Long term condition management: Selfmanagement of COPD

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Long term condition management Self-management
of COPD

• Dr Lisa Whitehead
• Senior Lecturer
• Centre for Postgraduate Nursing Studies
• University of Otago, Christchurch

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Plan of session

• Definition of long term conditions (LTC)
• Context of LTCs in New Zealand
• Key factors that underpin successful
  self-management programmes
• The role of healthcare professionals in promoting
  self-management

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Chronic disease definition

• WHO definition
• diseases of long duration and generally slow
  progression
• CDC- US
• conditions that are not cured once acquiredare
  considered chronicAdditionally, other conditions
  must have been present 3 months or longer to be
  considered chronic

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• COPD has a substantial impact on the health of
  New Zealanders. Although often undiagnosed, it
  affects an estimated 15 of the adult population
  over the age of 45 years (at least 200,000 New
  Zealanders.)
• The burden of COPD in New Zealand, 2003, Asthma
  and Respiratory Foundation of New Zealand

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Long term conditions in New Zealand

• Chronic neck and back problems (1 in 4 adults)
• Mental illness (1 in 5 adults)
• Asthma (1 in 5 adults aged 15-44 years)
• Arthritis (1 in 6 adults)
• Heart disease (1 in 10 adults)
• NHC, 2007

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• In 2006/07, two out of three adults had been
  diagnosed with a health condition that lasted, or
  was expected to last, six months or more.
• The most common health condition for adults was
  medicated high blood pressure (13.6), followed
  by asthma (11.2).
• New Zealand Health Survey 2006/2007

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Why the increase?

• Lifestyle risk factors
• Ageing of general population
• Social and economic determinants of health
• Improved surgical and pharmacological
  interventions

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Causes of long term conditions ( World health
Organisation)
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What makes LTCs different

• Need regular acute care
• Pro-active treatment/intervention for long term
  and palliative care
• Focus beyond medical, surgical and pharmaceutical
  care

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Drivers for health service reform

• Epidemiological shift (unhealthy lifestyles,
  ageing populations) led to change in service
  demands
• Historical model-poor fit Acute, episodic care
  model doesnt work well for LTCs.
• Escalating costs of chronic conditions- 70
  medical spending
• Poor adherence to medication, lifestyle advice
  (lt50 at 1 yr)

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Drivers for health service reform cont.

• Changing consumer expectations
• Quality gap EBM and best care vs usual care
• Health inequalities increasing
• Workforce shortages and lack of development
  opportunities
• Health system overload looming

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Long Term Condition Management

• LTCM is a systematic approach to coordinating
  health care interventions across levels
  (individual, organisational, local and national).

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• How are LTCs managed in your area of practice?
• What works?
• What doesnt work well?

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Factors that contribute to the effective
management of LTCs

• The literature suggests that the following
  components underpin effective management of
  LTCs
• Collaboration
• Personalised care plans
• Self-management education
• Adherence to treatment
• Follow up and monitoring.

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Major LTCM models

• Wagner chronic care model (US)
• Innovative care for chronic conditions (WHO)
• Stanford model (US)
• Expert patient (UK)
• Flinders (Australia)

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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Innovative care for chronic conditions (WHO)

• Focuses on community and policy aspects of
  improving chronic care rather than the primary
  focus of the chronic care model.
• Requires micro, meso and macro level
  collaboration

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Wagner CCM

• http//www.researchchannel.org/prog/displayevent.a
  spx?rID3877
• The above link takes you to a presentation by
  Professor Wagner on the Chronic Care Model.

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Self-management

• Self-management involves (the person with the
  chronic disease) engaging in activities that
  protect and promote health, monitoring and
  managing the symptoms and signs of illness,
  managing the impact of illness on functioning,
  emotions and interpersonal relationships and
  adhering to treatment regimes.

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• Lorig adds that self-management is also about
  enablingparticipants to make informed choices,
  to adapt new perspectives and generic skills that
  can be applied to new problems as they arise, to
  practise new health behaviours, and to maintain
  or regain emotional stability

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• The research also suggests that programmes that
  are successful in improving self-management have
  the following characteristics
• Targeting
• Goal Setting
• Planning.

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Self-management

• What are the characteristics of people who
  self-manage well?

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The Six Principles of Self-management A good
self-manager is an individual who Has knowledge
of their condition Follows a treatment plan
(care plan) agreed with their health
professionals Actively shares in decision making
with health professionals Monitors and manages
signs and symptoms of their condition Manages
the impact of the condition on their physical,
emotional and social life Adopt lifestyles that
promote health.
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Evidence on the effectiveness of self-management

• Self-management plans in the primary care of
  patients with COPD (McGeoch et al. 2006) NZ based
  study.
• Action plans for COPD Cochrane review (2009)
• Self-management programme on-line and face to
  face for patients with COPD (Nguyen et al, 2008)
• Asthma self-management plans (Asthma
  Respiratory Foundation of New Zealand)

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Stanford Chronic Disease Self-Management
Programme

• The Stanford model was developed at Stanford
  University, USA in the 1990s.
• Recognised that self-management skills are common
  to a range of chronic diseases.

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• Brief Description
• 6-week group-based course for 10-15 participants
• Utilises 2 leaders, one a health professional and
  one a peer leader

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Stanford cont.

• group environment reduces sense of isolation and
  facilitates self-efficacy
• facilitates empowerment of participants through
  peer learning and sharing
• strong goal setting and problem solving focus

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Flinders Model

• Aim to provide a consistent, reproducible
  approach to assessing the key components of self
  management that
• improves the partnership between the client and
  health professional(s)
• collaboratively identifies problems and therefore
  better (i.e. more successfully) targets
  interventions
• is a motivational process for the client and
  leads to sustained behaviour change
• allows measurement over time and tracks change
• has a predictive ability, i.e. improvements in
  self-management behaviour as measured by the PIH
  scale, relate to improved health outcomes.

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Assessment Tools

• Partners in Health Scale
• Cue and Response interview
• Problems and Goals Assessment

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Cue Response Interview

• AREAS FOR DISCUSSION
• When both parties have rated the question on the
  high end of the scale
• When scores differ markedly on any question
• AGREEMENT ON ISSUES
• Establish which identified issues the
  patient/client wishes to address and what
  interventions may be appropriate
• THESE BECOME ISSUES FOR THE SELF-MANAGEMENT PLAN

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Leading to

• Identification of Issues
• Formation of an individualised Care Plan
• Monitoring and reviewing

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Flinders Stanford

• Generic
• Taught by health professionals and peers to
  patients
• Traditional doctor/patient relationship
• Generic skills goal setting, problem solving,
  symptom management
• Based on cognitive and behavioural principles and
  techniques

• Generic
• Taught by accredited health professionals to
  health professionals
• Doctor patient partnership with patient sharing
  decisions and taking responsibility
• Assessment and care planning, behavioural change
  (goal setting)
• Based on cognitive and behavioural principles and
  techniques

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Policy and funding in NZ

• Develop DHB-based chronic conditions frameworks
• Reduce health inequalities
• Plan community engagement
• Integrate structures and services
• Improve information and knowledge systems
• Provide effective LTCM in PHOs
• Develop workforce capability and capacity
• (National Health Committee, 2007)

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Funding options

• Green prescription
• Care Plus
• http//www.cmdhb.org.nz/funded-services/pho/care-p
  lus.htm
• Services to Improve Access
• http//www.moh.govt.nz/moh.nsf/indexmh/phcs-projec
  ts-sia
• How are these funding streams currently being
  used in your area of work to promote LTCM?