Title: Chronic Condition SelfManagement Improving Management of Chronic Conditions in Older People
1 Chronic Condition Self-Management Improving
Management of Chronic Conditions in Older People
- ANHECA 23RD Annual Conference
- Adelaide, Wednesday 28 October 2004.
- John Lawrence, Research Manager,
- Flinders University Human Behaviour And Health
Research Unit - and
- Vee Pols, Senior Occupational Therapist,
- Resthaven Marion Therapy Services
2Overview
- Problems w. Traditional Therapy Service Model
- Solution Chronic Condition Self-Management
- New Program for Resthaven Marion
- Success Lessons - Evaluation Evidence
- Future Developments
3Traditional Therapy Service Model_at_ Resthaven
Marion
- Unlimited growth in service demand
- Client expectation of unlimited service access
- Client dependency clogging the service
- No increased budget
- Need for measurable outcomes from funders to
secure ongoing funds - An Impetus for Change
4Acute Chronic
- Ongoing
- Incurable
- QOL highly dependent on Pts SM decision making
- QOL highly dependent on ongoing support services
- Pt often has more knowledge
- Short term goals to meet long term outcomes
- Compliance and self reliance expected
- Episodic
- Cure expected
- QOL highly dependent on professional care
- QOL highly dependent on short term services
- HP generally the expert
- Short term goals
- Compliance expected
5What is Chronic Condition Self-Management ?
- Involves the person with the chronic disease
- engaging in activities that protect and promote
health, - monitoring and managing of symptoms and signs
of illness, - managing the impacts of illness on functioning,
emotions and interpersonal relationships and - adhering to treatment regimes.
- Centre for Advancement in Health (1996)
6Kate Lorig Stanford Uni
- CDSM is about enabling participants to
- make informed choices
- adapt new perspectives and generic skills that
can be applied to new problems as they arise - practice new health behaviours
- maintain or regain emotional stability
7SA Coordinated Care Trial 1997
- Patients who benefited did so by becoming better
self managers assisted by service coordinators
PARTNERSHIP S.M. DEVT - Some patients did not require coordinated care
because they were already good self managers
S.M. CAPACITY ASSESST - Service Coordination could deliver improved
outcomes but not within existing resources
SERVICE SHIFT - Self management not defined/operationalised
8SA Coordinated Care Trial 1997
- Self management capacity is affected by
- the illness
- personal attributes
- attributes of health providers
- cultural and social factors
- Self management ability needs to be assessed
before the right intervention is offered - Not all consumers need self management
intervention - Those who do respond to a wide range of learning
methods, some group, some individual
9New Principles of Effective Management of Chronic
Conditions
- Improved partnership between service providers
and clients - Personalised written care plan
- Tailored self-management education
- Planned follow up
- Monitoring of outcomes and adherence to treatment
plans
10The Flinders Model of Chronic Condition
Self-Management (CCSM)
- Partners In Health Program
11Six 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 professional
12Six 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
13Principles of Self-Management
Knowledge
Involvement
Care Plan
Monitor and Respond
Impact
Lifestyle
14Themes from the Literature
- Structured self management can be effective in
changing behaviour and improving health outcomes
for patients with chronic illness - Increased knowledge does not necessarily lead to
behaviour change - Effective self management programs are based on
social learning and behavioural theories .
15Themes from the Literature 2
- Knowledge and skill motivation and confidence
creating environments to prevent relapse - Tools (eg. Symptom Action Plans and diaries) are
effective in increasing responsibility for
managing the illness - Self management can reduce crises ie.
hospitalisation and emergency visits
16Flinders Model of CCSM Tools/Interventions
- PIH (Partners in Health) Scale
- Cue and Response Form
- 3. Problem and Goals
- 4. Care Plan
- 5. Partners Handbook
- 6. Symptom Action Plan (SAP)
- 7 Monitoring Diary
- 8 . Doctor visit Checklist
17Patient Responses
- I am motivated to look after myself. I now feel
confident about asking my GP questions. I plan
ahead and am more thoughtful about my condition.
I dont sit around feeing sick these days, I look
for solutions. - I dont drink as much as I did before. I
exercise regularly and take my time - I gauge
myself. I am more aware that I should live a
healthy lifestyle.
