Supporting Chronic Disease Self-Management: A collection of

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Supporting Chronic Disease Self-Management

• A collection of ideas from Eyre Peninsula

Collaborative ProjectsEPDGP, ERHS, SGRHS
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earlier 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

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demand 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

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collaboration 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

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progress 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

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opportunities

• 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

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the 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)

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key collaboration components

• Graham Berry - CDSM resource kit
• Kate Warren Example of case study
• LIFE course
• Malcolm Battersby - Flinders Model future

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CDSM resource kit

• Graham Berry EPDGP
• CDSM resource kit

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Project 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.

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Experiences 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

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Structure of Resource

• Guide
• Theory
• Tools and Strategies
• Case Studies
• Learnings
• Models
• Implementation Guides
• CDROM
• Web page

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CDSM Support Case Studies

• General Practice
• Aboriginal Health Service
• Care Plan Support Centre
• AHW in General Practice

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CDSM 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

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CDSM Support Case Studies

• Research
• Preventative strategies
• Use of the Internet
• Advocacy
• Providing the required health services
• Training health service providers

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Living Improvements for Everyone (LIFE)

• Kate Warren Spencer Gulf Rural Health School
• LIFE course
• Adaptation of Stanford SM 6 week course to suit
  Aboriginal people

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Stanford 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

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LIFE 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

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• Front cover
• People looking after themselves and each other

Session 1 Keeping active
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Session 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
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Session 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
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Flinders Model

• Malcolm Battersby - Flinders Model
• The future of Chronic Disease Self-Management

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Self-Management Support for Chronic
ConditionsThe Flinders Model

• Flinders Human Behaviour and Health Research Unit
• Flinders University
• Malcolm Battersby

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Background - 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

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BACKGROUND -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

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Learning

• 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

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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 professionals

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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

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Flinders Model

• Outcomes based
• Generic
• Motivational
• Medical with self-management (Holistic)
• Patient-centred
• Communication
• Coordination

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Problems 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

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Care 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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Flinders Model

• Outcomes based
• Generic
• Motivational
• Medical with self-management (Holistic)
• Patient-centred
• Communication
• Coordination

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Summary

• 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

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Future Developments

• Australian Better Health Initiative
• National undergraduate curriculum in chronic
  condition self-management
• Education, upskilling of the national primary
  care workforce
• Electronic care planning

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Contact details

• Flinders Human Behaviour and Health Research Unit
• Sharon.lawn_at_fmc.sa.gov.au
• Malcolm.Battersby_at_fmc.sa.gov.au
• Ph [phone] Fax [phone]
• http//som.flinders.edu.au/FUSA/CCTU/Home.html

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THANK YOU
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POCT
EPC Items
PIH Model
Chronic Condition Care
Patient Centred Care Plans
LIFE Program
Outcome focus
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compression of morbidityFries, J
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What I know about my illness is (PIH
scale)9 point scale-higher is better(very
significant over time- p0.000)
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Very significant (p 0.001)