1. SWPCP – Self management mapping.

2. Self management – What is it?
Self - management is defined as the task that individuals must undertake to live with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management and emotional management of their conditions
(Institute of Medicine 2004;cited by Kate Lorig, RN, DrPH. Stanford Patent Education Centre)

3. Cited by DHS - Self - Management Mapping Guide
Aim of self management
“to develop skills and confidence within patients and their families so they can take responsibility of their own care”
Zwar, N et el
Cited by DHS - Self - Management Mapping Guide
2007

4. Outcomes of self management.
Knowledge of condition and treatment options
Ability to negotiate a plan of care with their health care worker
Monitor and manage symptoms and signs of conditions
Manage the physical, emotional and social impact on their life
Engage in activities that protect and promote health

5. Wagner Chronic Care model
The Wagner Chronic Care Model has been endorsed by DHS and forms the foundation of PCP ICDM work
It describes the elements required to transform the current health system to one which takes a proactive approach to promote health and wellbeing
Each individual element namely SMS, DSD, DS, CIS are independent and build on one another to facilitate more productive interactions between more activated client and a prepared and proactive health care team.

6. Evidence for self management
Improved health outcomes3,5
Improved compliance with medication and therapy1,2,4
Improved symptom control and management (reduced pain, depressive symptoms)1-6
Increased self efficacy and motivation1,3-5
Reduced utilization of health services and inpatient length of stay2-5
Improved quality of life2-5
The evidence in support of promoting better client self management as part of chronic disease care is growing.
A number of studies have demonstrated that people who participate in chronic disease management programs have improved health outcomes as a result of
Improved medication compliance
Increased self efficacy and motivation
Improved skills in managing symptoms
Which in turn reduced their utilisation of health services and improved overall quality of life

7. Self - Management Support
What the consumer, not the health clinician does
Self - Management Support
What health care practitioners provide to assist a consumer with their self management practices
Self management support
* Respects choices and individual circumstances of the person with a chronic disease, but assists to address barriers to self management.
• Involves goal setting and problem solving as key components.
• Is an ongoing collaborative process between the health practitioner and person with a chronic disease; not something that is completed in a time-limited intervention. Self management is a life-long practice for the individual and self management support needs to be available when the person needs support in maintaining this approach.

8. Self - Management Models / Approaches
Flinders
Stanford University (Lorig)
Motivational Interviewing
Health Coaching
Action Planning
Building Habits
Other……
Flinders, Stanford, Motivational Interviewing and Health Coaching are the SM approaches the DHS SM Mapping Survey focused on.
These are the dominant evidence based self management models.
Flinders - This model is a generic set of tools and processes. Enables clients to undertake a structured process that allows for self assessment of SM behaviors, collaborative identification of problems and goal setting, leading to the development of individualized care plans.
Health professional delivered - 2 day training. Complete 3 flinders assessments and care plans
To become accredited need to fulfill above and additional 2 day training.
License is required to run the program
STANFORD - Structured on a group program that runs over 6 sessions for people with Arthritis or osteoporosis or other CD.
Sessions facilitated by 2 trained leaders (may include peer leader).
Training - 3 day training for both health professional and peer leader
Capacity to become an accredited trainer
Need a license.
MOTIVATIONAL INTERVIEWING - Is a directive client centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence.
HEALTH COACHING - Uses a Cognitive behavioral model for health outcomes applied to the individual based on readiness to change.
Health professionals apply evidence based psychological counseling and coaching principles. Helps motivate clients.
Two day training.

9. DHS Self Management Survey
Aim of survey
To improve understanding of current service system and to build capacity within the sector.
To identify self management program providers, service distribution, types of interventions, agency capacity, barriers and enablers, and training needs.
Inform planning for future PCP activities to enhance ICDM across the catchment 
Baseline data will assist in identifying future trends

10. Methodology
Identification of Chronic Disease listed in the Australian National Chronic Disease Strategy (Nov.2005)
Identified relevant agencies
Provided electronic survey template and supporting information
Met with agency representative to discuss and complete template
Collated data and forwarded to DHS for analysis and reporting
CD on the health of Australians & health care systems.
It identified 5 health priorities
Asthma - affects 14% of children and 10% of adults with the proportion dramatically increasing
Cancer - ranks second overall cause of death
Diabetes - prevalence has more than doubled over the past two decades. Type 2 is predicated to have the largest increase of the CD by 2020
Heart, stroke and vascular disease - leading cause of death 1 in 5 Australians have CV problems
Osteoarthritis, RA and Osteoporosis - affect 3 in 10 people. Cause more disability than other CD’s
Mental health was excluded in the SM mapping however it was recognized by DHS that many mental health issues are chronic conditions and that there is considerable self management support provided by Mental heath services however we did survey agencies we

