Making self management support a reality: learning from practice Learning event 13 May 2015 #selfmgt #thfpcc

The Health Foundation 2

25% LTC 70% GP 70% inpatient 65% outpatient 50% adherence Financial crisis Rights Gratitude Legislation, Policy Initiatives Professional bodies Voluntary sector Commissioning 5% written care plan 43% GP 47% nurse Context PopulationClimate GapLeadership #selfmgt and #thfpcc

NB : People may also be accessing a wide variety of other support e.g. from within their communities Life with a long term condition: the person’s perspective Interactions with the service: planned or unplanned ‘ Every system is perfectly designed to get the results it gets’ #selfmgt and #thfpcc

What is person-centred care? 5 There is no single agreed definition of the concept: it is used to refer to many different principles and activities #selfmgt and #thfpcc

Conflicts of interest Presentation title set in header 6 The well

What is self-management support? Should I take that pill today? Am I going to stick to that exercise regime? Do I really want that heart operation? A portfolio of techniques and tools that help patients choose healthy behaviours and a fundamental transformation of the patient-caregiver relationship into a collaborative partnership. Source: Bodenheimer T, MacGregor K, Shafiri C (2005).Helping Patients Manage Their Chronic Conditions, California: California Healthcare Foundation. … supporting people to make informed and personally relevant decisions about managing their own health and healthcare that they can enact. #selfmgt and #thfpcc

Moving to self-management support Based upon: In Brief: Person-centred care: from ideas to action 8 Current PracticePerson-Centred care Roles and beliefs Patients passive People active partners and managers of their health Clinical expert gives advice, fixes, cares for and promotes dependency Expertise used to support the person’s journey to living well in the presence/absence of symptoms Knowledge creates behaviour change Knowledge, skills, confidence create behaviour change ModelPrimarily medicalBiopsychosocial Values clinical outcomesValues outcomes that matter to people WhoWorkforce = clinicians Workforce = clinicians + peer support workers + navigators + health coaches + … HowClinician shares results and information during consultation Person receives results and information at appropriate time Training Communication skills for agreement to clinician determined goals Skills to support people to determine and enact their own goals ModeCompliance with clinically determined goals and treatment plans Collaborative care and support planning with adherence to co-produced goals #selfmgt and #thfpcc

Person- centred care and support Service provision that embeds the systems, tools and processes to enable PCC A model for change Based upon the Year of Care in Diabetes House of Care An integrated, whole system approach Workforce with knowledge, skills and confidence for technical tasks and to support people to have agency over their health and well-being Population with knowledge, skills and confidence to have agency over their health and well-being System stewardship and regulation that facilitates and holds services to account “More than medicine” Informal and formal sources of support and care #selfmgt and #thfpcc

10 Co-creating Health #selfmgt and #thfpcc

11 Agenda setting Identifying issues and problems Preparing in advance Agreeing a joint agenda Goal setting Small and achievable goals Builds confidence and momentum Goal follow-up Proactive – instigated by the system Soon – within 14 days Encouragement and reinforcement Becoming an active partner Making change Maintaining change The three enablers #selfmgt and #thfpcc