarding individual providers for each service delivered, aligns with brief, episode-specific management (Porter & Lee, 2013). The increasing burden of chronic conditions demands alternative approaches, such as SMS, to optimize care. To highlight the need for SMS in chronic care practice and policy, differences between chronic and acute conditions are emphasized (WHO, 2003). Stressing the distinctions implies that the traditional health system, although inappropriate for chronic care, remains optimally positioned for acute care. However, in a context of reform it is important to question whether traditional approaches do indeed maximize value in the management of acute conditions.
In this article, I advocate occupational therapy practitioners’ expansion of SMS from chronic to acute care as a means of increasing the value of services and highlighting the profession’s value. First, SMS is conceptualized and situated relative to value; next, the primary argument for expansion of SMS is detailed.
Understanding Self-Management Support
Conceptualization
Self-management extends beyond medical behaviors, such as taking medication, to participating in everyday life and addressing psychological sequelae of illness. It encompasses solving problems, making decisions, and performing actions (Lorig & Holman, 2003; Packer, 2013). It has multiple personal and nonpersonal determinants, including beliefs and contextual factors (Schulman-Green et al., 2016). Because of the complexity of self-management, many people require support from health care professionals. Although self-efficacy is discussed as a primary mechanism, SMS interventions harness many theoretical frameworks, such as health beliefs and self-determination (Pearson et al., 2007). SMS also has various designations, from health coaching to client empowerment; however, the unifying factor is a departure from traditional patient education (Glasgow et al., 2003).
Traditional patient education is characterized by knowledge transmission, disease-related content, and paternalistic relations to foster compliance. In contrast, SMS views knowledge as necessary but insufficient for behavior, recognizing the vital role of enhancing skills and confidence (Glasgow et al., 2003; Pearson et al., 2007). SMS also embraces a collaborative relationship between client and clinician, prioritizing the former’s goals and values surrounding health (Glasgow et al., 2003). Compliance thus shifts to adherence: “active, voluntary collaborative involvement of the patient in a mutually acceptable course of behavior” (Meichenbaum & Turk, 1987, p. 20).
Relationship to Value
Health care is in crisis as the United States both underperforms and outspends other nations (Schneider et al., 2017). SMS intrinsically aligns with national initiatives to improve care experiences and outcomes through client-centered care (National Quality Forum, 2014). Moreover, by fostering clients’ abilities to take control of their own health, SMS has the potential to reduce heath care utilization and costs (Pearson et al., 2007). The influence of SMS on client-defined outcomes and spending is compatible with a value-based framework of care (Kamal et al., 2018).
In addition to maximizing the value of services, SMS highlights the value of occupational therapy. Traditional biomedical models do not demonstrate the profession’s unique contribution in acute care. In contrast, SMS intrinsically aligns with occupational therapy’s philosophical basis of client-centered, holistic interventions, supporting the profession’s value for health promotion (Gupta & Taff, 2015; Lamb & Metzler, 2014; Packer, 2013; Stern, 2018).
Making the Case for Self-Management Support in Acute Care
Although concerns about value are not limited to chronic care, discussion of SMS is chiefly restricted to the management of chronic conditions. Despite the differences between acute and chronic conditions, SMS has the potential to promote the value of services for both populations. Like those with chronic conditions, people with acute conditions (1) need to participate in their own care, (2) require support for participation, (3) engage in care not limited to traditional medical behaviors, and (4) benefit from a focus of care extending beyond discrete episodes.
Relevance of Self-Management
Despite the shorter duration of acute versus chronic conditions, people with acute conditions do not receive medical supervision throughout the episode. Financial and logistical barriers limit access to medical supervision, increasing the need for clients’ participation in their care. Burdensome cost sharing and caps on services restrict access to health care, including rehabilitation (Agency for Healthcare Research and Quality, 2018). When rehabilitation benefits are exhausted, clients must continue to self-manage until their return to premorbid function.
The context of outpatient rehabilitation is specifically characterized by limited supervision. When clients are not in the clinic, it is “not optional but inevitable” that they are engaging in actions that influence their health (Glasgow et al., 2003, p. 564). During a course of outpatient rehabilitation for an acute condition, individuals are asked to engage in many unsupervised behaviors, including home exercises, wound care, and orthosis wear (Bassett, 2015; Jack et al., 2010; O’Brien, 2010).
Need for Support
People with acute conditions not only engage in self-management but also benefit from appropriate support. SMS is advocated in chronic care to address nonadherence, which contributes to suboptimal outcomes and inefficient spending (WHO, 2003). Although traditional patient education is recognized as inadequate for behavioral and lifestyle change, it may be regarded as sufficient for remediation. However, despite the increased weight of physiological determinants of health in acute care, behavioral determinants retain their relevance.
As noted by WHO (2003), “Adherence problems are observed in all situations where the self-administration of treatment is required, regardless of type of disease, disease severity and accessibility to health resources” (p. 11). In acute care, nonadherence is reported for therapy attendance, home exercise performance, and orthosis wear (Bassett, 2015; Jack et al., 2010; O’Brien, 2010). Compared with chronic care, overall adherence rates may be higher in acute care secondary to shorter duration of behaviors and perceived benefits of curative versus palliative interventions (O’Brien, 2010; Smith-Forbes et al., 2016). However, even low levels of nonadherence in acute care may contribute to more immediate costly consequences, for example, surgery for a reruptured tendon (O’Brien, 2010).