18Chronic Condition Management
- The patient
- The family/carer
- The clinician
- The community
- The health care system
- The provider organisation
19Benefits of CCSM
- Improved health
- Reduction in hospital admissions, unplanned GP
visits and emergency visits - Increased self efficacy and satisfaction
- Better clinical outcomes
- More efficient clinical practice
- Cost savings?? Cost shifting??
20Partners in Health Scale
- Measures self-management capacity
- Completed by the patient/client independently of
the GP or health professional - Contains 12 questions covering the 6 principles
of self-management - Individual can complete the Partners in Health
Scale prior to consultation - PIH Scale takes about 5-10 minutes to complete
21Cue Response Interview
- A tool for GP/health professionals
- Covers the same 12 questions in the Partners in
Health Scale - A series of open ended cues enables the PIH
questions to be explored in greater depth - Answers can be scored
- Checks assumptions
22Cue Response Interview
- AREAS FOR DISCUSSION
- When both parties have rated the question on the
high end of the scale - When scores differ markedly on any question
- AGREEMENT ON ISSUES
- establish which identified issues the
patient/client wishes to address and what
interventions may be appropriate - THESE BECOME THE SELF-MANAGEMENT PLAN
23Self-Management Care Plan
- Lists agreed self management issues, priority of
actions, who is responsible - Highlights clients own LIFE Problem and Goal
rated 0-8 - Compiles preventative medical, psychological
self management services or actions - Creates Services Plan for 12 months to support
- CCSM
-
24National Sharing Health CareInitiative
- 8 demonstration projects one in each state and
territory - Pika Wiya, Daruk, Katherine West, Danila Dilba
- Flinders CCSM education 2 day training, 3 hour
overview, train the trainer, accreditation - Allows further refinement and validation of PIH
25Stanford / Lorig CDSM Program
- Training clients in self-management
- Six week / 2 ½ hrs per wk
- Leaders - peer hlth professional (as peer)
- 5 10 people per group
- Covers ST goal-setting, self-talk, relation,
exercise, social contact etc.
26Steps to Change for Resthaven Marion
- 1. Rethinking goals to demonstrate measurable
outcomes - A focus on clients goals not service
providers goals - 2. Redesigning documentation
- Assessment forms
- Outcome forms
- 3. Training in Stanford programs
Arthritis/Chronic Conditions Self-Management - 4. Training in Flinders Chronic Conditions
Self-Management Tools
27RMTS - Clientele
- Generally 60 years (mean age 78 years)
- Multiple physical conditions psychosocial
issues - 70 female
- Some ethnicity issues e.g. NESB
- Generally from Marion local Council area
- Long-term Housing Trust areas
- Limited education/knowledge about health systems
28Pilot CCSM Program Group
- 30 clients recruited August 2001 May 2004
- Surge in demand in 2004 following promotion to
GPs - Age range 37 94
- 80 female
- Primary diagnosis - 13 (43) musculo-skeletal
condition.
29RMTS Referral Sources
- General Practitioners
- Self-refer (MTW only)
- Hospitals in southern area
- Community Agencies e.g.
- Metro Domiciliary Care
- Community Aged Care Packages
- Respite Services
30RMTS Service Mix
- 5 Supported accommodation at Resthaven Marion
- 95 Community - full range from living
independently to living in other supported
accommodation with maximum support from community
services
31RMTS Self-Management Model
- Initial interview use Partners in Health Cue
Response Problems Goals Resthaven TS plan of
Treatment to record - Clients goals
- Therapy interventions
- Outcomes
- Stanford program (6 weeks)
- 6-10 weeks later phone contact - review with
Partners in Health Cue Response Problems
Goals - Clients may be invited to repeat Stanford program
- Review as above 6-10 weeks later
32(No Transcript)
33CCSM Program Achievements
- Client
- Increased knowledge about impact of health
behaviours on quality of life - Client insight about mind over body control
- Building self-efficacy
- Increased trust/confidence to self-disclose and
adopt health partner role vs. health dependent
role - Health Professional
- Decreased dependency on service
- New health promoting behaviours e.g. short-term
goal setting, monitoring health symptoms, regular
exercise, increased social contact
34CCSM Improvement Evidence
35CCSM Case Study
- This 68 year old woman lives alone and was very
attached to a small old dog. She has no
immediate family and contact with friends was
infrequent. - Main chronic conditions are osteoarthritis and
obesity. - At the start her main symptoms were reduced
mobility, chronic pain in spine and knees,
fatigue and breathlessness. She had a phobia
about making phone calls. - During the program she developed the ability to
identify and achieve short-term goals to eat a
more healthy diet, walk the dog and write letters
to friends. - At 8 weeks after completing the program,
general activity levels had improved, she walked
the dog regularly and breathlessness and fatigue
were greatly reduced. She had initiated
counselling to overcome her phobia with making
phone calls. - At 12 months she appeared to have lost weight
and she reported she was in regular phone contact
with her network of friends. She had coped with
the loss of her aged dog and had recently
obtained a new dog which she was taking out for
regular walks.
