Chronic disease selfmanagement education programs

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Chronic disease self-management education
programs Where should Victoria go?
Joanne Jordan BA, BSc, MPH Research Fellow AFV
Centre for Rheumatic Diseases The University of
Melbourne jjordan_at_unimelb.edu.au
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Focus

• To determine the value of and potential for the
  integration of chronic disease self-management
  education programs into the care continuum
• International policy review
• Local (Australian centric) policy review
• Interviews with key stakeholders, GPs and
  consumers

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Background

• Impact of chronic disease in Australia
• gt70 of disease burden
• Health system geared to acute conditions
• Deficiencies in patient care
• Lack of education support for self-management
• Lack of ongoing and proactive care

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Background

• Seeking alternative ways to improve treatment
  quality and patient satisfaction
• Policy shift
• Medical didactic model ? Patient centred care

Chronic disease self-management has emerged as an
important component within the patient centred
care approach
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What is self-management?

• Consideration of
• the individual with the chronic condition
• their family and carers
• health professionals
• Involves a holistic approach and acknowledging
• medical
• psycho-social
• cultural aspects
• Aims to empower individuals

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Putting self-management into context

• Self-management is 1 component within chronic
  disease management
• Focus on formal self-management education
  programs to help assist patients to engage in
  self-care

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Self-management education interventions

• Stanford CDSMP
• Group based format
• Conducted over 6 weeks, 2.5 hours per week
• Led by health professionals/peer leaders
• Highly structured course

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Policy focus

• National Chronic Disease Strategy (NCDS)
• Self-management identified as one of four key
  action areas
• Self-care is important to manage chronic disease
  and supports need to be implemented at all levels
  of the health system
• Need for programs, initiatives to develop and
  enhance self-management

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Program focus

• Sharing Health Care Initiative Demonstration
  Projects
• 36.2 million initiative (2001-2004)
• Explored suitability of chronic condition
  self-management models within Australian setting

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Policy focus cont

• Australian Better Health Initiative (COAG)
• 500 million over 4 years for chronic disease
  prevention management
• Focus on programs to actively encourage patients
  to self-manage their condition
• 14.8 million over 4 years to fund awareness
  education self-management of arthritis and
  osteoporosis

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The way forward?
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• Integration of CDSMP into the care continuum

Lessons to be learnt from Policy program
trends at the international level
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International trends in CDSMP

• Focus on generic programs
• UK government leader in field
• Expert Patients Programme
• Anglicised version of Stanford CDSMP implemented
  throughout National Health Service
• 40 million spent since 2001
• Canada, Germany, Sweden, Denmark
• less advanced re policy and programs

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Self-management policies

• Stand alone
• e.g. Expert Patients Programme (UK)
• Incorporated as part of a chronic disease
  management strategy
• generic e.g. British Columbia (Canada)
• disease specific e.g. USA Arthritis Action Plan
• Legislation
• e.g. Germany
• Disease Management Programs

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International challenges with the integration of
CDSMP

• Recruitment of consumers
• Engagement with health professionals
• Workforce sustainability

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Recruitment of consumers

• Recruitment and retention of a critical mass of
  individuals has posed challenges
• Social marketing
• time and resource intensive
• reach a small proportion of the target population
• concern that some programs might increase health
  disparities
• EPP moving to Community Interest Company
• develop, market and deliver new and diverse s-m
  programs

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Health professional engagement

• Health professionals crucial to the viability of
  programs
• Primary conduits for patients with chronic
  conditions to enter self-management programs
• Gatekeepers to the health system

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Barriers to health professional engagement

• Wariness of new initiatives
• Lack of structured and uniform referral mechanism
• Uncertainty of benefits to patients
• Need for local evidence relating to patient
  outcomes and sustainability of programs

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Workforce Sustainability

• Complexities with peer led programs
• Position of peer leaders and trainers in the
  health sector
• Administration/resources/support

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Summary Issues at the international level

• Integration of CDSMP into the health sector is in
  its infancy
• Recruitment and retention of a critical mass of
  individuals (patients and leaders) has posed
  challenges
• Programs only reach a small proportion of the
  target population

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Summary Issues at the international level

• Engagement with health professionals
• Translation of community programs to the health
  sector
• Workforce issues

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Local policy context
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Australia Policy Initiatives

• Strong policy direction
• National Chronic Disease Strategy
• Sharing Health Care Initiative Demonstration
  Projects
• Australian Better Health Initiative

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State policy overview
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Comparison of State Policies

• HARP
• Early Intervention in Chronic Disease in
  Community Health Services Initiative

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What is the extent of integration of CDSMP within
Australia?

