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Supporting Chronic Disease SelfManagement:

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Kate Warren Spencer Gulf Rural Health School. LIFE course: ... Used with 3115 interventions patients in SA Health Plus CCT (1997-99) ... – PowerPoint PPT presentation

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Title: Supporting Chronic Disease SelfManagement:


1
Supporting Chronic Disease Self-Management
  • A collection of ideas from Eyre Peninsula

Collaborative ProjectsEPDGP, ERHS, SGRHS
2
earlier days of chronic illness care
  • Colleen Prideaux
  • Neville Carlier
  • Jerome Connolly
  • Paul White
  • John Arthurson
  • Michael Taylor
  • Glenys Bisset
  • Jim Collins
  • service coordinators
  • Stan McKenzie
  • Peter Morton
  • Ian Matthews
  • David Mills
  • Peter McDonald
  • Ray Blight
  • Graham Fleming
  • Malcolm Battersby
  • Shiam Agawal
  • Les Kropinyeri
  • Marg Nihill
  • Marion Holden

3
demand on health systems
  • rising incidence of chronic and complex illness
  • burden is preventable and/or manageable
  • emergence of chronic care v/s acute care models
  • self-management is now being adopted by
    governments (including Australia) as a key
    strategy in managing the impact of chronic illness

4
collaboration context
  • (1996-2000) COAG coordinated care trial on Eyre
    Peninsula -1850 patient controlled trial
  • (2001-2004) Sharing Health Care SA chronic
    disease self-management demonstration project in
    3 sites SGRHS
  • 2006-2007 CCSM resource collaboration
  • 2007-2010 implementation of the model

5
progress to date
  • COAG coordinated care trials 1996-2000
  • patient centred care planning goal setting
    (PIH)
  • emergence of self-management factors/implications
  • new EPC item numbers
  • health benefits cost saving evidence from COAG
  • National Sharing Health Care initiative
  • Stanford CCSM course
  • adaptation of CCSM course for Aboriginal people
  • emergence of the self-management strategy

6
opportunities
  • new item numbers for integrated care
  • national chronic illness strategies (cf managed
    care in the US and EPP in UK)
  • workforce changes and the emergence of team
    careNB medical training in problem based
    approaches to care
  • the baby boomer phenomenonthey are more aware
    and demanding consumers
  • need to gather definitive evidence of the
    efficacy financial sustainability new
    approaches to care

7
the future
  • completion of current project
  • build on resource kit for rural GP and
    communities
  • towards a 3 year training programme run via
    Divisions (ie GPs as the focus for the CCSM
    process)

8
key collaboration components
  • Graham Berry - CDSM resource kit
  • Kate Warren Example of case study
  • LIFE course
  • Malcolm Battersby - Flinders Model future

9
CDSM resource kit
  • Graham Berry EPDGP
  • CDSM resource kit

10
Project Aim
  • Produce a resource for
  • General Practitioners
  • Health professionals
  • Health services
  • Community Groups
  • That reports the experiences in supporting CDSM
    on Eyre Peninsula over the last decade.

11
Experiences have come from
  • SA HealthPlus
  • Sharing Health Care Initiative
  • CDSM demonstrations projects
  • Other research projects
  • Shape up for Life
  • Look, Think, Act
  • SMaRT
  • Private and public health service providers

12
Structure of Resource
  • Guide
  • Theory
  • Tools and Strategies
  • Case Studies
  • Learnings
  • Models
  • Implementation Guides
  • CDROM
  • Web page

13
CDSM Support Case Studies
  • General Practice
  • Aboriginal Health Service
  • Care Plan Support Centre
  • AHW in General Practice

14
CDSM Support Case Studies
  • Community participation
  • Designing CDSM support
  • Localisation of the Stanford CDSMP
  • A preventative program for students
  • Community Development
  • Volunteer health information and resource centre
  • Community Health Service

15
CDSM Support Case Studies
  • Research
  • Preventative strategies
  • Use of the Internet
  • Advocacy
  • Providing the required health services
  • Training health service providers

16
Living Improvements for Everyone (LIFE)
  • Kate Warren Spencer Gulf Rural Health School
  • LIFE course
  • Adaptation of Stanford SM 6 week course to suit
    Aboriginal people

17
Stanford Model of CDSM
  • Moving Toward Wellness
  • Responsibility for own health ? involvement in
    health care
  • Peer Education modelling
  • SM skills taught
  • Goal setting and problem solving
  • Symptom management
  • Safe use of medicines
  • Healthy eating
  • Physical activity
  • Communicating effectively with health workers,
    family carers
  • Outcomes include
  • Improved quality of life
  • Less hospitalisations
  • Less emergency visits to GPs and emergency
    departments

