ABHI PCIP Chronic Disease Self Management

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ABHI PCIPChronic Disease Self Management
A leading Division providing General Practice
with quality innovative services that improve
health outcomes for individuals and the community
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Objective

• Presentation focused on
• Improve access to and utilisation of tools and
  strategies that will assist in better managing
  patients with chronic disease.

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Strategies

• CDSM Quality Improvement
• Engage practices in a chronic disease self
  management quality improvement program
• Collaboratives approach
• Assessment and training in CDSM skills
• Assess practice nurse chronic disease self
  management skills and provide training to meet
  needs

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CDSM Quality ImprovementAssessment tool

• Assessment of Primary Care Resources Supports
  for Self Management (PCRS)
• Developed by Robert Wood Johnson Foundation in
  2006 based on the Wagner Chronic Care Model
• To help primary care settings focus on actions
  that can be taken to support self management by
  patients

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CDSM Quality ImprovementPRCS Assessment Tool

• Patient support
• Individualised assessment of patient self
  management educational needs
• Self management education
• Goal setting
• Problem solving skills
• Emotional health
• Patient involvement in decision making
• Social support
• Links to community resources

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CDSM Quality ImprovementProcess

• Practice team (GP, Practice Nurse other staff)
  complete assessment tool.
• Results compiled and reported back to practice.
• Practice establish CDSM team.
• Identify areas for change.
• Use Plan Do Study Act (PDSA) approach to
  implement change.
• Repeat assessment at completion of program.

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CDSM Quality ImprovementPractice engagement

• Original aim to engage 24 practices!
• Something about change.
• God grant me the serenity to accept the things I
  cannot change the courage to change the things I
  can and the wisdom to know the difference!

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CDSM Quality ImprovementPractice engagement
outcomes

• 19 Practices visited
• 11 practices showed some interest but did not
  complete the assessment
• 4 Practices not interested
• 5 Practices completed the assessment tool

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CDSM Quality ImprovementPractice engagement
outcomes

• Of the 4 Practices who completed the assessment
• 1 indicated that they were already achieving high
  quality across all 8 areas
• 1 completed the assessment, received the report
  and then had to pull out as it wasnt right for
  them at the time
• 3 completed the assessment and 2 have committed
  to exploring the results

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CDSM Quality ImprovementPractice results
Goal setting
Practice 1
Practice 2
?is not done ? occurs but goals are
established primarily by member(s) of the health
care team rather than developed collaboratively
with patients. ? is done collaboratively with
all patients/families and their provider(s) or
member of healthcare team goals are specific,
documented and available to anyone on the team
goals are reviewed and modified
periodically. ?is an integral part of care for
patients with chronic disease goals are
systematically reassessed and discussed with the
patient progress is documented in the patient's
chart.
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Assessment and training in CDSM skillsCDSM
training model

• Health Coaching Australia courses conducted
• ?Leeton, October 2008
• ?Wagga Wagga, May 2009
• Total trained 37
• ? 21 Practice nurses
• ? 4 Private Allied Health
• ? 9 Area Health employees (physio, diabetes
  eductor, respiratory, dietitian)
• ? 1 Primary Health Care Nurse
• ? 2 Program staff

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Assessment and training in CDSM
skillsAssessment of CDSM skills

• Assessment tool developed by the Whitehorse
  Division of General Practice.

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Assessment and training in CDSM
skillsEvaluation results
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Assessment and training in CDSM
skillsEvaluation of training

• Health Coaching Australia evaluation
• 100 of participants rating it as Above Average
  (37) or Excellent (63)
• 100 of the participants indicated they would
  recommend the course to their colleagues
• 97 indicated that the content relevance and
  usefulness to current work was Above Average
  (43) or Excellent (54)

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Assessment and training in CDSM
skillsEvaluation of training

• I work as a practice nurse/Diabetes educator. I
  was very frustrated in my role not knowing how to
  approach my patients in a way that was productive
  and effective. I was getting very overwhelmed
  with processes that seemed to be going nowhere
  and producing little results. I am very excited
  about these skills and am more confident about my
  ability to motivate and empower my patients.

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Assessment and training in CDSM skillsOutcomes
of training

• We are just starting up the Ambulatory Rehab
  Service out of Wagga Base so I am trying to fit
  the Health Coaching concepts in right from the
  day dot. Hopefully it will be reflected in
  everything from our forms from the referring GPs
  through to our initial goal setting for the
  client and across the multidisciplinary
  approach. Occupational Therapist, GSAHS

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Evaluation sustainability

• CDSM Assessment incorporated into Collaboratives
  program
• Culture of change established around CDSM
• Lead practices established to provide support to
  other practices once engaged in CDSM
• Exposure to CDSM and Health Coaching model across
  all Division staff Program areas, majority of
  general practices and the Area Health Service.

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Key to success?

• A small number of practices who are at the
  cutting edge of primary health care who are ready
  to take on the challenge.

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Thank You!

• Narelle Mills
• RDGPPH
• [phone]
• n.mills_at_rdgp.com.au