PERSPECTIVES AND CHALLENGES FOR IMPLEMENTING THE EXPERT PATIENT PROGRAM: A SCOPING REVIEW

ABSTRACT Objective: to map diverse evidence on perspectives and challenges for implementing the Expert Patient Program. Method: this is a scoping review, guided by the method proposed by the JBI and which followed the recommendations set forth in the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews, with its research protocol registered in the Open Science Framework, with DOI:10.17605/OSF.IO/D7K6A. The search for studies was carried out in July 2022 in databases and in national and international portals of theses and dissertations. Results: the final sample consisted of six scientific articles, all written in English. Health professionals' qualification, to identify and qualify expert patients, management's commitment to the program, use of mobile technologies and Evidence-Based Practice are among the perspectives for implementation. The challenges are related to lack of understanding of the term "self-management" and to the deficit of public policies and financial investment. Conclusion: the results found emphasize the importance of implementing the Patient Expert Program for the public health context, mainly in relation to the population with chronic non-communicable diseases.


INTRODUCTION
The increase in life expectancy with the demographic/epidemiological transition, experienced worldwide, has awakened new health needs, a fact evidenced by the global mortality trends.According to the World Health Organization (WHO), the number of chronic non-communicable diseases (CNCDs) as a cause of death increased from four to seven among the 10 that most caused fatalities.In Brazil, CNCDs correspond to 72% of all deaths [1][2] .
Based on this, the WHO included in its programs the encouragement of self-management, a term that is associated with activities carried out by individuals themselves, so that they can live well with chronic conditions and, more importantly, increase their own ability and confidence to deal with these issues 3 .
Promotion of this new care model encourages patients to move from a passive role to an active one, as managers of their own care and health conditions, so that they can develop the ability to make decisions about their current disease state, with a view to generating behavioral changes in their lifestyles with self-care promotion 4 .
Care self-management culture is complex and challenging, both for the patients, their family members and caregivers and for the health professionals who, most of the times, follow the routines of the already established health system 4 .This requires a break with the hegemonic paradigms currently experienced in health services, with a biologicist focus directed towards care of the disease and not to the individual in their completeness and integrality 5 .
In this context, health services and systems need to be able to carry out a new care model that implements self-management strategies as an important part of coping with chronic diseases, in order to stimulate and develop a self-responsibility culture that empowers and prepares the patients and involves the family members/caregivers.There is diverse that, in addition to health and well-being benefits, self-management strategies can reduce the economic impact of the increase in chronic conditions and provide for more sustainable health systems 6 .
One of these strategies is the Patient Expert Program, already consolidated in some countries such as Spain, which, in addition to improving people's experience and relationship with their health condition, aims at creating a support network among individuals who have common chronic characteristics, with similar conditions, in order to favor the achievement of individual or collective goals.Patients acquire a proactive and leadership role, and health professionals perform passive and observational activities 7 .
The observer's role is fundamental for attracting potential expert patients.The professionals are responsible for identifying the essential characteristics, such as self-knowledge, responsibility, leadership, empathy and proactivity, among others, which may contribute in the education of this active, participatory and independent individual within the health system, who wants and is able to contribute to their peers' self-knowledge process 8 .
However, the process to create and/or implement a new public health strategy or program involves several issues and conceptual and cultural readjustments.The implementation phase is considered the crucial moment for the materialization of public policies and/or health models, considering that the proposals are embodied in institutionalized action through the performance of implementing agents.It is at this stage that the perspectives and challenges for the implementation of actions become more evident and the production processes can be evaluated and analyzed 9 .
The current research may significantly contribute to health promotion, and its results may support the practice of professionals who work in services that assist people with chronic conditions, by allowing them to know the main perspectives and challenges for implementing the Expert Patient Program.
Therefore, the objective was to map diverse evidence on the perspectives and challenges for the implementation of the Expert Patient Program.