11. Limitations of survey
Individual interpretation of survey template – Surveyor, agency vs. lack of standardised approach for state-wide data collection.
Data may not be representative of whole agency approach
Scope of activity limited to select chronic diseases.
Is obesity a chronic disease? Do we include weight management groups?
Restrictive survey question design – limiting feedback for identification of enablers and barriers
Template not user friendly
It should also be mentioned, that the survey and the data collection process had a number of limitations which could possibly confound the results
One of the greatest flaws was the way in which the survey was conducted, whereby each individual PCP was responsible for collecting the Catchment data. This potentially creates error due to individual interpretation of the questions and the responses.
Further to this the responses gathered may not have been reflective of the practices across the entire organisations
Although it was requested that each agency representative report on behalf of the organisations, this could not be guaranteed.
In order to simplify the project, the scope was limited to include service providers of only the major chronic diseases.
The survey design was also quite restrictive in that it limited the number of responses and the amount of feedback agencies could report.

12. Consultations and self management mapping
18 Agencies in SWPCP
Aboriginal Health Promotion Chronic Conditions
Camperdown Community health
SWHC Community health, Chronic Illness
Aspire
SWHC Cardiac rehabilitation
SWHC Ocupational Therapy
Cobden District Health Service
SWHC counselling services
SWHC Psychiatric Services
Lyndoch Aged and Extended Care
SWHC Alcohol and Drug withdrawal and support
Terang and Mortlake Health Service
Otway division of general practice
SWHC Lismore
Timboon and district health
Salvation Army
SWHC Nutrition
WRAD
A range of service providers were approached to complete the survey which included

13. All of the agencies that completed the survey:
believe Integrated Chronic Disease Management (ICDM) is an organisational priority,
self management is an organisational strategic goal
Provide specific chronic disease management programs
Despite all agencies stating self-management is an organisational priority, staff trained in these models tend to be concentrated in some agencies more than others - in some cases there is just 1 or 2 clinicians doing this work in an agency which compounds the challenges for those individuals, and there may be opportunities for them to be supported through cross-agency partnerships facilitated by the PCP to extend this approach across the region. Since this survey was conducted there is now a Self Management Coordinator employed at SWHC Community Health ( Laura Main) who is working to promote training in self management

14. SWPCP Results: Staff Trained94
Overall, the survey results did not yield many surprises but rather confirmed expectations.
The Flinders Model has received much attention in the past year and consequently has a high number of staff who have undertaken training. Of those trained the majority of staff came from community health settings.
There were only 5 staff trained in the Stanford Model Better health self management, across the region - they are across 4 different agencies and opportunities may exist for peer support if not already in place, and further development in the region of capacity to deliver this important program
Health Coaching has gained more recognition for its application in health care and there has been a small but significant proportion of staff who have completed this training. Since this survey was completed there have been Health Coaching workshops in the area and there may well be more members providing this support to the community.
Similarly, a small proportion of staff who have undertaken Action Planning and Building Habits which has been largely been completed by staff working in WRAD and SWHC counseling services and Aspire.
Overall, CHS’S and appeared to lead the way in regards to the number of staff trained in SM models which would seem appropriate given the duration of care clients would receive in community health compared with acute health services.
There were also 94 other staff trained in other areas of self management including 50 from Psych services trained in STAR and various others, as these agencies identified that the programs provide self management support it is difficult to determine and measure what qualification or training these staff have received and to what extent and therefore are not included in this analysis.

15. Staff trained V’s Staff providing support.
Where staff have been trained in an evidence-based model of chronic disease self-management support, they are using the skills in their practice.
- whereas across the state more broadly, it has been found that many staff that are trained have not been able to implement the training into their practice
- In a few agencies there are some people providing support that have not been trained in the models, However in these agencies it was noted that there are others in the agency that are trained and can assist and provide support to these staff memebers
A significant point worth noting is that a significant number of Stanford Better Health self management programs are being delivered with the indigenous community through the AHPACC program with 13 groups offered

16. Disease focus.
Cardiovascular disease has been identified as the main focus in the area, followed with diabetes and respiratory disease.
There were significantly less self management programs with a focus on musculoskeletal.

17. Delivery Setting.
As you can see the majority of the self management programs offered in the SWPCP region were in the Community health/community setting, then followed by the Health service and then the Home.

