I was first introduced to the concept of self-management when I was completing my masters degree at Belmont University. I have to be completely honest, initially I did not truly understand what self-management was. My initial impression was that it was just disease-specific education and that other providers such as physicians and nurses were already providing this information. As a result of my own misinterpretation, I dismissed self-management as a service that would not be relevant or billable for occupational therapy.
During the time I was at Belmont, I was also working PRN for several SNFs as well as a home health agency. As I continued through the masters program, we studied the Occupational Therapy Practice Framework, at that time the 2nd edition was the most recent publication. The OTPF-2 discussed the importance of performance patterns, habits, routines, roles and rituals, in supporting or hindering occupational performance. With this knowledge fresh on my mind, I began to realize the impact that health literacy, motivation, habits, and routines had on my home health client's carry out of recommendations. I started to view client compliance in a different way; it seemed to me that most of my clients who were disregarding the recommendations of their medical and therapy providers wanted to get better, but their actions did not seem to be consistent with their goals. All of this information had started to peek my curiosity, but before I could seek answers I found myself graduating and interviewing with a private pain practice.
As I took on the challenge of developing an occupational therapy chronic pain program, I tried to learn as much as I could about pain and what role occupational therapy could play in helping those with pain. I was surprised by what the evidence suggested: pain should be addressed utilizing a biopsychosocial approach and the goal for those with chronic pain was to improve pain self-management. The literature described pain self-management as the process where individuals with pain are educated about their condition, engage in active problem-solving and decision-making, obtain and develop effective strategies for utilizing health resources and take actions to manage their pain. This process requires those with pain to become active participants in their own pain management (Institute of Medicine, 2011). As I read about self-management specific to pain, it seemed to me that it entailed a lot of strategies that occupational therapy already addressed. I thought back over my career working mostly in skilled nursing and home health and realized that I had not used those words specifically, but I frequently worked with clients to facilitate active problem-solving and decision-making. I realized that in every encounter I had with a client, I was facilitating them to take some sort of action to improve their ability to engage in occupations. It was during this time that I realized that I had been wrong. Self-management was absolutely relevant to occupational therapy, it was definitely medically necessary, and I felt confident I could justify why it would be billable for individuals with pain. I realized that as an OT practitioner, my goal was not to relieve my client's pain; it was to help them live their lives even though they have pain. This would require effective self-management.
This was a huge realization for me; one that also brought regret as I thought about all of the clients I had worked with earlier in my career who had chronic pain. I had worked to try to relieve their pain and when I couldn't, I had nothing left to offer them. I felt like at discharge they were left with only the hope that their medical providers would someday find a way to relieve their pain. This regret is probably what drives me the most to work with Niccole to promote occupational therapy's role and value in treating pain.
Niccole and I continued to work to help improve pain self-management for our clients and we began to identify barriers that our clients faced in achieving effective self-management. For a majority of our clients there was a lack of understanding. They had received pain education but they did not fully understand it or how it related to their individual pain experience. Where my curiosity had previously been peeked, I now recognized how readiness for change, roles, habits, routines, performance skills such as cognition, attention, and contextual factors (social, physical, cultural and temporal) all impacted someone's ability to effectively manage their pain. It became obvious to both Niccole and I that these barriers were often misinterpreted as non-compliance. After realizing this we were confident in addressing these factors because as OT practitioners, we already had the training and skills to address all of them. As we worked with clients to effectively become more active participants in their pain treatment, we began to see improvements in our outcomes, but most importantly our clients were reporting that their quality of life was improving, they were doing things they wanted to do and their pain was not controlling their lives as it once did.
During our time working in pain management, we also identified a need for occupational therapy to address medication management for our clients who were receiving prescription pain medication. It also became apparent that our client's self-management needs expanded beyond their chronic pain to any comorbid conditions they may also be experiencing. Depression and anxiety are often comorbidities to pain. Many chronic conditions such as arthritis and neuropathy can cause or contribute to chronic pain. It was our experience that while each condition requires unique treatment and strategies, the overall principles required for effective self-management remained consistent among different conditions. As we looked to our practice framework, we were able to begin to identify how all of these interventions were part of the occupation of health management considered to be in the occupation category of IADLS according to the OTPF-2 and OTPF-3.
Four years later, in 2020 the Occupational Therapy Practice Framework: Domain and Process, Fourth Edition recognized OT's value in this area and added Health Management, including self-management, as a distinct category of occupation to be addressed within the domain of occupational therapy. The Health Management category includes social and emotional health promotion and maintenance, symptom and condition management, communication with the health care system, medication management, physical activity, nutrition management and personal care device management. Like pain, the goal for many chronic conditions is focused on managing the condition to allow individuals to participate in the occupations that bring meaning to their lives. The literature has shown that occupational therapy reduces hospital readmissions (Rogers, et al, 2017). It is only reasonable to assume occupational therapy that includes self-management interventions would further reduce hospital readmissions for conditions such as CHF, diabetes, hypertension and COPD.
I now work in home health and I address self-management everyday. I utilize the OTPF-4 to guide my practice as well as to support how addressing health management is within my scope of practice and medically necessary. It is important to point out that self-management is more than providing instructions or education. I don't tell my clients what they should be doing; I work with my clients to help them develop strategies into their daily lives that help them to better manage their chronic conditions, follow the recommendations that their medical providers have made, and engage in meaningful occupations despite having a chronic illness. I work with clients who have CHF on developing new routines for completing and recording daily weights. I address medication management and assist my clients to develop strategies for storing, taking and tracking their medications to reduce the risk for aberrant medication behaviors. I partner with my clients to obtain and organize their health information and resources. My treatment may include working with a client on effectively communicating with their medical providers and managing appointments. For many of my clients, anxiety impacts their ability to sleep or participate in their home exercise programs. Utilizing a client-centered approach, we work together to implement coping strategies into their daily routine. What I love the most about addressing self-management is that I get to work with client's to develop individual strategies that meet their unique needs utilizing my training that recognizes the impact of social, contextual as well as physical and psychological factors on occupational performance.
There is extensive literature to support the effectiveness of self-management for those with chronic conditions and I am convinced that no discipline is as distinctly qualified to address the physical, psychological and social factors that effect self-management as well as occupational therapy is. Unfortunately, most OT practitioners are not addressing self-management in their practice. My fear is that if we don't address it, other disciplines will.
Written by Kimberly Breeden, MS, OTR/L
Founding Partner, Aspire OT
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