การสนับสนุนการดูแลตนเอง Self-Management Support

1. การสนับสนุนการดูแลตนเองSelf-Management Support ประณีตศิลป์ เชาวน์ลักษณ์สกุล

3. ขอบเขตเนื้อหา • ความหมาย • ความแตกต่าง (What is a difference?) • Self management (SM) VS SM Support • Traditional Health Education VS SM Education • What are the existing SMS? • How are the SMS effect DM outcomes? • What are the predictors of SM? • What are the barriers of SMS?

4. Definitions Self care VS self-management VS self -management Support • Self care หมายถึง กิจกรรมที่แต่ละบุคคล ครอบครัว และชุมชน ปฏิบัติเพื่อสร้างเสริมสุขภาพ ป้องกันโรค ควบคุมการกำเริบของโรค หรือรักษาสุขภาพ means activities that individuals, families, and communities undertake with the intention of enhancing health, preventing disease, limiting illness, and restoring health’’ (Clark, 2008).

5. Definitions Self management VS Self Management Support • “Self-management” “Day-to-day tasks that an individual must understand to control or reduce the impact of disease on physical health status. At home management tasks and strategies are undertaken with the collaboration and guidance of the individual’s physician and other health care providers” (Clark et al, 1991).

6. Definitions • “A treatment that combines biological, psychological, and social intervention techniques, with a goal of maximal functioning of regulatory processes” (Nakagawa-Kogan et al., 1988).

7. Definitions “the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a long term disorder’’ (Barlow, 2001; Department of Health England, 2005).

8. Definitions • Increasing the individual’s consumer’s capacity to engage in “activities to promote (their own) health” and empowering them to monitor and respond appropriately to the signs and symptoms related to their disease and as thus minimize the negative impact on their level of “functioning, emotions, and interpersonal relationships (Ermel, Crombie, Ham, & Bendigo Health Care Group).”

9. Definitions • “Self-management support” “activities in the clinic that prepare and empower patients to have a central role in their health care, including goal setting, action planning, problem solving, and follow-up” (Wagner, et al., 2001). “the process of making multi-level changes in health care systems and the community to facilitate patient self-management (Glasgow RE. et al, 2003, Rothman AA & Wagner EH., 2003 cited in Coleman & Newton, 2005).

10. Definitions • “Inter-disciplinary group education, based on the principles of adult learning, individualised treatment and case management theory” (Alderson et al., 1999).

11. Definitions • “Self-management support” 1. กิจกรรมหรือโปรแกรมที่จัดขึ้นในคลินิกเพื่อเตรียมหรือเสริมกำลังให้ผู้ป่วยมีบทบาทสำคัญในการดูแลสุขภาพของตน อาทิ การตั้งเป้าหมาย แผนปฏิบัติการ การแก้ไขปัญหา และการติดตาม (Wagner, et al., 2001). 2. กระบวนการของระบบบริการสุขภาพและชุมชนที่จะกระตุ้นให้ผู้ป่วยดูแลตนเอง (Glasgow RE. et al, 2003, Rothman AA & Wagner EH., 2003 cited in Coleman & Newton, 2005).

12. Definitions • การสอนสุขศึกษากลุ่มระหว่างสาขาวิชาชีพ บนหลักการเรียนรู้แบบผู้ใหญ่ เฉพาะรายบุคคล และการจัดการรายกรณี (Alderson et al., 1999).

13. A concept analysis of SM Reaction of diagnosed Reactions to being diagnosed with a long-term condition are unpredictable. • Self efficacy • Resource use • Collaboration • Education • Problem solving and decision-making • Goal setting and monitoring • Empowerment • Development of competencies that allow people to gain control • Improved health outcomes • Increased self-confidence (Embrey, 2006)

14. What is a difference? SMS Education • Diabetes Education (Didactic Education) • What is taught ? • How are problems formulated? • Relation of education to the disease • What is the relationship between patient and health professionals? • What is the theory underlying the education? • Who is the educator? • What is the goal?

15. Table 2. Comparison of Traditional Patient Education and Self-management Education (Bodenheimer, Lorig, Holman, & Grumbach, 2002)

16. Table 2. Comparison of Traditional Patient Education and Self-management Education (Bodenheimer, Lorig, Holman, & Grumbach, 2002)

17. Table 2. Comparison of Traditional Patient Education and Self-management Education (Bodenheimer, Lorig, Holman, & Grumbach, 2002)

18. Table 2. Comparison of Traditional Patient Education and Self-management Education (Bodenheimer, Lorig, Holman, & Grumbach, 2002)

19. Table 2. Comparison of Traditional Patient Education and Self-management Education (Bodenheimer, Lorig, Holman, & Grumbach, 2002)

20. Table 2. Comparison of Traditional Patient Education and Self-management Education (Bodenheimer, Lorig, Holman, & Grumbach, 2002)

21. Table 1. Comparison of Traditional and Collaborative Care in Chronic Illness

22. Table 1. Comparison of Traditional and Collaborative Care in Chronic Illness

23. Table 1. Comparison of Traditional and Collaborative Care in Chronic Illness

24. Table 1. Comparison of Traditional and Collaborative Care in Chronic Illness (Bodenheimer, Lorig, Holman, & Grumbach, 2002)

