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Chronic Condition SelfManagement Improving Management of Chronic Conditions in Older People


John Lawrence, Research Manager, Flinders University. Human Behaviour And Health Research Unit ... adapt new perspectives and generic skills that can be ... – PowerPoint PPT presentation

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Title: Chronic Condition SelfManagement Improving Management of Chronic Conditions in Older People

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

  • Problems w. Traditional Therapy Service Model
  • Solution Chronic Condition Self-Management
  • New Program for Resthaven Marion
  • Success Lessons - Evaluation Evidence
  • Future Developments

Traditional Therapy Service Model_at_ Resthaven
  • 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

Acute 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

What is Chronic Condition Self-Management ?
  • Involves the person with the chronic disease
  • engaging in activities that protect and promote
  • 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)

Kate 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

SA Coordinated Care Trial 1997
  • Patients who benefited did so by becoming better
    self managers assisted by service coordinators
  • 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
  • Self management not defined/operationalised

SA 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
  • Those who do respond to a wide range of learning
    methods, some group, some individual

New Principles of Effective Management of Chronic
  • 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

The Flinders Model of Chronic Condition
Self-Management (CCSM)
  • Partners In Health Program

Six 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

Six 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

Principles of Self-Management
  • K
  • I
  • C
  • MR
  • I
  • L

Care Plan
Monitor and Respond
Themes 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 .

Themes 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

Flinders 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

Patient 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.

Chronic Condition Management
  • The patient
  • The family/carer
  • The clinician
  • The community
  • The health care system
  • The provider organisation

Benefits 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??

Partners 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

Cue 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

Cue Response Interview
  • When both parties have rated the question on the
    high end of the scale
  • When scores differ markedly on any question
  • establish which identified issues the
    patient/client wishes to address and what
    interventions may be appropriate

Self-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

National Sharing Health CareInitiative
  • 8 demonstration projects one in each state and
  • 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

Stanford / 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.

Steps 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

RMTS - Clientele
  • Generally 60 years (mean age 78 years)
  • Multiple physical conditions psychosocial
  • 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

Pilot CCSM Program Group
  • 30 clients recruited August 2001 May 2004
  • Surge in demand in 2004 following promotion to
  • Age range 37 94
  • 80 female
  • Primary diagnosis - 13 (43) musculo-skeletal

RMTS 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

RMTS 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

RMTS 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
  • Clients may be invited to repeat Stanford program
  • Review as above 6-10 weeks later

(No Transcript)
CCSM 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
  • Health Professional
  • Decreased dependency on service
  • New health promoting behaviours e.g. short-term
    goal setting, monitoring health symptoms, regular
    exercise, increased social contact

CCSM Improvement Evidence
CCSM 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
  • Main chronic conditions are osteoarthritis and
  • 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.

Client 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)

Evolution 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

Future 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

The 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.

  • Thank You

Partners 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
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
Principles of Collaboration
  • Understanding of clients beliefs, wishes and
  • Understanding of the family beliefs and needs
  • Collaborative identification of problems and
  • Negotiated agreed care plans, regularly reviewed
  • Active follow up

Enhancing 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

  • Partnerships
  • Holistic approach
  • Proactive
  • Adaptive and problem solving
  • E mpowerment

Self-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

Problem 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

Goal 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
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