Chronic disease care doing it better

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Chronic disease care doing it better!

• Early intervention in Chronic Disease

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Program
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Purpose of workshop

• What is best practice in chronic disease care
  within a community health setting?
• What changes need to occur to improve chronic
  disease care within and across organisations?
• Strategies and priorities for implementing those
  changes.

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Chronic disease A definition

• "an illness that is permanent or lasts a long
  time. It may get slowly worse over time. It may
  lead to death, or it may finally go away. It may
  cause permanent changes to the body. It will
  certainly affect the person's quality of life.
• Chronic Illness Alliance

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Need to consider

• The broad spectrum of chronic diseases
• Children and adolescents
• Depression/mental health conditions?
• Addiction problems such as gambling?

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Why Change?

• Meet the increasing demand for chronic disease
• To refine and streamline care delivery to ensure
  care practices are consistent with best practice
  and effectively using available resources
• To meet consumer expectations and policy
  directions (funding)

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Chronic Care policy directions

• Commonwealth
• Australian Better Health Initiative-National
  chronic disease strategy
• Care in your community
• Harp Chronic Disease Management
• Community Health Servicescreating a healthier
  Victoria
• Chronic disease management program guidelines
• The Early Intervention in Chronic Disease in
  Community Health Services
• PCP
• Service coordination
• Health promotion
• Partnership

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Chronic Disease Management Guidelines

• person centred care
• consumers are active partners
• increasing choice and control
• right care at the right place and the right time,
• proactively promoting health
• targeting population subgroups of greatest need
• building a whole of service system response.

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Organised Resourced Health Organisation

• Systematic planning, delivery and coordination
  of care
• Effective use of resources
• Evaluate service, identify service gaps
• Strong clinical governance through robust
  clinical practices and protocols
• Capacity to be responsive to community need

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Community resources and polices

• Support for service system integration
• Promotion of service coordination practices and
  protocols
• Promote agreements across agencies for referral,
  clinical pathways, care planning
• Support region wide planning for chronic disease
  care
• Support and resource consumer and peak body
  organisations

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Prepared proactive health care team

• Systems and tools to support systematic planning
  and delivery of care
• Appropriate training to deliver best practice care

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Informed activated patient

• Clear point of entry/needs identified
• Collaborative care plan
• Between organisations
• Clear point of entry/ease of access
• Services articulates/compliment
• Capacity to share information
• Clear and consistent communication

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Key areas for change

• Delivery system design
• organise care teams to deliver systematic,
  effective, efficient clinical care and self
  management support.
• Self-management support
• empower and prepare patients to manage their
  health and health care.

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Key areas for change

• Decision support
• promote clinical care that is consistent with
  scientific evidence and patient preferences.
• Clinical information system
• organise patient and population data to
  facilitate efficient and effective care.

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What consumers want?

• An improved level of communication
• To be linked to a variety of health and support
  services.
• Appropriate, timely and quality health-care
• Accessible services.
• The better use of information technology
• http//www.nationalasthma.org.au/html/management/p
  rof_develop/pd005_pchc.asp

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BREAK
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Delivery system design
Key Concept

• Key changes

• One point of access
• Agreed minimum data set/agreed process.

Clear point of access

• Common assessment, agreed criteria for
  categorising planning care
  and agreed care pathways
• Individuals at high risk identified prioritised

• Assessment care pathways

• Develop key worker role/arrange teams and
  processes to support key worker role care
• All clients have documented care plan meeting
  min.crit.

Care plan /case management
Follow up and review

• Planned and systematic follow up and review
  documented and implemented

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Decision support
Key Concept

• Key changes

Embed evidence-based guidelines into assessment

• Embed evidence-based guidelines into care
  delivery system
• Provide workforce development to support above

Embed evidence-based guidelines into care plans

• Develop standardised care plans to prompt
  consistent evidence based care
• Adapt guidelines to consumer friendly resource

Integrate specialist care primary expertise

• Protocols service agreements for
  communication/care planning case conferencing
  consultation
• Trial mutually agreed-on care plans that can be
  used by primary specialist teams

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Clinical information system
Key Concept

• Key changes

• Service Coordination protocols
• IT capacity

Share information with providers to coordinate
care.

• Facilitate individual patient care planning.

• Ensure data base contains information to prompt
  guideline based care
• IT systems that populate client record

• Monitor delivery of best practice care

• Monitor performance of practice team and care
  system.

Organize patient and population data

• Identify high risk groups, groups not presenting
  for care or groups not meeting best practice
  guideline care

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Self-management support
Key Concept

• Key changes

• Care plan includes client goals/self management
  assessment tools utilised

Collaborative care planning

• Self management support strategies

• Identify effective self-management support
  strategies that include assessment, goal-setting,
  action planning, problem-solving and follow-up.

• Self management strategies incorporated into all
  programs
• Provide a number of options

Self management integrated into services
Capacity building of health professionals

• Dedicated self management programs
• Coaching/motivational interview
• Goal setting/problem solving

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Self Management

• A whole of agency approach

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What is self management?

• Based on patient perceived problems
• Builds confidence (self-efficacy) to perform 3
  tasks
• Disease Management
• Role Management
• Emotional Management
• Focus on improved health status and appropriate
  health care utilization
• Kate Lorig

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Program v organisational approach
Community health Mainstream services
Self Management Programs
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Self management a concept not a program?