18. Referrals
The majority of the referrals for the programs that have been recorded and commented on came from the Health Service followed by the GP and self

19. Target Population Older people All
Younger people (HAPR identified younger people as a taget for all there programs which tended to skew the results as they ran a lot of programs)

20. Enablers to providing self-management support at an agency level
The main enablers that would assist with providing SM support :
- Access too self management support training
- Clinicians willingness to change practice
- Systems in place to routinely identify self management support needs of client
- High level of staff retention

21. Barriers to providing self-management support at an agency level
Some of the main barriers identified are
Time interventions take
Other priorities for clinicians
Limited referrals from GP.
Limited access to self management training
As you can see that some of these enablers and barriers do contradict each other, due to the limitations and interpretation of the survey questions

22. Support required to embed self management – Practitioner level
Organization
Support from other staff in the agency
Increase time for skill development
Implement consistent assessment tools
Promote availability of SM programs
Increase consultation time
Managerial support
Training
Continuing professional development and maintaining knowledge and skills
GP training on SM to increase awareness
More training support from management
Funding
Increased funding for SM training and the time that this takes
Additional staff resources
Increased resources to support clients in programs and follow-up care
In order to embed self management into the practice at a practitioner level, staff reported a need for increased managerial support whereby self management is recognized as a priority, and appropriate time provided to for health professionals to practice self managment.
Progressing the implementation of self-management into practice was seen by those interviewed to require continuing professional development and support from management and the PCP's potential role was stated as advocacy and informing policy
In doing this , sufficient time could also be allocated for staff skill development and client consultation
There was also a call for improved support post self management training to enable the development of skills and staff confidence
To facilitate this, it was felt that more funds need to be directed towards supporting self management training and to establish key worker roles to adequately attend to client’s needs
The PCP’s role was seen to be responsible for reporting concerns back to DHS and coordinating and promoting self management training and increase general awareness of SM programs
PCP Support
Inform DHS re. policy direction awareness of trends
Coordinate and promote SM training
Raise awareness of SM and allow practitioner networking
Encourage and promote referral to practitioners trained in SM,

23. Support required to embed self management – agency
Organization
Review of systems, processes and structures to support SM
Reduce emphasis on client throughput and encourage attending to client needs.
Facilitate change management
Ensure managers have a good understanding of self management practices.
Training
Provide training regarding SM principles
Review training models so that the training required to embed SM into assessment, client skill development, and group programs are supported
Educate and empower staff to move away from the dependence model of care
Provide support and time for staff development
Funding
Continue funding the development of client programs
Allocate additional funding for training courses in SM
At an agency level this was very reflective of support as that required at practitioner level
PCP Support
Promote SM training and facilitate workshops/seminars
Assisting with policy direction and being aware of the trends
Bring agencies together to progress, collaboration and implementation of SM across catchment.
Facilitate support from management as well.

24. Support required to embed self management – PCP
Coordination
Coordinate a regional approach to embed SM into practice
Facilitate sharing of information and resources
Support integration of SM and strengthen partnerships
Cooperation
Facilitate sharing of resources
Awareness of current trends
Share learning's and information across the PCP
Networking
Engage GP involvement
Promote condition specific programs/ services to increase community awareness
At a Catchment level, the need for a coordinated regional approach was identified to assist in leading the implementation of SM practices
The PCP was seen to have a valuable role in facilitating sharing of resources a SM reference group which would lead this implementation process and coordinate SM training and promotion.
PCP Support
Promote training, SM information and advertising to raise awareness of SM
Assisting with policy direction.

25. Findings
The high prevalence of chronic disease supports the high demand for more effective services. SM interventions have been shown to be more effective at improving health outcomes and client .
Staff skills and access to training have been identified as being key barriers to the provision of SM support. Clinicians have competing work priorities. The lack of follow-on training support for skill development contributes to the time SM interventions take, thus limiting the application of staff’s SM training.
Individual staff training alone is not conducive to practice change. Managerial leadership and support is required to drive the provision of SM support via the implementation of systems to ensure consistent assessment of client needs and the delivery of consistent SM practice.

26. Key areas of work
Improving the integration and planning of chronic disease services in the region
Working with agencies to develop an integrated approach in the use of self management practices across the region
Assist with workforce development opportunities to support best practice.

27. Statement of intent for SWPCP ICDM
Vision
To improve the health and well being of people with chronic disease and reduce preventable admissions to hospital for this group.
To identify groups at risk of a chronic disease and intervene at an early stage to avoid the development of a chronic illness
Promote and support client self-management