Patient Self-Management: Is Motivating Your Patients With Kidney Disease A Challenge?

Self-management of one’s health involves individuals becoming educated and taking an active role in their day-to-day healthcare activities. Self-management for chronic kidney disease (CKD) patients includes working with their health care team to set goals, monitor their health, adhere to prescribed best practices and treatments (lifestyle changes, medication compliance, etc) while accessing recommended resources available to them.¹ The 15% of American adults with chronic kidney disease (CKD) face potential complications including cardiovascular disease, cognitive impairment, poor quality of life, and early demise. Self-management strategies have been called “one of the keys to improving CKD outcomes and quality of life.”¹

An article, Patient Activation:  The Cornerstone of Effective Self-Management in Chronic Kidney Disease, published March 2022 Kidney and Dialysis, notes that “In order for an individual to be able to look after their health and effectively manage their long-term condition, they need to have the knowledge to understand what to do and why, the skills to be able to perform the required tasks or behaviors, and the confidence that they can do it.”² The challenge for clinicians is motivating their patients to become knowledgeable, empowered, and competent self-managers. Fortunately, busy nephrologists can have an interdisciplinary team of professionals to help teach, empower, and motivate their patients.⁴ This article also reviews successful tools that professionals have available to them to equip patients for effective self -management.

Nephrology Interdisciplinary Teams

Nephrology interdisciplinary health care teams face the challenge of motivating their CKD patients to become competent self-managers of their health status. The interdisciplinary model for nephrology has been “associated with improved health outcomes, including lower all-cause mortality, slower decline in kidney function, higher likelihood of arteriovenous access (AV) fistula or graft placement, and lower risk of hospitalization.”⁴ Interdisciplinary teams vary but can include nephrologists, transplant nephrologists, advanced practice nurse practitioners and physician assistants, nephrology nurses, pharmacists, registered dietitians, nephrology social workers, and patient navigators. The team may also include vascular surgeons and interventional radiologists who provide dialysis vascular access and geriatricians and palliative care specialists to provide care to nephrology patients.⁴  

Drs Tanya S. Johns, Kalyan Prudhvi, and Ms Rachel Motechin and their co-authors of an article, Interdisciplinary Care and Preparedness for Kidney Failure Management in a High-Risk Population, published in May 2022 Kidney Medicine, found that “interdisciplinary compared with usual care was associated with better patient preparedness, particularly early access to transplant listing.”⁴ Their study was held at Montefiore hospital in the Bronx, New York, a county recognized as one of the poorest urban counties in America with 30% of Bronx households living below the federal poverty line. It included 295 incident kidney failure patients with 87% African American or Hispanic individuals who were 47% female and a mean age of 59.9 years.⁴ Study results showed that in addition to the improved patient preparedness for renal replacement therapy initiation and transplant waitlisting, a lower prevalence of hypertension was found for patients in the interdisciplinary care group when compared to the usual care group.⁴

Understanding The Value Of Patient Activation & Self-Management Strategies

Patient Activation has been identified as a “dynamic behavioral concept that describes the degree to which individuals understand their role in their healthcare and how competent they feel in performing that role.”² Activation is a critical beginning to self-management. Patients can move from states of low activation (feeling disengaged, unmotivated, and overwhelmed) through to high activation (feeling knowledgeable and able to maintain the behaviors taught by their healthcare team). It should be noted that individuals can move up and improve or regress to a lower self-management stage when life events and stresses affect them or their loved ones’ lives and health in negative ways.²

The authors of the article, Patient Activation:  The Cornerstone of Effective Self-Management in Chronic Kidney Disease note that an estimated 43-60% of patients living with CKD have low levels of activation, lack knowledge, and understanding of why they need to self-manage and how to incorporate best practices into their daily lives. CKD patients with low activation are most likely older, have poor kidney function, multiple comorbidities including increased risks of cardiovascular disease and anemia. The lower levels of patient activation and motivation are also “strongly associated with lower levels of health literacy and higher levels of depression and anxiety.²  

Four activation levels on the self-management continuum:

• This lowest level of self-management includes passive, overwhelmed patients who are unprepared to take an active role in their health
• Patients lack needed knowledge and confidence to self-manage²
• Patients have begun learning and taking action but lack confidence and need support to sustain healthy behaviors
• The highest level of self-management includes individuals who became self-managers of their health but may need help and support to sustain them when stresses or life events adversely affects them²

Assessing Patient Activation & Self-Management

Multiple tools can be used to assess patients’ readiness for activation, motivation, and self-management. These tools include the Chronic Kidney Disease-Self–Management Knowledge Tool, the Patient Assessment of Care, and the Patient Activation Measure (PAM). The PAM-13 tool is the only evidence-based validated tool which has been recognized as a reliable measurement of patient activation and can be used in three ways:²