• Individual with the chronic condition working in
  partnership with their carers and health
  professionals so that they can
• Know their condition and various treatment
  options
• Negotiate a plan of care
• Engage in activities that protect and promote
  health
• Monitor and manage the symptoms and signs of the
  condition
• Manage the impact of the condition on physical
  functioning, emotions and interpersonal
  relationships
• (Flinders University, 2007)
• http//som.flinders.edu.au/FUSA/CCTU/What20is20S
  elf20Management.pdf

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Evidence

• Good evidence to support self management
• Improves quality of life
• Supports behavior change
• Decreases health care utilisation
• www.cfah.org.au
• Barlow. J et al
• WHO

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References

• Barlow J. et a Self management approaches for
  people with chronic conditions a review
  Patient Education and Counseling 48 (2002)
  177-187
• Patients as effective collaborators in managing
  chronic conditions www.cfah.org.au
• Adherence to long term therapies www.who.org go
  to publications link
• NHS self care studies www.dh.gov.uk/selfcare

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Some people dont want to self manage

• If you get out of bed every day you are a self
  manager (Bob Montgomery)
• Manage the impact of the condition on physical
  functioning, emotions and interpersonal
  relationships

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Most people are self managers

• The public say they are active self carers
• 77 say they lead a healthy lifestyle
• 87 say they often treat minor ailment themselves
• 64 of those who have recently been in hospital
  say they often monitor their acute illness
  following discharge
• 82 of those who have a long term health
  condition, say they play an active role in caring
  for their condition themselves
• Source DH/MORI survey (2005) Public views on
  self care

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People want to do more self care

• 9 in 10 people were interested in being more
  active self carers
• gt 75 said if they had guidance/support from a
  professional or peer they would feel far more
  confident about taking care of their own health
• Over 1/2 who had seen a care professional in
  previous 6 months not been encouraged to do self
  care
• 1/3 said they had never been encouraged by the
  professionals to do self care
• Source DH/MORI survey (2005) Public views on
  self care

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Emerging issues

• Self management only for white middle class

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Is it the client or the service?

• UK experience hard to engage some communities
• What is the issue?
• Engagement or self management
• Sharing Health Care Initiative
• Wakerman J, et al. Sustainable chronic disease
  management in remote Australia. Medical Journal
  of Australia, 2005 183(10 Suppl) S648.
• AIPC Peer- led program
• Stanford Spanish American program
• UK Bangladeshi community http//patienteducation.
  stanford.edu/bibliog.html

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Factors affecting ability to self manage

• Motivation
• Knowledge of condition
• Knowledge of symptom management plan
• Co morbidities
• Health Beliefs
• Self Efficacy
• Social Context

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Self Efficacy

• Self efficacy is your belief in your ability to
  perform a task
• Strongest predictor of behaviour change
• Health distress negative correlation

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Promoting self efficacy

• Promote performance accomplishment
• Use verbal persuasion
• Role modeling
• Identifying feelings and helping work through
  strategies to deal with feelings

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Skills for self managing

• Goal setting
• Problem solving
• Communication
• Symptom management

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Implementing Self management

• Agency wide approach
• Organisational support
• Assessment
• Care Planning
• Resources
• Delivery System Design
• Consumer Consultation/Peer Support
• Workforce Development

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Initial contact

• Clearly informed of the service being offered and
  options discussed
• Given written information about the service,
  expectations of type of service, standards and
  client responsibilities
• Not eligible for the service referred to
  appropriate resources.

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Assessment

• Client and family/other are listened to,
  respected and treated as partners in care
• Self management needs and activities are assessed
  and recorded in a standardised form
• Problems are explored and clearly documented
• Role in managing their condition is discussed
  along with health risk and benefits of change

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Change in focus needed
Source UK NHS Care Planning website
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Key Challenge

• Implementing an assessment process that provides
  equal weight to
• Professional requirements and understanding of
  disease process
• Consumers concerns and desires

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Assessment

• 1. LookFind the issue.
• Ask Tell me what concerns you most. Tell me what
  is hardest for you. Tell me what youre most
  distressed about and what youd most like to
  change.
• 2. Think explore those issues with us.
• Ask, Is there an underlying issue? Do you really
  want this problem to be solved? Whats the
  issue?
• 3. Act Develop a collaborative goal.
• Ask, What do you think would work? What have you
  tried in the past? What would you like to try?
• Transition in Chronic Illness Booklet 10
  Self-Care RDNS Research Unit

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NHS Care Planning Project
Source UK NHS Care Planning website
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Care plan It is the verb ratherthan the noun!
Source UK NHS Care Planning website
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Care Plan Requirements

• Documented plan of care that has all of the
  following elements completed
• Client stated/agreed issues/problems
• Client stated/agreed objectives/goals,
• Client stated/agreed strategies/action
• Review date of care plan
• Timeframe for attainment of objectives/goals
• Responsibilities for implementing
  strategies/action
• Participants in development of care plan
• Consumer Acknowledgement (signed or verbal
  acknowledgement recorded)
• Date care plan developed

Victorian Healthcare Association, Clinical
Indicators in Community Health 2008
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VHA Pilot results

• Complete care plan 5

Client stated/agreed Issues/Problems 62 Client
stated/agreed Objectives/Goals 66 Client
stated/agreed Strategies/Actions 66
Implementation Responsibilities 55
Participants Identified 49 Dated
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Source Alison Brown Clinical Governance Project
Manager VHA
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VHA Pilot results

• Care Plan Review 14
• Goal Attainment 12
• Goals Partially Met 12

Source Alison Brown Clinical Governance Project
Manager VHA
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