Nonadherence is a multifactorial issue. Client factors include lack of information and skills, poor motivation and self-efficacy, and maladaptive beliefs (Jack et al., 2010; O’Brien, 2010; Smith-Forbes et al., 2016; WHO, 2003). Knowledge transmission does not adequately address these barriers, in particular in the face of limited health literacy (Glasgow et al., 2003). SMS has been advocated as a universal precaution that is beneficial for people at all levels of health literacy (Brega et al., 2015). Behavior change strategies embedded within SMS can “bridge the intention–behaviour gap” observed with medical management (Bassett, 2015, p. 105). If SMS is advocated to address nonadherence in chronic care, a similar rationale begs its examination relative to acute care.
Beyond Medical Management
In addition to increasing adherence to medical behaviors, SMS can promote holistic health, that is, wellness extending beyond the physiological (Packer, 2013). In contrast to prolonged, multiphase trajectories of chronic care, acute care is often perceived as a brief upward trajectory contingent on remediation of physiological impairment. However, despite the logical prioritization of remediation in acute care, a Cartesian split that focuses on medical management to the exclusion of other aspects of health does not optimize care experiences or outcomes.
Acute conditions interfere with life roles and routines, as with participation restrictions after orthopedic trauma (see, e.g., Kaskutas & Powell, 2013; Schier & Chan, 2007). Addressing role management with SMS can improve client-centered outcomes that encompass participation. Moreover, supporting clients to fit rehabilitation demands into their everyday lives can increase adherence to medical behaviors, facilitating traditional impairment remediation (Bassett, 2015; O’Brien, 2010; Smith-Forbes et al., 2016).
People with acute conditions also experience emotional responses to injury or illness (e.g., Vranceanu et al., 2014). Failure to address psychosocial factors limits clients’ ability to experience holistic health, including emotional well-being (Packer, 2013). In addition, depression and anxiety limit understanding and motivation, interfering with adherence to medical behaviors (Jack et al., 2010; Schulman-Green et al., 2016). Whereas the prescriptive focus of traditional patient education may reinforce nonadaptive fears, SMS can facilitate recovery by reframing maladaptive beliefs and strengthening motivation and self-efficacy (Bekkers et al., 2014; Connolly et al., 2014; Smith-Forbes et al., 2016). Supporting psychosocial management while promoting participation in meaningful roles can both increase adherence to traditional medical interventions and contribute to client-defined holistic health outcomes.
Beyond the Episode
In addition to improving health outcomes for the episode of care, SMS has broader implications for the value of services. Within chronic care, SMS is endorsed as a move from reactive to proactive models, avoiding a reductionistic focus on a specific episode of illness (WHO, 2003). Providing clients with the tools to manage their own health curtails future exacerbations that necessitate medical intervention, reducing utilization and costs over the duration of long-term illness. Despite the apparent fit of reactive care for acute conditions, the benefits of a proactive approach are also relevant.
Acute conditions often have contributing chronicity, such as frailty or osteoporosis. Failure to manage the chronic determinants may lead to additional episodes of acute illness, which can be considered the equivalent of readmission in chronic care. In addition, without appropriate management, acute disability has the potential to become chronic. Supportive strategies that promote health behavior after acute injury can prevent chronic sequelae, including debility, chronic pain, and opioid addiction (Bérubé et al., 2017). Harnessing SMS for behavior change in acute care encourages sustainability of health outcomes and decreases utilization and costs within a value-based framework.
Putting It Together
As detailed earlier, SMS has implications for increasing the value of services within acute care. SMS can facilitate adherence to medical management, improving health outcomes while minimizing extraneous spending. Its shift toward holistic conceptualizations of health aligns with client-defined outcomes. It also has the potential to improve long-term outcomes and costs by addressing issues beyond the episode of care. Expanding SMS to increase the value of services in acute care also highlights the value of occupational therapy in this practice area by emphasizing collaborative, holistic care for health promotion.
Looking Forward
The U.S. health care system is in crisis, supporting the need to question traditional practice models in a quest for optimal services for all conditions, from chronic to acute. In this article, I have advocated expanding SMS from chronic to acute care as a means of increasing the value of services and highlighting the value of occupational therapy.
Occupational therapy practitioners may be optimally situated to expand SMS from chronic to acute care because of SMS’s compatibility with the profession’s philosophical roots. To be specific, practitioners’ psychosocial training and advanced understanding of habits and roles may facilitate the development of successful SMS programs for individuals with a range of conditions (Lamb & Metzler, 2014; Packer, 2013). Occupational therapy professionals, with their emphasis on participation, are also positioned to develop measures that shift from intervention-specific biomedical outcomes to long-term holistic outcomes that extend beyond medical settings (Packer, 2013; Porter & Lee, 2013).
Although addressing and measuring health behavior is not the exclusive property of any profession, occupational therapy practitioners have the potential to be leaders in this emerging conversation. My hope is that the present discussion will spark a dialogue surrounding SMS for acute conditions amid broader negotiations of occupational therapy’s role in health care reform.
Footnotes
Acknowledgment
This article was written in partial fulfillment of the requirements for the Doctor of Philosophy degree in Occupational Therapy at New York University.