• The PAM-13 tool can be used as a screening tool to assess a patient’s coping and self-managing and willingness to make lifestyle changes and adhere to the recommended treatment plan²
• A second value of the PAM-13 tool is documenting the assessment results in the patient’s electronic health record. The PAM-13 tool is included as a quality metric by the Centers for Medicare & Medicare Services (CMS) for value-based care models, both the Kidney Care First and Comprehensive Kidney Care Contracting models. PAM-13 is also endorsed by the National Quality Forum Quality Positioning System
• The PAM-13 tool is being used for research and evaluation as an outcome measure to assess patient activation and motivation and patients’ score changes as time passes, identifying support when patients need help²

Motivating CKD Patients To Become Successful Self-Managers

The article, Top 4 Patient Motivation Techniques for Health Improvements, published in August 2017 on the Patient Engagement HIT website, gives information about patient activation and motivation. “Creating a diagnosis and appropriate treatment plan is only half the battle for doctors; actually getting patients to follow through is its own beast.”⁵

Some patients are not motivated; in fact, they are noncompliant. Signs of non-compliance include a past history of non-compliant behaviors, lack a support network, and living a lifestyle not conducive to being activated and self-managed. What can healthcare providers do to activate their patients to become successful at self-management?

• Begin with a positive rapport relationship between professional and patient⁵
• Center the patient’s plan of care around the patient’s goals with specific details that contribute to best practices
• Use motivational interviewing to set goals. Motivational interviewing is recognized as goal setting that is patient centered, goal directed, and focused. Motivational interviewing includes open-ended questions, affirming feedback, and reflective listening by the professional to engage the patient in setting health goals⁵
• Incentive-based wellness programs have been found helpful in motivating and activating patients.  Many employers and insurance payers provide wellness incentive programs that professionals can encourage their patients to join
• Mobile health apps and games are readily available. Studies have found that targeted, specific apps and games can be valuable and supportive of patients⁵

On-Line Peer Support For Patients With Kidney Disease

Drs Yan Du and co-authors of article, Experiences and Disease Self-Management in Individuals Living with Chronic Kidney Disease: Qualitative Analysis of the National Kidney Foundation’s Online Community, published in March 2022 BMC Nephrology journal, note the value that the National Kidney Foundation on-line community provides to patients. They concluded, “Challenges of living with CKD were found not only in those with advanced kidney disease and those on dialysis, but also in those with early and middle stages. Information and emotional support from the online forum serve as a platform to empower CKD individuals with the knowledge, skills and confidence for CKD self-management. Proactive and innovative strategies with a combination of virtual and real settings to improve self-management for individuals with all-stage CKD needs to be explored and tailored.”¹

Patients who are educated, empowered, and confident in their ability to adhere to their care plan have better outcomes including slower kidney decline and lower all-cause mortality. The challenge for clinicians working with patients involves the steps of motivating and supporting the individuals who can become self-managers of their health. Overcoming these challenges and guiding patients to embrace self-care is well worth the outcomes of active, informed patients who show improved health and quality of life.^1,2,5

References

1. Du Y, Dennis B, Ramirez V, Li C, WangJ, Meireles C. Experiences and disease Self-Management in Individuals living with Chronic Kidney Disease: Qualitative Analysis of the National Kidney Foundation’s Online Community. BMC Nephrology. 2022;23:88. https://doi.org/10.1186/s12882-022-02717-7 Published March 2022. Accessed March 2023.
2. Lightfoot C, Nair D, Bennett, P, et al. Patient Activation: The Cornerstone of Effective Self-Management in Chronic Kidney Disease? Kidney Dial. 2022;2(1):91-105.  https://doi.org/10.3390/kidneydial2010012 Published March 2022. Accessed March 2023.
3. Mayes J, Billany R, Vadaszy N, et al. The Rapid Development of a Novel Kidney-Specific Digital Intervention for Self-Management of Physical Activity and Emotional Well-being during the COVID-19 Pandemic and Beyond: Kidney Beam. Clinical Kidney Journal. 2022.15(3):571-573. doi: 10.1093/ckj/sfab239. PMID: 35198162 Published December 2021. Accessed March 2023.
4. Johns T, Prudhvi, K, Motechin R, et al. Interdisciplinary Care and Preparedness for Kidney Failure Management in a High-Risk Population. Kidney Medicine. 2022;4(5): 100450. doi: 10.1016/j.xkme.2022.100450 Published March 2022. Accessed March 2023.
5. Heath, S. Top 4 Patient Motivation Techniques for Health Improvement. Patient Engagement HIT. https://patientengagementhit.com/news/top-4-patient-motivation-techniques-for-health-improvement Published August 2017. Accessed March 2023