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of CHRONIC CONDITION MANAGEMENT

of CHRONIC CONDITION MANAGEMENT

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of CHRONIC CONDITION MANAGEMENT

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  1. THE FLINDERS PROGRAM™ of CHRONIC CONDITION MANAGEMENT FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT 1

  2. Welcome and Introductions Current Role Client Group Interest in Chronic Condition Management Expectations of the Workshop 2

  3. Day 1 Background & Evidence The Flinders Program Day 2 Review of Day 1 Additional Resources for Interviews (Stages of Change, Motivational Interviewing, Problem Solving) Volunteer Interview Planning for Practice Change The Program 3

  4. Aims To enable participants to: • Better understand effective chronic condition management including self-management • To understand and use the Flinders Program and tools • Plan for practice change 4

  5. Learning Objectives Conduct interview with a person using the Flinders Program to: • Assess Self Management capacity • Identify significant Problem & mid/long term Goal • Develop Flinders Program Care Plan 5

  6. The Flinders Program • Certificate of Competence • Part of a Quality Assurance Process • Submit a minimum of 3 care plans • Licence to use the Flinders Program 6

  7. History of Flinders Program Coordinated Care Trials SA Health Plus 1997-1999 Flinders Program developed Sharing Health Care Initiatives C’wealth Dept Health & Aging 2001 - 2004 Partners In Health scale trialed and standardised 2001 7

  8. Valuable Learnings: • Service Coordinators did not base their case management decisions on severity of condition/s but rather on how well clients self-managed • Therefore needed an objective way of assessing a patients self management knowledge, behaviour and barriers.

  9. National Chronic Disease Strategy(www.coag.gov.au) • Action Areas: • Prevention • Early intervention • Integration and coordination • Self-management • Priority recommendations • Clinicians receive education in self-management support • Self-management support is incorporated into routine clinical care 10

  10. Why Do We Need To Change? • Disease burden has changed towards chronic conditions around the world. Health systems have not. • Effective interventions exist for most chronic conditions, yet patients/clients do not receive them. • Current health systems are designed to provide episodic, acute health care and fail to address self-management, prevention and follow up. • Chronic conditions require a different kind of health care (mismatch). WHO Health Care for Chronic Conditions team (CCH) http://whqlibdoc.who.int/hq/2002/WHO_NMC_CCH_02.01.pdf 11

  11. What characterises : Acute… care models ? Chronic…

  12. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions 14 www.improvingchroncicare.org Improved Outcomes

  13. Self-Management: Who’s Responsible? Self-management - is what the person with a chronic condition does by taking action to cope with the impacts of their condition. Self-management support - is what others such as services, health professionals, family, friends and carers do to support the person to self-manage. They may do this by providing physical, social or emotional support to the person. 15

  14. Activity – Brainstorm What are the characteristics of people who self-manage well? What barriers might they experience? 16

  15. Definition of a Good Self-Manager The Centre for Advancement in Health (1996) proposes the following definition: “[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.” (p.1) 17

  16. Definition of a Good Self- Manager Kate Lorig (1993) states that self-management is also about enabling: “Participants to make informed choices, to adapt new perspectives and generic skills that can be applied to new problems as they arise, to practice new health behaviours, and to maintain or regain emotional stability”. 18

  17. 6 Principles of Self-Management • 1. Know your condition • Be actively Involved with the GP & health workers to make decisions & navigate the system • Follow the Care Plan that is agreed upon with the GP and other health professionals 19

  18. 6 Principles of Self-Management cont. 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 20

  19. Principles of Self-Management K I C MR I L Knowledge Involvement Care Plan Monitor and Respond Impact Lifestyle 21

  20. Self-Management … • Does not reduce the cost of care by reducing services • Is not “SELF-TREATMENT” • Will not discourage visits to the doctor • Does not increase the risk of becoming unwell • Need not threaten workers’ role and expertise 22

  21. Activity – Brainstorm What are the capabilities of those who support others to self-manage well? What barriers might they experience? 23

  22. Characteristics of Successful Self-Management Support • Assessment of self management • (learn what the client knows, their actions , strengths and barriers) • 2. Collaborative Problem Definition • (between client and health professionals) • 3. Targeting, Goal Setting & Planning • (target the issues of greatest importance to the client, set realistic goals and develop a personalised care plan) (Von Korff et al, 1997; Battersby & Lawn, 2009) 24

  23. Characteristics of Successful Self-Management Support 4. Self-Management Training and Support Services (include instruction on disease management, behavioural support, & address physical & emotional demands of having a chronic condition) 5. Active and Sustained Follow-up (reliable follow-up leads to better outcomes) (Von Korff et al, 1997; Battersby & Lawn, 2009) 25

  24. Core Skills for the Health Care Workforce 19 Capabilities for Supporting Prevention and Chronic Condition Self-Management • 3 Sub groups of capabilities • Patient Centred • Behaviour Change • Organisational/System Battersby & Lawn, 2009