36Client Feedback
- Im more confident to think positive and keep
active. (Female 83 yrs) - With input from each person there it helped me
to understand a lot of the way our bodies, minds
and emotions interact with one another. (Female
76 years) - faith building (Male 65 yrs)
- I feel very happymuch improved back pain and
much improved understanding about (the treatment
of) diabetes and pain. (Female 69 yrs)
37Evolution of a CCSM Program at Resthaven Marion
- 1. Traditional Therapy Service Model
- 2. Chronic Conditions Self-Management model
offered in-house to clients from August 2001 - 3. Promotion to General Practitioners in Marion
area July 04 - 4. Transition phase commencing Jan 2004 to
implement Common Point of Entry for chronic
Cardiac and Respiratory referrals from FMC RGH
NHS to participating Therapy Services in the
South
38Future Developments
- Collaboration between 3 major hospitals in
Southern Region and Southern Therapy Services re
Cardiac Respiratory patients - Hospital will screen and select for
- Referral to Common Entry at MTS
- Referral to MTS and other Therapy Services for
- Assessment using Flinders CCSM tools
- Stanford program
- Traditional therapy programs
- Referral to other community agencies
39The Take Home Message
- Self-Management is rapidly becoming a key
strategy for managing service demand blowouts. - Flinders Model of Chronic Condition
Self-Management offers a powerful tool for
assessing and 1 to 1 support of CCSM - Stanford Model is useful for CCSM group training
- Resthaven Marion Therapy Services Model combines
Flinders and Stanford to create individual,
organisational and systems change.
40 41Partners In Health ProgramEvaluation 1997
70 (of patients) felt better able to cope with
life as a result of the Partners in Health (PIH)
Program. 75 interviewed considered support by
their GPs helped them to better manage their own
care 85 considered support offered by their
Service Coordinator in the partners process
assisted them to manage better
42PARTNERS IN HEALTH PROGRAMEVALUATION Cont.
75 of GPs stated that participation in the Pilot
had influenced patients to manage their health
much better or better 50 of GPs commented
that they had changed their management of
patients very much as a result of participation
in the Pilot and 25 considered they had changed
management of patients a little
43Principles of Collaboration
- Understanding of clients beliefs, wishes and
circumstances - Understanding of the family beliefs and needs
- Collaborative identification of problems and
goals - Negotiated agreed care plans, regularly reviewed
- Active follow up
44Enhancing Self-Management
- Assessment
- Partners in Health Scale and
- Cue and Response Interview
- Problems and Goals Assessment
- Care Plan
- Identification of Issues and Goal Setting
- Schedule services
- Monitor and Review
45Self-management
- Partnerships
- Holistic approach
- Proactive
- Adaptive and problem solving
- E mpowerment
46Self-Management Myths
- Self-management is SELF-TREATMENT
- Self-management is just a way to reduce the cost
of care by reducing services - Self-management means that visits to the doctor
are discouraged - Self-management means that there is an increased
risk of becoming unwell
47Problem Measurement
- Constant pain and discomfort leading to
irritability and angry outbursts resulting in
avoiding friends, family and doctors. - Rating Scale
- This problem interferes with my daily activities
- 0 1 2 3 4 5 6 7 8
- Does Not Slight Definite Often Severe
48Goal Measurement
- To use medication in prescribed way to assist me
to spend 2 hours 3 times per week socialising
with my family and friends outside of my home - Rating Scale
- My progress towards achieving this goal
- 0 1 2 3 4 5 6 7 8
- Complete 75 50 25 No
- Success Success