METHOD
This is a scoping review (ScR), prepared based on the guidelines set forth in the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) 10 , with its research protocol registered in the Open Science Framework (OSF)(https://doi.org/10.17605/OSF.IO/D7K6A).
This type of study has the purpose of identifying, mapping and synthesizing the diverse evidence and gaps in existing knowledge around a given research field.The conduction process preserves methodological rigor through the following design: (1) identification of the research question; (2) identification of relevant studies; (3) selection of studies; (4) data analysis and extraction; and (5) data synthesis and presentation [10][11] .
Stage 1 consisted in formulating the research question, using the PCC mnemonic strategy for such purpose, namely: (P [Population] -Patient; C [Concept] -Health plan implementation; Selfmanagement; and C [Context] -Health systems).Thus, the question asked was as follows: Which are the perspectives and challenges for implementing a care self-management program?
In stage 2, before performing the searches in the databases, the descriptors that represent the study object were identified, using Medical Subject Headings (MeSH), for descriptors in English, and Descriptors in Health Sciences (Descritores em Ciências da Saúde, DeCS), for those in Portuguese.The descriptors selected were the following: patient participation, health plan implementation, selfmanagement/health plan implementation, self-management, and health systems.
Thus, after selecting the descriptors, an open and extensive search was carried out in the literature and on the OSF platform as a way to ensure that there no published reviews or protocols with the study object in question or a similar theme.From such non-identification, the stages for consolidation of the ScR were followed.Subsequently, selection of the materials in the databases and in the Gray Literature was initiated in June 2022, through the Journals Portal of the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES) and based on identification in the Federated Academic Community (Comunidade Acadêmica Federada, CAFe), as a way to standardize collection in the listed databases.
Selection of the studies consisted in reading the titles and abstracts of the texts retrieved from the theses and dissertations databases and repositories.The papers were screened to reach stage 3, according to eligibility criteria, by reading the full texts to check if they answered the guiding question and to extract the data.The analyses were carried out by pairs; therefore, a pair of reviewers worked independently and on the same day and time and, in case of disagreement, there was discussion for consensus.In case of doubts, the opinion of a third reviewer with expertise in the area of the study object was requested.
As for the eligibility criteria, the publications included were those that responded to the study objective and the guiding question, in any language and available in full electronically.Studies in editorial format, letters to the editor and opinion articles were excluded.Duplicate documents were considered only once.The only filter applied was "open access".
The databases used to search for the studies were the following: PubMed; Scopus; Web of Science; Science Direct; Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); COCHRANE; The Education Resources Information Center (ERIC); The National Library of Australia's Trobe (Trove); the Academic Archive Online (DIVA); the DART-Europe E-Theses Portal; Electronic Theses Online Service (EThOS); Repositório Científico de Acesso Aberto de Portugal (RCAAP); the National ETD Portal; Theses Canada; Latin America theses and dissertations; and CAPES theses and dissertations database.

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In stage 4, the process to separate, summarize and report the essential data found was carried out during the full reading of the texts, determining whether they actually met the inclusion and exclusion criteria, using a Microsoft Excel Office ® spreadsheet, which allowed synthesis, data interpretation and basic statistical analysis of the extension, nature and distribution of the studies selected that comprise the final sample 12 .
Thus, the data were organized in this spreadsheet, analyzed and descriptively presented through figures, charts and graphs that ease visualization of the results, in compliance with stage 5.There was no need for appreciation by any Research Ethics Committee, as this was a research study conducted with public domain materials that did not involve human beings.

RESULTS
Originally, the search identified 236,047 studies in the databases and repositories of listed dissertations and theses, but only 230,758 were available in full for analysis.Figure 1 represents the flow of the selection process, and the final sample consisted of six studies.
Figure 2 shows the distribution of the countries where the studies were carried out.

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Chart 1 presents the detailed characterization of the studies selected and the synthesis of the perspectives and challenges faced for implementing the Expert Patient Program.

