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Self-management support in action
Dr Janine Bycroft
Health Navigator Charitable Trust
Self Management Support
What is self-management?
“People with chronic conditions having greater control in
looking after themselves, with the support of their
families (where desired) and in partnership with health
professionals and community resources.”
(National Health Committee, 2005)
To have greater control, people need:
• Self care skills
• Knowledge & understanding
• To know what their early warning signs are, action to take
• Healthcare team willing to partner with them
Seven Principles of Self-Management
KIC MR ILS
K – Knowledge and understanding
I – Involvement
C – Care Plan – same page care
MR - Monitor & respond – how, what, when
I – Impact – emotional, social and physical impact
L – Lifestyle – that protects & promotes health
S – Support
(Prof M Battersby, Flinders Programme 2011)
Self-Management Support
Is what we, as clinicians and a health system (along with whanau,
community and peers) do to support, encourage and enable people to
manage the often complex medical, psychological and emotional roles of
living with a long-term illness/condition more effectively.
It requires:
– Collaboration
– Paradigm shift from acute care model to planned, proactive model
– Systems approach to facilitate increasing self-management capacity at every encounter with health system
– Change in role for providers – coach, partner rather than expert giving advice all the time
•Includes health literacy
•Builds on resilience & development of life skills
•Most needed for high needs populations
Self-Care critical component
Health Promotion
7
Evidence - Myriad of reports concluded SMS essential
component
8
NHS – Supporting people with LTC to Self Care – Department of Health, UK.
4 visits/yr = 1/7 of one square
CCM (6 hours contact) = still less than one square
1 square = 7 hours
8736 hours/ year
Time Spent with Healthcare Team – rest is “on your own”
Expanded Chronic Care Model
11
ABCC NZ Study – 10 Action Areas
1. Conceptual understanding
2. Leadership
3. Adherence to clinical guidelines
4. Collaboration
5. Sustainable community links
6. Self-management and collaborative care
7. Reducing health inequalities
8. Delivery system design
9. Decision support
10.Knowledge transfer
ABCC NZ Study Workbook 2010
British Health Foundation 2011: Helping people help themselves
Strategies to support self-management
13
Video - How to implement self management support
http://youtu.be/DrSaYzWWWJ0
Joined Up Care - Video
www.kingsfund.org.uk/audio-video/joined-care-sams-story
15
Integrating Self-Management Support (SMS) into Practice
12 Principles
1. Brief targeted assessment to guide SMS
2. Evidence-based information to guide shared decision making
3. Clinicians use a nonjudgmental approach
4. Collaborative priority and goal setting
5. Collaborative problem-solving
6. Diverse providers can offer SMS
7. Individual, group, telephone, and self-instruction formats can be employed
8. Enhance patient self-efficacy
9. Ensure active follow-up
10. Guideline-based case management for selected patients
11. Linkages to evidence-based community-based self-management programs
12. Multifaceted interventions are more effective
Battersby, M. , Von Korff Schaefer, J. et al. Twelve Evidence-Based Principles for Implementing Self-Management Support in
Primary Care – Joint Commission on Quality & Patient Safety December 2010 Volume 36 Number 12
16
1. Brief, targeted assessment
Partners in Health Scale
CVD Risk Assessment
Health knowledge and beliefs
Patient activation measure
More detailed:
Flinders Assessment
NASC Assessment
Mental health assessment tools
17
2. Evidence-based information to guide shared decision making
Risk communication
Supporting shared decision making
– Decision aids
– E-health
– Option grids
Decision Aids - limited development in NZ so far
4-5 Collaborative agenda setting, goal setting etc
1. Improve how we communicate
2. Use communication techniques – eg Ask-Tell-Ask, Closing
the Loop/Show Me
3. Holistic approach, continuity and relationship important
4. Reduce health literacy demands, create a shame-free
environment, encouraging questions
5. Together set the agenda, assist person to set their own
goals, ownership critical to behaviour change
6. Structured problem solving – eg Heart Foundation e-health
modules
Heart Foundation Communicating Risk e-modules
http://learnonline.health.nz/
6-7: Diverse providers & formats
Health Navigators –
West Coast
Community Health
Coordinators
Lay leaders
Interdisciplinary teams
Healthcare assistants
One-on-one
Telephone support
Group visits
Group programmes
Online
One size doesn’t fit all – need a range of options to suit different
people, learning styles, work and whanau commitments
The Journal
Online self-help programme for depression
https://myjournal.depression.org.nz/
www.beatingtheblues.co.nz/
3 & 8. Healthcare Professionals with right skills, tools and
attitude
Enhance self-efficacy
Attitude matters
Range of courses, training
Health Navigator NZ
website
Self-Management Toolkit
Flinders Programme
Canadian Self Management
Toolkit website
Health Foundation SMS
Resource Centre
RANZC Psychiatrist's online
programme for chronic
condition self-management
23
Cultural Competency Training
www.caldresources.org.nz www.mauriora.co.nz
24
9. Ensure active follow-up
Monitor & respond
Clear written instructions
Planned follow up calls useful
Proactive follow-up – Telephone coaching between visits to support behaviour change
25
Telephone Coaching & Follow up calls
www.chcf.org/publications/2008/08/video-on-coaching-patients-for-successful-selfmanagement
26
10. Clinical pathways and case management
How much self-management is in your
clinical pathway?
Tend to be very medically focused
27
Integrating Self-Management Support (SMS) into Practice
12 Principles
1. Brief targeted assessment to guide SMS
2. Evidence-based information to guide shared decision making
3. Clinicians use a nonjudgmental approach
4. Collaborative priority and goal setting
5. Collaborative problem-solving
6. Diverse providers can offer SMS
7. Individual, group, telephone, and self-instruction formats can be employed
8. Enhance patient self-efficacy
9. Ensure active follow-up
10. Guideline-based case management for selected patients
11. Linkages to evidence-based community-based self-management programs
12. Multifaceted interventions are more effective
Battersby, M. , Von Korff Schaefer, J. et al. Twelve Evidence-Based Principles for Implementing Self-Management Support in
Primary Care – Joint Commission on Quality & Patient Safety December 2010 Volume 36 Number 12
Skills Training –
Self-Management Education
Skills based rather than disease information
SME more effective than traditional disease education at supporting behaviour change
Self-management programmes
Generic eg Stanford Model
– MHOL, LIFE, Arthritis NZ,
– Online versions not yet in NZ
Disease specific - Diabetes, cardiac rehab, pulmonary rehab etc
‘Give a man a fish and
you feed him for a day,
teach him to fish and
you feed him for life.’
29 Participants love it – often find it “life changing”
12. Multifaceted interventions are more effective
Systems approach
Ticking the box for Self Mgt Education – not enough!
Planned, proactive care & visits (Year of care)
Teamwork, MDT meetings & care coordination
Intra-structure to support shared summary records
and electronic shared care plan
Patient portal
Enhanced discharge planning processes
Application of continuous QI processes
Clinical audits
Stepped Approach to Care Planning
Figure 2: Self-Management Support Toolkit – Health Navigator Charitable Trust & ADHB
32
Care Plan Agreed Issues
Agreed Interventions Shared Responsibilities
Review Process
The Flinders Programme
Problems and Goals +
Assess Self-Management
Psychosocial Support
Community / Carer Support
Self- Management
Medical Management
Take Home Messages
Patients are the largest untapped resource & they want to be supported to self care
Whole of system approach needed
Wide range of training, support and resources to improve self-management support
Care Planning is one of the important changes we can implement to help shift from clinician-centred care to patient-centred care or self-directed care
Reduces acute demand, reduces costs, improves system effectiveness & workforce sustainability