  25. Brainstorm • What does client / patient / person centred mean • What skills are required for effective ‘partnering’ 27

  26. Patient Centred Capabilities • Ability to negotiate - see the issues from the patient’s point of view • Share decisions • Collectively solve problems • Establish goals • Implement action • Clarify roles and responsibilities • Evaluate progress 28

  27. Behaviour Change Capabilities • Frameworks for behaviour change • Collaborative problem definition • Motivational interviewing • Goal setting & Goal achievement • Structured problem solving Battersby & Lawn,2009

  28. Organisational/System Capabilities • Multi/Inter disciplinary teams • Communication systems • Evidence based practice • Research • Partnerships with community

  29. Group Discussion How does your current management of chronic conditions support clients to self-manage? What would you like to change? 31

  30. Research Projects Noarlunga (Mental Health) • 38 participants with severe mental illness • Combined Stanford Groups & Flinders Program • Significant improvement in - Partners in Health ratings - Problem rating 5.19 – 3.16 (p<0.001) - Goal rating 5.35- 3.55 (p<0.001) - Mental Health Summary Score SF12 • Reduced hospital admission rates 32

  31. RGH (Chronic & Complex Lung Disease) • Prospective unblinded, RCT, 12 months follow up • Resp’y rehab with and without Flinders Program • Statistically significant improvement - in 6 minute walk (p<0.05) - the impact scale of the SGRQ (p<0.05) • Clinical Improvement - in 6 minute walk (>54m) - QOL Score (SGRQ total score) 33

  32. Eyre Peninsula (Aboriginal Diabetes) 60 Participants • Modified Assessment Tools care planning • Resulted in improved - Knowledge, treatment and lifestyle score (approx 46%) - Problem Rating 6.22 – 5.28 (p<0.001) - Goal Rating 7.26- 5.42 (p<0.001) - Mean HbA1c 8.74 – 8.08 (p<0.001) 34

  33. Sharing Health Care Whyalla • Participants - People with complex & chronic illness Aboriginal people > 35 years of age Non-Aboriginal people > 50 years of age (diabetes, CVD, asthma, osteoporosis, arthritis) • Interventions -Flinders Program care planning -Condition specific programmes -Self-management courses (6 week Stanford CDSM training) -Symptom management/action plans -Structured reminders, recalls & continuing care plans Harvey, P. W., J. Petkov, G. Misan, K. Warren, J. Fuller, M. Battersby, N. Cayetano and P. Holmes (2008 ). "Self-management support and training for patients with chronic and complex conditions improves health related behaviour and health outcomes." Australian Health Review32(2): 330- 338.

  34. PIH

  35. PIH

  36. Hospital admission

  37. Vietnam Veterans Alcohol Related Chronic Conditions • 9 month RCT n=77 • Usual Care vs Usual Care + FP +/- Stanford • Statistically significant improvement (intervention n=46) i) Alcohol dependence as per DSM-IV • Baseline 61% > 9 months 41% > 18 months 35% • At 9 months alcohol dependence was ~ 8x more likely in control group compared to intervention ii) ‘Risky alcohol-related behaviours’ on mean AUDIT scores for intervention compared to control at 9 months sustained to 18 months

  38. Benefits of self-management programs • Better clinical outcomes • Improved health & QOL • Reduced hospital admissions, unplanned GP visits, emergency visits • Increased self-efficacy • Increased satisfaction with service • More efficient clinical practice (Warsi et al, Newman et al.) 38

  39. FlindersProgram Applications Distribution: Australia; New Zealand; USA; Canada Population Groups include:- Indigenous Health; Child Health; Aged Care; Mental Health; Disability; War Veterans; Renal Services; MS Society; General Practice Networks; Rural & Remote. RACGP- GPMP & TCA Care Planning Templates based on the Flinders Program principles of self-management http://www.racgp.org.au/clinical resources/templates 41

  40. 42

  41. Principles of Self-Management K I C MR I L Knowledge Involvement Care Plan Monitor and Respond Impact Lifestyle 43

  42. The Flinders Program Problems and Goals Assess Self-Management + Self- Management Medical Management Community / Carer Support Psychosocial Support Care Plan Agreed Issues Agreed Interventions Shared Responsibilities Evidence Based Practice Review Process 44

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  44. Partners In Health Scale • Measures self-management capacity • Completed by client independently • Contains 13 questions covering the 6 principles of self-management • Takes 5 – 10 minutes to complete • Can be used to record change over time 46

  45. Introduction

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  47. 49

  48. Cue & Response Interview • A tool for GP / health professionals • Covers the same 13 questions in the Partners in Health Scale • Open-ended cue questions enable issues to be explored • Answers are scored 50

  49. Cue & Response Interview Cue questions need to explore: • Understanding / Knowledge • What actually happens • What are their Strengths • What are the Barriers 51

  50. Open ended questions Affirmations Reflective listening Summaries Key Skills for Communication 52 (Moyers & Rollnick, 2002)