18
LIFE Course
  • Adapted for Aboriginal people - PWHS
  • Major changes include
  • New grief and loss activity
  • Order of activities
  • Language Australianised
  • Examples made relevant
  • Artwork included relevant to topics

19
  • Front cover
  • People looking after themselves and each other

Session 1 Keeping active
20
Session 2 Relaxation, spirituality, grief and
positive thinking
Session 3 Healthy eating and bush tucker
including goanna, witchetty grubs, honey ants,
quandongs, wild figs, bush tomatoes, bush bananas
and bush berries
21
Session 4 Communication, communities and family
Session 5 Bush medicine, western medicine,
doctors, health care workers, people and patients
Session 6 Family and families, camps, shelter
and water
22
Flinders Model
  • Malcolm Battersby - Flinders Model
  • The future of Chronic Disease Self-Management

23
Self-Management Support for Chronic
ConditionsThe Flinders Model
  • Flinders Human Behaviour and Health Research Unit
  • Flinders University
  • Malcolm Battersby

24
Background - SA HealthPlus
  • SA HealthPlus Coordinated Care Trial
  • 1997 1999
  • Patients with chronic and complex illnesses
  • 8 projects in 4 regions of South Australia

  • Hypothesis
  • Coordinated Care would improve health outcomes
    for the same or less cost
  • Battersby et al, BMJ, March 2005

25
BACKGROUND -Year 1 review
  • Some patients did not require Coordinated care
    because they were already good self managers
  • Service Coordination could deliver improved
    outcomes but not within existing resources
  • Patients who benefited did so by becoming better
    self managers assisted by service coordinators
  • Self management was not defined or
    operationalised

26
Learning
  • Self-management capacity is modulated by the
    illness and personal attributes as well as
    attributes of health providers and cultural and
    social factors
  • Self-management ability needs to be assessed
    before the right intervention is offered
  • Not all consumers need self-management
    intervention and those who do will respond to a
    wide range of learning methods, some group, some
    individual

27
Six Principles of Self-Management
  • 1. Know your condition
  • Have active Involvement in decision making with
    the GP or health workers
  • Follow the Care plan that is agreed upon with
    the GP and other health professionals

28
Six Principles of Self-Management
  • 4. Monitor symptoms associated with the
    condition(s) and Respond to, manage and cope
    with the symptoms.
  • 5. Manage the physical, emotional and
  • social Impact of the condition(s) on your life.
  • 6. Live a healthy Lifestyle

29
Flinders Model
  • Outcomes based
  • Generic
  • Motivational
  • Medical with self-management (Holistic)
  • Patient-centred
  • Communication
  • Coordination

30
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34
Problems and Goals Approach
  • Adapted from the therapeutic assessment
    intervention used in the behavioural
    psychotherapy field (Isaac Marks)
  • Used with 3115 interventions patients in SA
    Health Plus CCT (1997-99)
  • 60 of patients improved their problem rating
    score
  • Up to 60 made progress with goals
  • Battersby M, Ask A, Markwick M, Collins J.- A
    case Study using the Problems and Goals
    Approach Aus Journal Primary Health 2003 7(3)
    45-48
  • Battersby M et al - Health Reform through
    Coordinated careSA HealthPlus. BMJ
    2005330662-6

35
Care Plan
  • Identified issues from PIH and CR
  • Identified issues from PG assessment
  • Lists preventative medical, allied health,
    psychological and self management services or
    actions
  • Management Aims
  • Interventions
  • Responsibilities
  • 12 month planned appointments / tests etc
  • Sign off

36
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37
Flinders Model
  • Outcomes based
  • Generic
  • Motivational
  • Medical with self-management (Holistic)
  • Patient-centred
  • Communication
  • Coordination

38
Summary
  • Self-management support is based on an
    operational definition of self-management
  • Outcome measurement is integral to the clinical
    process
  • PIH, CR and PG enables measurement of patient
    self-management and competency assessment of
    clinicians/students for individuals and
    populations ie as a KPI

39
Future Developments
  • Australian Better Health Initiative
  • National undergraduate curriculum in chronic
    condition self-management
  • Education, upskilling of the national primary
    care workforce
  • Electronic care planning

40
Contact details
  • Flinders Human Behaviour and Health Research Unit
  • Sharon.lawn_at_fmc.sa.gov.au
  • Malcolm.Battersby_at_fmc.sa.gov.au
  • Ph (08) 8404 2323 Fax (08) 8404 2101
  • http//som.flinders.edu.au/FUSA/CCTU/Home.html

41
THANK YOU
42
POCT
EPC Items
PIH Model
Chronic Condition Care
Patient Centred Care Plans
LIFE Program
Outcome focus
43
compression of morbidityFries, J
44
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45
What I know about my illness is (PIH
scale)9 point scale-higher is better(very
significant over time- p0.000)
46
Very significant (p 0.001)
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