DISCUSSION
Currently, it is increasingly common to find people committed to health promotion and who value issues related to well-being and treatment continuity.This perspective does not centralize the responsibility for success only on health professionals, but includes patients and the population in general as active, participative and involved agents in this process 19 .
A new protagonist emerges given this scenario, the expert patient, who is defined as an individual who actively assumes self-management of their health-disease process.They are also capable of developing and improving skills necessary for self-care, as well as seeking information about treatments and the best way to deal with the disease, in addition to being able to help other individuals in similar conditions, with a reliable educational role 20 .
Led by patients with CNCDs, a program to promote self-management is not based on traditional patient education models, but on carrying out educational activities on the management of health conditions by the expert patients themselves, based on sharing experiences and tips necessary to be able to empower other individuals to self-manage their chronic diseases [13][14]21 .
Thus, expert patients have potential conditions to reformulate the health system and decentralize the care figured in the medical authority, as the search for information about diagnoses, diseases, symptoms, medications, hospitalization and treatment costs makes them more active and knowledgeable about their diseases and factors related to them, as well as being able to educate other patients with similar conditions 22 .-Leadership by someone with a chronic condition who found the program personally useful and committed to sharing it with others; -Physicians and other qualified health professionals as trainers so that they can share the program with their professional colleagues; -The self-management program as public health nurses' mission. Challenges: -Difficulty among the health professional to understand the concept of "self-management"; -Increased financial costs related to the program; -Use of volunteer lay leaders to maintain a well-trained and motivated group of volunteers.
IV -Use of various mobile technologies that supported self-management of chronic diseases; -Agile learning to use the device, following the instructions given by the study coordinator, devices that are easy to use and did not encounter technical difficulties; -Several participants found that using the devices together helped them develop a routine, such as adjusting eating behaviors, tracking blood glucose, tracking trends to share and discuss with their physician; -Satisfaction of the participants with the fitness tracker and reminders and stage log to help them schedule and track exercise targets and sleep regimens; -Provide positive messages and support self-management behaviors, such as medication use, physical exercise and sleep.
-It eased conversations with other people and physicians about the patients' health condition.Challenges: -The participants reported difficulty with the glucometer, such as manually recording glucose readings, connecting to Bluetooth, updating the glucometer, or scanning glucose test strips.
IV -Oncokompas is a self-help app that assesses a survivor's quality of life, based on a feasibility study among health professionals and patients who value independent use; -The supported self-management approach (combined care) was explored, with the importance of empowering the users and respecting their privacy, which resulted in the implementation of Oncokompas as an autonomous self-management tool. Challenges: -Lack of evidence regarding cost/effectiveness and uncertainty about long-term reimbursement by the health care provider; -The professionals reported that aged individuals had difficulty with a given technology; -Another barrier to adopting Oncokompas is related to the concept of self-management: some hospitals questioned whether access to an online self-management tool should be provided through a hospital or directly to the patients themselves.

III ||
Chart 1 -Cont.-Patients' knowledge of their condition, ability to understand and operate the solutions, their ability to incorporate or customize solutions into daily practices;

