Title: Supporting Chronic Disease Self-Management: A collection of
1Supporting Chronic Disease Self-Management
- A collection of ideas from Eyre Peninsula
Collaborative ProjectsEPDGP, ERHS, SGRHS
2earlier 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
3demand 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
4collaboration 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
5progress 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
6opportunities
- 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
7the 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)
8key collaboration components
- Graham Berry - CDSM resource kit
- Kate Warren Example of case study
- LIFE course
- Malcolm Battersby - Flinders Model future
9CDSM resource kit
- Graham Berry EPDGP
- CDSM resource kit
10Project 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.
11Experiences 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
12Structure of Resource
- Guide
- Theory
- Tools and Strategies
- Case Studies
- Learnings
- Models
- Implementation Guides
- CDROM
- Web page
13CDSM Support Case Studies
- General Practice
- Aboriginal Health Service
- Care Plan Support Centre
- AHW in General Practice
14CDSM 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
15CDSM Support Case Studies
- Research
- Preventative strategies
- Use of the Internet
- Advocacy
- Providing the required health services
- Training health service providers
16Living Improvements for Everyone (LIFE)
- Kate Warren Spencer Gulf Rural Health School
- LIFE course
- Adaptation of Stanford SM 6 week course to suit
Aboriginal people
17Stanford 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
18LIFE 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
20Session 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
21Session 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
22Flinders 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
24Background - 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
25BACKGROUND -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
26Learning
- 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
27Six 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
28Six 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
29Flinders Model
- Outcomes based
- Generic
- Motivational
- Medical with self-management (Holistic)
- Patient-centred
- Communication
- Coordination
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34Problems 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
35Care 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
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37Flinders Model
- Outcomes based
- Generic
- Motivational
- Medical with self-management (Holistic)
- Patient-centred
- Communication
- Coordination
38Summary
- 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
39Future Developments
- Australian Better Health Initiative
- National undergraduate curriculum in chronic
condition self-management - Education, upskilling of the national primary
care workforce - Electronic care planning
40Contact 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
41THANK YOU
42POCT
EPC Items
PIH Model
Chronic Condition Care
Patient Centred Care Plans
LIFE Program
Outcome focus
43compression of morbidityFries, J
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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)
46Very significant (p 0.001)