25. Table 1. Comparison of Traditional and Collaborative Care in Chronic Illness (Bodenheimer, Lorig, Holman, & Grumbach, 2002)

26. Table 1. Comparison of Traditional and Collaborative Care in Chronic Illness (Bodenheimer, Lorig, Holman, & Grumbach, 2002)

27. DM Management Skills • Problem solving • Problem definition, generation of possible solutions including the solicitation of suggestions from friends and health care professionals, solution implementation, and evaluation the results • Decision making • Resource utilization • Forming of a patient/health care provider partnership • Taking action (Lorig, 2003)

28. DM Management Skills “ไม่ให้แค่ปลา แต่สอนวิธีการหาปลา” “วิเคราะห์ สังเคราะห์ ตัดสินใจ > รู้จำ”

29. Classifications of SM • Knowledge or information • Life style behaviors (diet, physical activities) • Skill development (skill to improve glycemic control e.g., self – monitoring of blood glucose) • Skills to prevent and identify complications (foot care) • Coping skills (to improve psychosocial function e.g., intervention that used empowerment techniques or promoted relaxation or self-efficacy) (Norris, Lau, Smith, Schmid, & Engelgau, 2002)

30. Long term, continuous FU, supporting

31. The Predictors of SMS • Meta-regression • Duration of contact time between educator and patient was the only significant predictor of effect with 23.6 hours of contact time needed for each 1% absolute decreased in GHb (Norris, Lau, Smith, Schmid, & Engelgau, 2002)

32. SMS Processes Problem-based solving Glycemic control Goals setting & Plans Patients SM Behaviors • Nutrition • Exercise • Medication • Self-monitoring • Problem solving • Risk reduction • Psychosocial adjustment • Education& Empower • Topics-ADA • Types • Group • Individual • Group discussion • Providers • Physician • Nurses • Dietician • Pharmacist • Physiotherapist • Others • Supports • FU-Phone/Visit • Resources use Evaluation & Feedback

33. รูปแบบ self-management support • The Stanford and Flinders Programs - are complimentary approaches to chronic condition self-management (CCSM). - developed by Kate Lorig and associates at Stanford University – USA. - It has been well researched for over 20 years. http://www.risen.org.au/CDSM/CDSM_Program_Flinders.asp

34. รูปแบบ self-management support • The Stanford and Flinders Programs - กิจกรรมสำคัญ ได้แก่ -a group setting - using peer leaders and standardised structured sessions - Individuals share experiences and learn generic self-management skills and strategies that will help them help themselves. http://www.risen.org.au/CDSM/CDSM_Program_Flinders.asp

35. รูปแบบ self-management support • The Flinders Program - was developed by Malcolm Battersby and associates at the Flinders Human Behaviour and Health Research Unit (FHB&HRU) in Australia. - is a one-on-one model, with interventions /actions agreed between clinician and patient and tailored to the identified needs and priorities of the individual. http://www.risen.org.au/CDSM/CDSM_Program_Flinders.asp

36. รูปแบบ self-management support • The Flinders Programis underpinned by:- - cognitive behavioural therapy (CBT) principles. - provides a structured, patient centered framework for collaborative problem definition, goal setting, care planning and review and offers a generic approach to chronic condition self-management that can be applied to a wide range of health conditions. http://www.risen.org.au/CDSM/CDSM_Program_Flinders.asp

37. A five-component heuristic model (Glasgow, et al., 2002)

38. The Big Bad Sugar War (BBSWAR) Figure 1. St. Peter Family Medicine Residency Program. Self-Management Goal Cycle with the Big Bad Sugar War approach to setting goals. (Langford, Sawyer, Gioimo, Brownson, & O'Toole, 2007)

39. Background: find out about the patient, how they view their disease, what is concerning them, what support they have at home, how well they are managing, and so forth. • Barriers: explore what has not worked well in the past for the patient and what makes it difficult to make lifestyle changes such as healthy food choices and physical activity. • Successes: focus on what a patient has done well, and celebrate their accomplishments no matter how small they may seen. (Langford, Sawyer, Gioimo, Brownson, & O'Toole, 2007)

40. Willingness to change: once you know the patient’s background and have explored barriers and celebrated successes, find a behavior that he or she is willing to change. • Action plan: coach the patient to set a specific and detailed goal that is important to him or her. Write down the goal, and give the patient a copy. • Reinforce and remember: conduct telephone follow-up to provide encouragement and motivation. Refine, redefine, or stretch the goal at the next MA planned visit, provider visit, or group visit. It is vital for the health care team to remember patient goals and incorporate them into conversations at each visit. (Langford, Sawyer, Gioimo, Brownson, & O'Toole, 2007)

41. Goal setting Supports • Planed visit = routine health checks and laboratory tests prior to traditional individual appointments • Mini-group medical visits = a provider and medical assistant meet with 3 patients at one time • Open office group visits = 7-12 patients attend 2-hour sessions staffed by a provider (Langford, Sawyer, Gioimo, Brownson, & O'Toole, 2007)

43. Self-management support • Assessment, not only knowledge but needs to know more about what patients value and what they do. • Advice, needs to link to scientific evidence, not provider biases • Agree, on shared goals • Assist, by identifying barriers and problem-solving to deal with them • Arrange, a specific follow up plan

44. Thank you for your attention