CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY NMHS CCSM : K.BISCHOFF Sept 2013 1 Slide 1 Chronic Condition Self-Management Karen Bischoff CCSM Program Coordinator NMHS Public Health and Ambulatory Care (PH&AC) September 2013 Acknowledgement of Country I respectfully acknowledge the past and present traditional owners of the land in which we are meeting, the Noongar people. It is a privilege to be standing on Noongar country. I also acknowledge the contributions of Aboriginal Australians and non-Aboriginal Australians to the health and well being of all people in this country in which we live and share together - Australia.
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CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 1
Slide 1
Chronic Condition Self-Management
Karen BischoffCCSM Program Coordinator
NMHS
Public Health and Ambulatory Care (PH&AC)
September 2013
Acknowledgement of Country
I respectfully acknowledge the past and present traditional owners of the land in which we are meeting, the Noongar
people. It is a privilege to be standing on Noongar country. I also acknowledge the contributions of Aboriginal
Australians and non-Aboriginal Australians to the health and well being of all people in this country in which we live and
share together - Australia.
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 2
Identify how you can improve your delivery of Self-management Support in your work place
Understand the role of Self-management Support in the delivery of chronic care
Gain an overview of Health Providers skillsrequired by to deliver Self-management Support to consumers
Understand the Health Systemcontext for delivering chronic care
Gain an overview of the skillsconsumersrequire to self-manage their conditions
Understand the Policy context for delivering chronic care
Understand the Consumer andCommunityperspective living with a chronic condition
Invitation to participate in embedding CCSM Support process
1946 Public Health system open to all WA’ns not just destitute
1958 (Royal) Perth Hospital
1958 Chest Clinic;1963> SCGH
1982 First AIDS case recorded
1983 Medicare
Historic foundations1855 : Convict built Colonial Hospital, later renamed the Perth Public Hospital, the Perth Hospital and, in 1946, the Royal Perth Hospital.
Royal Perth Hospital Opening 1948
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
DefinitionsSelf-management is ‘the active participation by
people in their own health care’.
Self-management support is what health providers, organisations and the community does to assist people living with chronic conditions to better ‘self manage’.
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 21
Innovative Care for Chronic Conditions Framework
www.who.int/diabetesactiononline/about/ICCC/en/
4. Community 3. Health System
SELF-MANAGEMENT
2. Health CareProviders1. Consumer
Innovative Care for Chronic Conditions Framework
www.who.int/diabetesactiononline/about/ICCC/en/
4. Community 3. Health System
1. Consumer2. Health Care
Providers
SELF-MANAGEMENT SUPPORT
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 22
Definitions Continued
The self-management approach emphasises the consumer’s central role in managing their health anywhere along the care continuum;
Self-management programs and services offer consumers the knowledge, skills and resources to help them better manage their health.
-----------------------------------------------------------------------Self-management is ‘the active participation by people in their own health care’.
Self-management support is what health providers, organisations and the community does to assist people living with chronic conditions to better ‘self manage’.
Chronic Condition Pyramid
Based on: UK Department of Health (2005) Improving chronic disease management [Kaiser Permanente Care Management Institute, California, USA]
WELL POPULATION
HIGHER RISK
HIGH COMPLEXITY
UNDIAGNOSED, AT RISK
DIAGNOSED, STABLE
100% of the population
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 23
Ideal Balance of Care
At Risk, Undiagnosed and
Well population
S e l fS e l fS e l fS e l fS e l fS e l fS e l fS e l f -------- M
a n a g e me n t
Ma n a g e m
e n t
Ma n a g e m
e n t
Ma n a g e m
e n t
Ma n a g e m
e n t
Ma n a g e m
e n t
Ma n a g e m
e n t
Ma n a g e m
e n t
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
High proportion of professional care
Equally shared care
Complex Carewith comorbidities
Higher Risk Cases
Diagnosedand Stable
High proportion of Self Management/Care
Ideal Balance of Care
At Risk, Undiagnosed and
Well population
S e l fS e l fS e l fS e l fS e l fS e l fS e l fS e l f -------- M
a n a g e me n t
Ma n a g e m
e n t
Ma n a g e m
e n t
Ma n a g e m
e n t
Ma n a g e m
e n t
Ma n a g e m
e n t
Ma n a g e m
e n t
Ma n a g e m
e n t
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
P r o f e s s i o n a l C a r e
High proportion of professional care
Equally shared care
Complex Carewith comorbidities
Higher Risk Cases
Diagnosedand Stable
High proportion of Self Management/Care
Actual line???
