Sharing Health Care Project Chronic Disease Self-Management Program Manager - Jill Kelly Project Co-ordinator - David Menzies

Sharing Health Care Project Background: $14.4 million Sharing Health Care (SHC) initiative SHC is part of $210 million Enhanced Primary Care (EPC) package for older Australians with chronic complex conditions Focus on people over 50 years (over 35 years ATSI)

Components of Sharing Health Care 8 Demonstration projects around Australia RACGP Literature Review on Chronic Disease Self-Management RACGP Clinical Guidelines ( GPs & AHP ) Education modules from Flinders University

Literature Review – Components of a SM program Collaborative definition of problems Goal setting & planning Continuum of self-management training Active and sustained follow-up

“The Good Life Club” An alliance of 8 agencies: –Community Health Services: Inner East, Monashlink, Manningham and Whitehorse Community Health Services; –Chinese Health Foundation Australia –Box Hill Hospital –Whitehorse City Council –Whitehorse Division of General Practice (auspice)  3 year project until mid 2004

Target Group for Good Life Club: People living in Boroondara, Manningham, Monash, and Whitehorse; Over 50 years of age; Diabetes Sub target will be older men and Chinese community;

Project Objectives Improve the health related quality of life for people with diabetes & cardiovascular disease (where this exists as a co-morbidity) Improve the use of the health care system by people with these chronic diseases Encourage collaboration between individuals, their families and health care professionals in the management of these chronic conditions

Major strategies: Telephone coaching Increasing linkages betw. Treating Health Professionals Promotion of Multi-disciplinary care planning Website Club activities Organisational development

“Coaching” Model Who: Allied Health Professionals in CHS OR Practice Nurses What: Building self-management capacity over time Facilitate access to services Promoting partnership with the GP Using “stages of change” model Literature review to inform model Coach can contribute to Care Plan review

Coaching model When: Regular contact over 12 months (more frequent in early stages) How: Phone contact Approx 15 minutes Focus on self-management

Stages of change model Precontemplation Contemplation Ready to change Making a change Maintaining change Maintaining healthier lifestyle Relapse

Good Life Club Coaching Model Self-management The Coaching role decreases as the members self-management skills increase Coaching

Coach Training - evidence DiSC study, needs analysis, methodology, RCT results. [Edwards, 1999 ] [Jones, 2003; Jones, 2001] Change counseling in diabetes. [Doherty, 2000] Teacher training as behaviour change process [Kealey, 2000] DAWN study. [Alberti, 2001] Diabetes prevention project. [The Diabetes Prevention Program Research Group, 2002] Coaching to achieve target cholesterol. [Vale, 2002]

What is being evaluated? Process evaluation Outcome Evaluation (Baseline, 6,12,18 months): Clients: –Health-related quality of life –Functional status –Satisfaction with life –Social functioning –Psychological distress –Mortality –Use of Health Services

Evaluation… Satisfaction of clients, Health Service Provider & GPs Recruitment & marketing Workforce development Organisational development Governance

Lessons Learnt - Coaches Skill development over time Management of competing demands (perhaps a dedicated coach??) Coach co-ordinator CHS restraints of pm. Behaviour change is difficult - psychosocial issues major influence.

Client recruitment – what worked Dept of Vet Affairs – time to engage! HBA – no money! Men like the model GP engagement – Divisions of GP

Lessons Learnt - clients Appreciate regular contact Motivation enhanced Use of , internet is growing

Consumer participation strategy Manageable strategy – use of resources Focus groups Targeted focus groups e.g. (website, men)

Lessons learnt - GPs Long time to engage Build credibility WIIFM

Working with consortium Forming, storming, norming…… Understanding perspectives Broad view… Want evidence Needs leadership at all levels of management

Organisational case study Community Health Service Workforce development (skills, broader view, competing demands) Increased multi-disciplinary communication Information Management – reports to referrers/GPs Management support Reward systems Resources Change management – lengthy process

Sustainability…? HARP ???