Improving Outcomes by Helping People Take Control The theory and practice of Co-creating Health.

Improving Outcomes by Helping People Take Control

The theory and practice of Co-creating Health

Care pathways: providingspecific interventions

Care planning: A system of regular scheduled appointments, providing proactive structured support

NB : People may also be accessing a wide variety of other support e.g. from within their communities

Life with a long term condition: the person’s perspective

Interactions with the service: planned or unplanned Problem solving: Time limited consultation/s providing motivational support

Why support self-management?

3

“Self management support can be viewed in two ways: as a portfolio of techniques and tools that help patients choose healthy behaviours; and a fundamental transformation of the patient-caregiver relationship into a collaborative partnership.”

Bodenheimer T, MacGregor K, Shafiri C (2005). Helping Patients Manage Their Chronic Conditions. California: California Healthcare Foundation.

What is supportedself-management?

4©The Health Foundation

Co-creating Health

Achieve measurable improvements in the quality of life of people living with long term conditions and improve their experience of health services by embedding self management support within mainstream health services.

The problems:

• Lack of care coordination • Lack of active follow-up• Patients inadequately trained to

manage their illnesses

‘Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible.’

Supporting people on

their journey of activation

Supporting people on

their journey of activation

Understanding have role; confident and capable in role

The Chronic Care Model

Developed by the MacColl InstituteACP-ASIM Journals and Books 5

6

Evidence for supporting self management grows every year.

• Research is up to date

• Internationally, studies are consistently positive

• Research has used a range of methodologies.

• Studies are from small to large scale.

It shows that supporting self-management can improve:

• self confidence / self efficacy

• self management behaviours

• quality of life

• clinical outcomes

• patterns of healthcare use

The evidence

7

Active support works best

Research shows that more active support focused on self-efficacy (confidence) and behaviour works best to improve outcomes.

Source: Prof Judy Hibbard, University of Oregon

Information and knowledge alone are not enough.

Approaches that focus on whether people are ready to change work well.

8

• Self monitoring and agenda setting reduce hospitalisations, A&E visits, unscheduled visits to the doctor and days off work or school for people with asthma (Gibson et al 2004).

• Goal setting for older women with heart conditions reduces days in hospital and overall healthcare costs (Wheeler et al 2003).

• Telephone support may improve self care behaviour, glycaemic control, and symptoms among vulnerable people with diabetes (Piette et al 2000).

• Motivational interviewing improve self efficacy, patient activation, lifestyle change and perceived health status (Linden et al 2010).

• Individual education and group sessions improve symptoms for people with high blood pressure (Boulware et al 2001).

Examples of improvement

9

The Co-creating Health model

©The Health Foundation

10

Agenda setting– Identifying issues and problems

– Preparing in advance

– Agreeing a joint agenda

Goal setting– Small and achievable goals

– Builds confidence and momentum

Goal follow-up– Proactive – instigated by the system

– Soon – within 14 days

– Encouragement and reinforcement

Becoming an active partner

Making change

Maintaining change

The Three Enablers

11

An Integrated Approach

Programme Who Role change Focus

Patient

From passive patient to self-management

Activation and partnership: confidence and skills

Clinician

From expert who cares to enabler who supports self-management

Building the knowledge, skills and attitudes needed to provide effective self-management support

Service

From clinician-centred services to services that have self-management support as their organising principle

Embedding the 3 enablers into everyday practice by building them into systems and care pathways

Self-management Programme

Advanced Development Programme

Service Improvement Programme

Self Management Programme outcomes

12

... producing statistically significant changes in:• positively engagement with life• constructive attitude/approach towards condition• more positive emotional well being• using self-management skills and techniques

“I used to go to the doctor only when they summoned me, and then say ‘What are you going to do to fix my problem?’. But now I’m saying like, ‘I’m not sure these particular painkillers are working the way we hoped, can we try something else? What could I do myself? ’ “

Person living with along-term condition

Skills developed ....

• Setting the agenda

• Setting goals

• Problem solving

• Develop the confidence

• Understand their condition

• Develop skills

13

Practitioner Development Programme outcomes

Practice positively influenced:

• patients’ confidence to self manage • agenda setting • setting own goals• collaborative problem solving• goal follow up• patients’ experience

Community matron

Clinician tutor

“It’s a change from the traditional approach where say ‘You need to do this”, and the patient says “you’re the boss”, but doesn’t actually do it. We used to wonder why that wasn’t working”

“Now I use agenda setting with my patients and I start by asking ‘what do you want us to do today?’ Patients appreciate this different approach because you are giving them the power. You work out the goals and the steps together and they are empowered to carry on and work on it on their own. So you may need to see them a bit more at first, but in the long run you need to see them less often.”

Patient Confident in Self

Management

Organisational Changes

Pre-visit changes

During visit changes

Post-visit changes

Primary Drivers Secondary Drivers

Outcome

Service Improvement Programme

IMPROVEMENT

The 3 Enablers

Agenda Setting

Goal Setting

Goal Follow Up

Adapted from Robert Lloyd and Richard Scoville, Better Quality through Better Measurement

15

DiabetesThe

Whittington Hospital and

Haringey and

Islington PCTs

Guys & St Thomas and Southwark PCT

COPDAddenbrokes and

Cambridgeshire PCT

NHS Arran and Ayrshire

DepressionSW London MH Trust and

Wandsworth PCT

Torbay Care Trust and PCT

Chronic PainCalderdale

and Huddersfield Trust and

Kirkees PCT

A model for all LTCs

A model for all long-term conditions

Improving lives in chronic pain?

P intensity P Interference PAM PSEQ0

10

20

30

40

50

60

Pre SMP

6 Months Post SMP

Ou

tco

me

me

as

ure

Sc

ore

p = 0.001p = 0.01 p = 0.02 p = 0.05

Pre and 6 Months Post Self-Management Programme scores for Pain in-tensity, Pain Interference, Pain Activation and Pain Self Efficacy

17©The Health Foundation

Conclusion

Person living with a long-term condition

‘I’d like to thank you both for giving me back the life I thought I’d lost, its made me realise I was holding myself back’