SWPCP – Self management mapping.. Self management – What is it? Self - management is defined as the task that individuals must undertake to live with.

SWPCP – Self management mapping.

Self management – What is it?

Self - management is defined as the task that individuals must undertake to live with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management and emotional management of their conditions

(Institute of Medicine 2004;cited by Kate Lorig, RN, DrPH. Stanford Patent Education Centre)

Aim of self management

“to develop skills and confidence within patients and their families so they can take responsibility of their own care”

Zwar, N et el

Cited by DHS - Self - Management Mapping Guide

2007

Outcomes of self management.

Knowledge of condition and treatment options Ability to negotiate a plan of care with their

health care worker Monitor and manage symptoms and signs of

conditions Manage the physical, emotional and social

impact on their life Engage in activities that protect and promote

health

Wagner Chronic Care model

Evidence for self management

Improved health outcomes3,5

Improved compliance with medication and therapy1,2,4

Improved symptom control and management (reduced pain, depressive symptoms)1-6

Increased self efficacy and motivation1,3-5 Reduced utilization of health services and

inpatient length of stay2-5

Improved quality of life2-5

Self - Management

What the consumer, not the health clinician does

Self - Management Support

What health care practitioners provide to assist a consumer with their self management practices

Self - Management Models / Approaches

Flinders Stanford University (Lorig) Motivational Interviewing Health Coaching Action Planning Building Habits Other……

DHS Self Management Survey

Aim of survey

To improve understanding of current service system and to build capacity within the sector.

To identify self management program providers, service distribution, types of interventions, agency capacity, barriers and enablers, and training needs.

Inform planning for future PCP activities to enhance ICDM across the catchment 

Baseline data will assist in identifying future trends

Methodology

Identification of Chronic Disease listed in the Australian National Chronic Disease Strategy (Nov.2005)

Identified relevant agencies

Provided electronic survey template and supporting information

Met with agency representative to discuss and complete template

Collated data and forwarded to DHS for analysis and reporting

Limitations of survey

Individual interpretation of survey template – Surveyor, agency vs. lack of standardised approach for state-wide data collection.

Data may not be representative of whole agency approach

Scope of activity limited to select chronic diseases.

Is obesity a chronic disease? Do we include weight management groups?

Restrictive survey question design – limiting feedback for identification of enablers and barriers

Template not user friendly

Consultations and self management mapping

18 Agencies in SWPCP

Aboriginal Health Promotion Chronic Conditions Camperdown Community health SWHC Community health, Chronic Illness Aspire SWHC Cardiac rehabilitation SWHC Ocupational Therapy Cobden District Health Service SWHC counselling services SWHC Psychiatric Services Lyndoch Aged and Extended Care SWHC Alcohol and Drug withdrawal and support Terang and Mortlake Health Service Otway division of general practice SWHC Lismore Timboon and district health Salvation Army SWHC Nutrition WRAD

All of the agencies that completed the survey:believe Integrated Chronic Disease

Management (ICDM) is an organisational priority,

self management is an organisational strategic goal

Provide specific chronic disease management programs

SWPCP Results: Staff Trained

0

5

10

15

20

25

30

35

40

Number of staffFl

inde

rs

Sta

nfor

d MI

Hea

lth c

oach

ing

Act

ion

Pla

nnin

g

BH

Oth

er

Self Management Approach

94

Staff trained V’s Staff providing support.

05

1015202530354045

Number of staff

Flin

ders

Sta

nfor

d MI

Hea

lth c

oach

ing

Act

ion

Pla

nnin

g

BH

Oth

er

Self Management Approach

Numer of staff trained

Number of Staff providingsupport

Disease focus.

0

2

4

6

8

10

12

Flinders MI HC Stanford

Musculoskeletal

CVD

Resp

Diabetes

Delivery Setting.

0

2

4

6

8

10

HealthService

Communityhealth

Home

Referrals

0

2

4

6

8

10

12

Self

GP

Health Service

Target Population

0123456789

10

Flinder

s MI

HC

Stanfo

rd

All

Women

Men

older people

younger people

ATSI

CALD

Enablers to providing self-management support at an agency level

0 1 2 3 4 5 6 7 8 9

Access to self management support training

Clinicians willingness to change practice

High level of staff retention

Systems in place to routinely identify self management support needs ofclient

High demand for self management interventions

Internal agency support to facilitace ICDM including provision of selfmanagement

Management support for self management as part of ICDM

Venue avaliability

Vebnue capacity

Peer leader avaliability

Client understanding of self management pronciples

Barriers to providing self-management support at an agency level

0 1 2 3 4 5 6 7 8 9 10

Limited access to self management training

High staff turn over

Low demand for self management interventions

Limited facilitation of change management

Time interventions take

Other priorities for clinicians

Venue avaliability

Venue capacity

Peer leader avaliability

Limited referrals from Gp

Staff resistance to change prctice

lack of management support

client knowledge and understanding of chronic disease

Support required to embed self management – Practitioner level

Organization

Support from other staff in the agencyIncrease time for skill developmentImplement consistent assessment toolsPromote availability of SM programsIncrease consultation timeManagerial support

Training

Continuing professional development and maintaining knowledge and skillsGP training on SM to increase awarenessMore training support from management

Funding

Increased funding for SM training and the time that this takesAdditional staff resources Increased resources to support clients in programs and follow-up care

PCP SupportInform DHS re. policy direction awareness of trends Coordinate and promote SM trainingRaise awareness of SM and allow practitioner networkingEncourage and promote referral to practitioners trained in SM,

Support required to embed self management – agency

Organization

Review of systems, processes and structures to support SMReduce emphasis on client throughput and encourage attending to client needs.Facilitate change management Ensure managers have a good understanding of self management practices.

Training

Provide training regarding SM principlesReview training models so that the training required to embed SM into assessment, client skill development, and group programs are supportedEducate and empower staff to move away from the dependence model of careProvide support and time for staff development

Funding

Continue funding the development of client programsAllocate additional funding for training courses in SM

PCP Support Promote SM training and facilitate workshops/seminars Assisting with policy direction and being aware of the trends Bring agencies together to progress, collaboration and implementation of SM across catchment. Facilitate support from management as well.

Support required to embed self management – PCP

Coordination

Coordinate a regional approach to embed SM into practice Facilitate sharing of information and resourcesSupport integration of SM and strengthen partnerships

Cooperation

Facilitate sharing of resourcesAwareness of current trendsShare learning's and information across the PCP

Networking

Engage GP involvement Promote condition specific programs/ services to increase community awareness

PCP Support Promote training, SM information and advertising to raise awareness of SM Assisting with policy direction.

Findings The high prevalence of chronic disease supports the high demand

for more effective services. SM interventions have been shown to be more effective at improving health outcomes and client .

Staff skills and access to training have been identified as being key barriers to the provision of SM support. Clinicians have competing work priorities. The lack of follow-on training support for skill development contributes to the time SM interventions take, thus limiting the application of staff’s SM training.

Individual staff training alone is not conducive to practice change. Managerial leadership and support is required to drive the provision of SM support via the implementation of systems to ensure consistent assessment of client needs and the delivery of consistent SM practice.

Key areas of work

Improving the integration and planning of chronic disease services in the region

Working with agencies to develop an integrated approach in the use of self management practices across the region

Assist with workforce development opportunities to support best practice.

Statement of intent for SWPCP ICDM Vision

To improve the health and well being of people with chronic disease and reduce preventable admissions to hospital for this group.

To identify groups at risk of a chronic disease and intervene at an early stage to avoid the development of a chronic illness

Promote and support client self-management