2Self 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)
3Cited 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 elCited by DHS - Self - Management Mapping Guide2007
4Outcomes of self management. Knowledge of condition and treatment optionsAbility to negotiate a plan of care with their health care workerMonitor and manage symptoms and signs of conditionsManage the physical, emotional and social impact on their lifeEngage in activities that protect and promote health
5Wagner Chronic Care model The Wagner Chronic Care Model has been endorsed by DHS and forms the foundation of PCP ICDM workIt describes the elements required to transform the current health system to one which takes a proactive approach to promote health and wellbeingEach 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.
6Evidence for self management Improved health outcomes3,5Improved compliance with medication and therapy1,2,4Improved symptom control and management (reduced pain, depressive symptoms)1-6Increased self efficacy and motivation1,3-5Reduced utilization of health services and inpatient length of stay2-5Improved quality of life2-5The 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 ofImproved medication complianceIncreased self efficacy and motivationImproved skills in managing symptomsWhich in turn reduced their utilisation of health services and improved overall quality of life
7Self - Management Support What the consumer, not the health clinician doesSelf - Management SupportWhat health care practitioners provide to assist a consumer with their self management practicesSelf 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.
8Self - Management Models / Approaches FlindersStanford University (Lorig)Motivational InterviewingHealth CoachingAction PlanningBuilding HabitsOther……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 plansTo become accredited need to fulfill above and additional 2 day training.License is required to run the programSTANFORD - 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 leaderCapacity to become an accredited trainerNeed 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.
9DHS Self Management Survey Aim of surveyTo 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
10MethodologyIdentification of Chronic Disease listed in the Australian National Chronic Disease Strategy (Nov.2005)Identified relevant agenciesProvided electronic survey template and supporting informationMet with agency representative to discuss and complete templateCollated data and forwarded to DHS for analysis and reportingCD on the health of Australians & health care systems.It identified 5 health prioritiesAsthma - affects 14% of children and 10% of adults with the proportion dramatically increasingCancer - ranks second overall cause of deathDiabetes - prevalence has more than doubled over the past two decades. Type 2 is predicated to have the largest increase of the CD by 2020Heart, stroke and vascular disease - leading cause of death 1 in 5 Australians have CV problemsOsteoarthritis, RA and Osteoporosis - affect 3 in 10 people. Cause more disability than other CD’sMental 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
11Limitations of surveyIndividual interpretation of survey template – Surveyor, agency vs. lack of standardised approach for state-wide data collection.Data may not be representative of whole agency approachScope 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 barriersTemplate not user friendlyIt should also be mentioned, that the survey and the data collection process had a number of limitations which could possibly confound the resultsOne 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 organisationsAlthough 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.
12Consultations and self management mapping 18 Agencies in SWPCPAboriginal Health Promotion Chronic ConditionsCamperdown Community healthSWHC Community health, Chronic IllnessAspireSWHC Cardiac rehabilitationSWHC Ocupational TherapyCobden District Health ServiceSWHC counselling servicesSWHC Psychiatric ServicesLyndoch Aged and Extended CareSWHC Alcohol and Drug withdrawal and supportTerang and Mortlake Health ServiceOtway division of general practiceSWHC LismoreTimboon and district healthSalvation ArmySWHC NutritionWRADA range of service providers were approached to complete the survey which included
13All of the agencies that completed the survey: believe Integrated Chronic Disease Management (ICDM) is an organisational priority,self management is an organisational strategic goalProvide specific chronic disease management programsDespite 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
14SWPCP Results: Staff Trained 94Overall, 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 programHealth 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.
15Staff 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 memebersA 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
16Disease 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.
17Delivery 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.
18ReferralsThe 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
19Target 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)
20Enablers 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
21Barriers to providing self-management support at an agency level Some of the main barriers identified areTime interventions takeOther priorities for cliniciansLimited referrals from GP.Limited access to self management trainingAs you can see that some of these enablers and barriers do contradict each other, due to the limitations and interpretation of the survey questions
22Support required to embed self management – Practitioner level OrganizationSupport from other staff in the agencyIncrease time for skill developmentImplement consistent assessment toolsPromote availability of SM programsIncrease consultation timeManagerial supportTrainingContinuing professional development and maintaining knowledge and skillsGP training on SM to increase awarenessMore training support from managementFundingIncreased funding for SM training and the time that this takesAdditional staff resourcesIncreased resources to support clients in programs and follow-up careIn 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 policyIn doing this , sufficient time could also be allocated for staff skill development and client consultationThere was also a call for improved support post self management training to enable the development of skills and staff confidenceTo 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 needsThe 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 programsPCP SupportInform DHS re. policy direction awareness of trendsCoordinate and promote SM trainingRaise awareness of SM and allow practitioner networkingEncourage and promote referral to practitioners trained in SM,
23Support required to embed self management – agency OrganizationReview of systems, processes and structures to support SMReduce emphasis on client throughput and encourage attending to client needs.Facilitate change managementEnsure managers have a good understanding of self management practices.TrainingProvide training regarding SM principlesReview training models so that the training required to embed SM into assessment, client skill development, and group programs are supportedEducate and empower staff to move away from the dependence model of careProvide support and time for staff developmentFundingContinue funding the development of client programsAllocate additional funding for training courses in SMAt an agency level this was very reflective of support as that required at practitioner levelPCP SupportPromote SM training and facilitate workshops/seminarsAssisting with policy direction and being aware of the trendsBring agencies together to progress, collaboration and implementation of SM across catchment.Facilitate support from management as well.
24Support required to embed self management – PCP CoordinationCoordinate a regional approach to embed SM into practiceFacilitate sharing of information and resourcesSupport integration of SM and strengthen partnershipsCooperationFacilitate sharing of resourcesAwareness of current trendsShare learning's and information across the PCPNetworkingEngage GP involvementPromote condition specific programs/ services to increase community awarenessAt a Catchment level, the need for a coordinated regional approach was identified to assist in leading the implementation of SM practicesThe 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 SupportPromote training, SM information and advertising to raise awareness of SMAssisting with policy direction.
25FindingsThe 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.
26Key areas of workImproving the integration and planning of chronic disease services in the regionWorking with agencies to develop an integrated approach in the use of self management practices across the regionAssist with workforce development opportunities to support best practice.
27Statement of intent for SWPCP ICDM VisionTo 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 illnessPromote and support client self-management