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 24
Paradigm Shift required
1900’s thinking
Time
Paradigm Shift required
1900’s thinking
2000’s mission
Time
Limited
Resources
and Time
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 25
CONTEXT
� Chronic Care Models
� Chronic Care Pyramid
� Balance of CareProfessional Care vs. Self Management
� National Chronic Disease Strategy
� WA Health Models of Care
� WA CC/CCSM Frameworks++
� Area Health Services (NMHS)
� NGOs, Local Governments…
� Communities
LEVELIN
TE
RN
AT
ION
AL
CO
MM
UN
ITY
ST
AT
E / A
HS
NA
TIO
NA
L
ACTION AREAS:
1. Prevention across thecontinuum
2. Early detection andtreatment
3. Integration and continuityof prevention and care
4. Self Management
National Chronic Disease Strategy
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 26
Strategic Documents …
Evidence shows ….
a multi-level, multi-component, system-wide approach, across the continuum of care is required.
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 27
WA Chronic Conditions Self-Management (CCSM) Strategic Framework 2011-2015
WA Chronic Conditions Self-Management Strategic Framework 2011-2015
Multi-level, multi-component, system-wide, across the care continuum approach
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 28
WA Primary Health Care Strategy
Principle 1: PartnershipPrinciple 2: Health literacy and
Self-ManagementPrinciple 3: System designPrinciple 4: AwarenessPrinciple 5: Social determinants
of healthPrinciple 6: Implementation through
consultation & engagement
WA Chronic Health Conditions Framework 2011-2016
Guiding Principles:
Principle 1 : Integration and servicecoordination
Principle 2 : Interdisciplinary care planningand case management
Principle 3: Evidence-based andconsumer-centred care
Principle 4: Health literacy and Self-Management forchronic health conditions
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 29
WA Chronic Conditions Self-Management Strategic Framework 2011-2015
CCSM PRINCIPLES :
� Holistic practice
� Person-centred approach� Partnership with HP
� Participation by client, carers
� Shared responsibility 4 outcomes
� Client empowerment and enhanced capacity
� Co-ordination of care� Quality Information
� An ongoing, lifelong approach to health and self care.
WA Strategic Framework for Safety and Quality
in Health Care 2008 -2013
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 30
WA Health Clinical ServicesFocus areas include:
� Safety and Quality - Client-centred approach
� Address / Redistribute Demand- Inpatient- Outpatient- Emergency Department
Self-management support is what health providers, organisations and the community does to assist people living with chronic conditions to better ‘self manage’.
Self-management programs and services offer consumers the knowledge, skills and resources to help them better manage their health.
The self-management approach emphasises the consumer’s central role in managing their health anywhere along the care continuum.
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 42
A Partnership approach…
� The Consumer/ Patient, Family and Carers
and
� The Health Care Team
and
� Community Partners
A Partnership approach…Cancer Model of Care
Are we there yet?
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 43
A Partnership approach…CKD Model of Care
Are we there yet?
… Delivering evidence-based quality care …
What is the Health Provider AGENDA?
Treatment
Discharge
Traditional
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 44
Health Provider Agenda
For CANCER
From WA Health Models of Care
Health Issue
ReconcilingHP and Consumer Agendas
SHARED RESPONSIBILITY
Partnership approach
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY
NMHS CCSM : K.BISCHOFF Sept 2013 45
Self Management Support – HP Core Skills
I. Person-centred skills
II. Behaviour Change skills
III. Organisational / System capabilities
Ref: Capabilities for Supporting Prevention and Chronic Condition Self-Management:Flinders University, South Australia
In additional to clinical skills and knowledge
I. General Person-Centred Skills
Reference: Capabilities for Supporting Prevention and Chronic Condition Self-Management:Flinders University SA
1. Health promotion approaches
2. Assessment of health risk factors
3. Communication skills, Reflective listening
4. Assessment of self management capacity(strengths and barriers)
5. Care planning
6. Use of peer support
7. Cultural awareness; Ability to understand Health information [Health Literacy]
8. Assessment of coping and support skills [Psychosocial]
CHRONIC CONDITION SELF-MANAGEMENT (CCSM) POST GRADUATE STUDY DAY