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-Visible effect of the solution and its effectiveness in managing the condition, such as sending accurate readings, family and healthcare provider support, need for motivational factors, and their ability to independently make decisions about medication adjustment; -Health professionals: supporting patients in managing their conditions, reassessing the patients' conditions and providing feedback on their progress, providing support in setting goals and advising on medication dosage adjustment; -The factors that influenced adoption by health professionals included diverse evidence that integration of existing systems and practices, alignment of the solution with the work organization goals, adaptability to learn and incorporate changes, transfer of the decisionmaking power to patients and the effect of the physician-patient relationship, time and resource constraints, incentives and motivation, assessment of the patient's skill level, interest and adaptability of the solution to current roles and responsibilities.
-Managers: in charge of responsibly delivering the solution to the intended users, on time and within budget, and had tasks such as working with solution designers and developers, consulting with user groups, promoting the solution to users, and documenting effectiveness of the solutions.Challenges: -Creation of effective policies for the implementation of actions that support self-management capable of providing the necessary benefits; -Effectively engaging with sustainable business models, funding and resources; -Making adoption mandatory for health professionals.In this way, health management does not occur unilaterally, but shared between patients and professionals, where there is a mutual commitment to health promotion, in addition to attributing values to health services and the patients' co-responsibility in the management of their chronic health status, so as to provide better treatment results 19 .
Faced with this, there is a need to train health professionals so that they are able to identify possible expert patients and participate in their training as educators and specialists in the self-care promotion 20 .
It is during formal education that health professionals and expert patients deepen theory and experience, in order to support the educational contribution to be conveyed to other apprentice patients.Therefore, it becomes necessary that these protagonists of the care self-management program be duly trained and qualified 7 .
Development of a course in partnership with governmental and community organizations, of a training nature and with the objective of qualifying lay patients as experts, was carried out in a collaborative manner and culminated in the satisfaction of this population group, improving selfmanagement of chronic diseases and health status and reducing the demands on services 17 .
In the meantime, educational actions to promote self-management constitute a light and lowcost technology that may imply satisfactory changes in the Unified Health System health care model and in Brazilian health services in relation to monitoring of CNCDs 23 .
Among the results of this review, two studies stand out, respectively carried out in the Netherlands and in the United States of America, which present the app use as a tool for self-management [15][16] .Employing mobile apps becomes useful for encouraging self-care among patients and as an educational resource to be used by health professionals 24 .
From this perspective, use of these apps in a care self-management program will entail benefits aimed at increasing adherence to the recommended therapy, monitoring periodicity of the medications, controlling treatment costs and tracking blood glucose and blood pressure levels, among other care measures 15,18,25 .
Recording and monitoring the routine experienced by the patients enable better monitoring by health professionals and the practice of supported self-management, with creation of goals and the methods used to achieve them 16 .
Therefore, Telemonitoring through mobile apps can be seen as a possibility of improving communication between these population groups and promoting self-management, as it comprises interaction, clinical and behavioral data sharing, recognition of problems, decision-making improvements, definition of objectives and identification of modifiable behaviors.All of this will assist in adaptation and in better management of chronic diseases 23,26 .
Another point raised in the results of this study was the contribution of Evidence-Based Practice (EBP) to the implementation of a care self-management program [13][14] .Conceptualized as an approach capable of qualifying health care through the search for better current scientific evidence, with implementation in the practice and evaluation of the results, it incorporates the health professionals' clinical competence and the patients' particularities for decision-making 27 .
A study carried out in the United States of America 13 indicates the commitment to the care self-management program as a Nursing mission; linked to this, there is evidence-based Nursing, in which technical and specific knowledge related to self-care is applied, adding itself to this context by complementing and supporting expert patients during the exchange of experience and tips on how to live with the disease in everyday life, shared in educational activities 7,28 .
It is worth emphasizing that management of the health systems should be committed to and value the training of expert patients, as knowing the importance of this type of coping with CNCDs 11/15 can exert impacts on managers' decision-making regarding the definition of macro-and micro-political processes in the production of lines of care for people with chronic diseases 23 .
One of the challenges faced for the implementation of a self-management care program is defining and understanding this concept for the health professionals involved in this process 13,16 .
For its implementation, it becomes necessary that the definition of self-management be understood in a clear and objective way and differentiated from self-care.Thus, the concept of self-care is related to the regulatory ability that allows people to carry out essential activities for the preservation of life, health, development and well-being.In turn, self-management is related to controlling a disease, mainly chronic ones, together with the patient's family, community and health professionals, discovering mechanisms and adopting strategies to achieve such control 29 .
Furthermore, the implementation of a care self-management program constitutes a paradigm shift in the Brazilian context.The hegemonic health model with a focus on illness and fragmentation of the human body into parts undergoes a transition to the expanded concept of health and contemplation of the being in its multiple spheres (bio-psycho-social-spiritual-cultural), articulating all actors involved in health services, such as patients, health professionals and the community at large 30 .Therefore, changes of this kind are considered challenging for traditional health services.
Therefore, this requires structural transformations in the way health programs are managed, in addition to demanding a change in the professionals' mentality and performance regarding the hegemony of authoritarian medical care and making room for a new patient profile, considered as active as duly informed subjects, knowledgeable about their diseases and who develop strategies to self-manage their care 31 .
The health professionals' difficulty accepting this new role assigned to the patients is also related to changes in their everyday practices linked to care, and they are not always prepared for this 14 .
The challenges for implementing programs in health services are also related to the creation of public policies, funding and management [13][14]18 and depend on the involvement of different actors, such as managers, technicians, politicians and social agents in the municipal, state and federal spheres 32 .
Financial incentives in programs centered on people and health are crucial for promoting care management, expanding the patients' autonomy in making their choices and changing the reality they live in 33 .With this, self-management programs and training of expert patients corroborate with the paradigm shift in the health model and should arouse the management's interest regarding the importance of implementing management of CNCDs in health systems.
Therefore, it becomes necessary for health service managers to be aware of the care provided in the context of chronic diseases and longevity, in order to manage them effectively and to promote well-being and autonomy, considering the literacy ability in health and the digital skills of this population group in the short-and medium-term 33 .
Consequently, the use of technologies by expert patients for care self-management is also highlighted; however, its accessibility does not happen in the same way among all patients, mainly among aged ones, but is seen as a future possibility for younger population segments [15][16]31 .
Using Telemonitoring as a technological tool to support self-management faces other challenges, such as the initiative of management and funding entities.However, even if financial investments are necessary for implementation, the benefits for patients with chronic diseases outweigh the related expenses 34 .
The contributions of this study to the Nursing and Health areas are based on the mapping of fundamental perspectives to guide implementation of the self-management program in Brazil, presenting experiences that, even with the challenges faced, proved to be successful and possible to be reproduced at the national level.