• Short term trials or demonstration projects
• e.g. Sharing Health Care Initiative

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Sharing Health Care Initiative (SHCI)

• 1999 Enhanced Primary Care Package
• Shift from acute to primary care
• SHCI considered a range of generic CDSM models
  for integration into wider health care system
• 12 demonstration projects
• (8 focused on for SHCI evaluation)

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Sharing Health Care Initiative (SHCI)

• Evaluation (DHA)
• A lot enthusiasm contribution
• GP engagement limited
• Inability to capitalise on MBS / EPC items
  relating to chronic disease to assist with
  referral process
• Social marketing strategies predominant

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SHCI Evaluation Barriers Enablers

• Barriers to patient participation
• dissemination of information
• transport
• ill health
• too busy/disinterested
• Successful strategies
• targeted specific groups and
• modified content/delivery to suit needs e.g. CALD

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Integration themes international local

• Profile of self-management needs to be raised
  within health sector
• Engagement of health professional is essential
• Structured referral pathways and networks across
  the care continuum are required
• Programs need to be flexible in both content and
  delivery

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To integrate or not to integrate?

• Self-management has the potential to make a
  profound contribution to health and wellbeing
  across the care continuum
• However it is currently unknown if programs are
  meeting the needs of consumers health
  professionals in terms of
• content,
• accessibility, and
• reach

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Feedback at the grassroots level Consultation
with Victorian GPs Consumers
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Qualitative study

• Methods
• Interviews 17 GPs and 43 consumers
• Purposeful sampling employed
• Consumers GPs, Rheumatologists and existing
  research database
• GPs recruited via 3 Div of General Practices
  (Northern, Dandenong South Gippsland)

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Common Barriers (GPs Consumers)
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Barriers (GPs)
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Common Enablers (GPs Consumers)
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Enablers (GPs)
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Enablers (GPs)
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Enablers (Consumers)
Key factor for consumer participation is
recommendation from health professional
Well I think all GPs should know about it and
then the GP, if they know their patient well
enough and have a good rapport should be able to
say I think this should benefit you and should
encourage you to go along really that is the
basis for that, you go to a GP who is the first
port of call
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• What needs to be done to take
  self-management forward?

SELF-MANAGEMENT SERVICE IMPROVEMENT FRAMEWORK
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Framework 4 elements
Health service delivery
Self-management interventions
Community
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Policy integration

• Key actions

• Overarching strategy outlining consistent
  approach to self-management across health sector
• Recommendation of specific self-management
  interventions to be utilised across care and
  disease continuum
• Links between NCDS and other state initiatives to
  prioritise self-management within the health
  sector

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Health service delivery

• Key actions

• Training education of all healthcare providers
  in self-management principles
• Multiple referral pathways
• Sustainable workforce
• Resources

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Self-management interventions

• Key actions

• Flexibility in delivery, content and form
• Local community context
• Feedback mechanism between program providers and
  health professionals on patient progress
• Evaluation/Quality assurance

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Evaluation Quality Assurance

• Health Education Impact Questionnaire (heiQ)
• Piloted as national quality and monitoring system
  across self-management programs in Australia
• Broad range of self-management education
  interventions
• Benchmark and provide national data on
  effectiveness of programs

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Community

• Key actions

• Health promotion tailored strategies
• Variety of program formats
• Local settings

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Framework 4 elements
Health service delivery
Self-management interventions
Community
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Policy Recommendations
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Acknowledgements

• Joan Nankervis
• Bella Laidlaw
• Dr Caroline Brand (principal investigator)
• Dr Richard Osborne (principal investigator)

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Thank you jjordan_at_unimelb.edu.au