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This study has limitations related to the predominance of studies with low levels of evidence and because there is still no model program for self-management the care implemented in the Brazilian context.

CONCLUSION
The current study gathered the main scientific evidence on the perspectives and challenges for implementing a self-management care program.System managers, as well as health professionals, mainly nurses, need to know and understand the importance of the Expert Patient Program within the reality of the services where they work, with a view to reducing morbidity and mortality and increasing the patients' quality of life.
Therefore, it is concluded that, despite the challenges for implementing this program, the results obtained in other countries justify its consolidation, with the perspective of future satisfactory results regarding the managerial aspects of self-care and, mainly, due to the results achieved by the patients involved.
In this way, it is hoped that this paper can encourage the production of new studies that explore the theme of expert patients in the Brazilian health system as a way of coping with CNCDs and promoting encouragement of self-care, self-management of their health conditions and, therefore, the incentive to improve quality of life.
IV ‡ Key: *ID = Identification; † A = Article; ‡ IV = Evidence from experts' opinion, descriptive studies, case reports or expert committee reports; § I = Evidence from systematic reviews containing only randomized controlled clinical trials; || III = Evidence from analytical studies, controlled clinical trials without randomization, cohort studies, case-control and quasi-experimental; ¶ II = Evidence obtained from a randomized controlled clinical trial.Chart 1 -Cont.Texto & Contexto Enfermagem 2023, v. 32:e20220222 ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2022-0222en10/15 -Limited access to systematic reviews by public policy makers and their scientific grounds for improving health service policies; -At the global level, health services are lack the practice of adhering to the best available evidence to inform decisions on implementing specific interventions, resulting in suboptimal results and inefficiencies;-Complex changes in health services and in the health professionals' routine; -Financial arrangements and management of health policies.