1. Queensland University of Technology
CRICOS No. 00213J
HLN004 Chronic conditions
prevention and management
Lecture 6
Chronic Disease Self Management
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What is 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, emotion and interpersonal
relationships and adhering to treatment regimes”
“participants to make informed choices, to adapt to
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”
(Flinders Human Behaviour and Research Unit, 2009)
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Patient Self Management vs
Self Management Support
• Patient Self Management= actions individuals take
for themselves
• Self Management Support= facilities that health care
and social care services provide to enable patients to
enhance management of their health
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What is effective management of
chronic disease?
Literature suggests that we need to consider these
components in effective management of chronic
disease:
- Collaboration
- Personalised care plans
- Self-management education
- Adherence to treatment
- Follow up and monitoring
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Self Management
At the policy level, self management has risen
to prominence through:
– The National Chronic Disease Strategy (NCDS)
– Patient programs developed through the Sharing
Health Care Initiative
– Australian Better Health Initiative (moving toward
policy reform, health system changes, supporting
health care professionals through
education, training, clinical audit and financial
incentives)
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Self management initiatives
• Have been based on social, cognitive, behavioural
and self efficacy theories
• Initiatives can include drug management, symptom
management, psychosocial
management, psychological management, lifestyle
changes, social support, goal setting and information
on how to access appropriate services
(Williams, Harris, Daffurn, Davies, Pascoe and Zwar, 2007, p.121)
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Examples of self-management
education interventions
Type of Intervention Examples
Individual Face-to-face consultation Flinders University model of
clinician-administered support
Telephone coaching Coaching patients ON Achieving
Cardiovascular Health (COACH)
program
Internet Individual course New South Wales Arthritis
Foundation course
Internet group course UK National Health Service’s
Expert Patients Programme online
Group: ongoing cycle Rehabilitation programs
Group: formal/structured Stanford University program
Written information Non-government organisation
publications
Population Television/multimedia, social
marketing
Back pain beliefs campaign; Quit
anti-smoking campaign
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The facets of self management support for patients
and health professionals and possible modes
of delivery
Jordan, Briggs, Brand and Osborne, 2008
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Patient Self Management
Current evidence suggests that patients with effective self
management skills:
– Make better use of health care professionals’ time
– Have enhanced self care
– Reduced demand on health service utilisation
– Reduced health care costs
• Reliance on one type of program has limitations
• Evaluation of the Australian Sharing Health Care Initiative -
flexible approach to both delivery and program content
provides greatest health impact
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Capacity to self-manage
• Ability to self-manage will influence the preferred
model and or approach assess beforehand
– Group vs individual intervention
• Capacity to self-manage influenced by:
– the illness itself
– client characteristics
– social and cultural factors
– health professionals’ attitudes and behaviours
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Critical Components for individuals to participate in the
management of their chronic condition
(Jordan, Briggs, Brand and Osborne, 2008)
• A wide range of factors influence a person’s capacity to participate in self-management
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Common Models and Approaches
Models (cognitive behaviour)
• Flinders: assessment and care planning, behavioural
change- goal setting
• Stanford: generic skills- goal setting, problem
solving, symptom management
• United Kingdom National Health Service Expert
Patients Program (based on the Stanford model)
• The United States Institute for Healthcare
Improvement’s model and tools for self-management
support
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Flinders Model
• Generic set of tools and processes enables clinicians and
clients to undertake structured process for
– Assessment of self-management behaviours
– Collaborative identification of problems
– Goal setting (for development of individualised care plans)
• Tools include
– Partners in Health Scale
– Cue and Response Interview
– Problem and Goals assessment
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Aim of the Flinders Model
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
– 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, related to improved health
outcomes
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Flinders Model
Format
• Detailed one-to-one assessment and care planning
• Use of standardised forms and tools
• Requires health professionals to complete a 2 day training
and approval of 3 case studies
Advantages
• Individualised and client-centred (using clients’ goals)
• Differentiates between care for chronic conditions vs acute
conditions
• Promotes systems change within organisations to enhance
chronic condition care and self-management
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The Flinders Model
1. Assess
– Use partners in Health Scale
– Use Cue and Response Interview
– Problems and Goals Assessment
2. Agree on Care Plan
– Identification of Issues and Goal Setting
– Agreed goals
– Agreed interventions
3. Useful tools
– Symptom Action Plan
– Doctor visit checklist
– Patient Handbook
4. Monitor and Review
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Flinders Model - Principles of Self-
Management
1. Know the condition you have
2. Involve yourself in the decision making with health
practitioners
3. Care plan adherence as agreed
4. Monitor symptoms
5. Respond to symptoms as learnt in order to enhance
management of the condition
6. Impact of the condition(s) on your life (physically,
emotionally and socially) need to be managed
7. Lifestyle is important, so live a healthy one
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Barriers within the Flinders Model
• Time intensive in its format when all tools are used
• Some clients perceive the approach as confronting
• Although training professionals adequately equips
them to assess and plan, it does not provide the
mechanisms for supporting ongoing self
management and behaviour change
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Stanford Model (or Lorig Course)
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Stanford Model
Format
• Group based structured course (10-15 participants)
– 6 week duration
• Requires a health professional and a peer leader to lead the
course (leaders are required to attend a 3 day training course)
Advantages
• Focus on problem solving and goal setting
• Empowerment via peer sharing and learning
• Group work reduces perceived isolation and facilitates self-
efficacy
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Stanford Model (Lorig course)
Subjects covered include:
1) Techniques to deal with problems such as
frustration, fatigue, pain and isolation
2) Appropriate exercise for maintaining and improving
strength, flexibility, and endurance
3) Appropriate use of medications
4) Communicating effectively with family, friends, and
health professionals
5) Nutrition, and,
6) How to evaluate new treatments.
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Stanford Model
Barriers
• Group environments do not suit everyone
• Reduced capacity to address individual needs
• Structured content makes it difficult to address
individual learning needs, learning styles and
learning speeds
• Participants need to find ongoing peer contact after
the six week course
More information:
http:/patienteducation.stanford.edu/programs/cdsmp.
html
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Common Models and Approaches
Approaches
• Motivational Interviewing
• Health Coaching
• The COACH Program
• Better Health Self-Management
• Group Education
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Advancing chronic disease self
management in Australia
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Chronic Disease Self Management and the
National Chronic Disease Strategy
• Recognised in the NCDS that it is essential that
support is put in place at all levels of the health
system to optimise people’s ability to self manage
• Making self management key action area recognises
that many health behaviours required to effectively
manage chronic disease daily responsibility of
people themselves
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Advancing CDSM programs in
Australia
• Increasing focus on self management programs as
well as self management support systems in
Australia
• CDSM programs are increasingly recognised as part
of secondary prevention of chronic disease
• The 2008-2009 federal budget placed a renewed
emphasis on preventive health care,
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(Jordan and Osborne, 2006)
Barriers to and enablers for the integration of chronic disease self-management
education programs into the Australian health care system
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Self Management Support
in Australia
• Currently lack of coordination of initiatives in area of
CDSM support
• To improve integration, self management support
needs to be incorporated as an integral aspect of
health service redesign in terms of infrastructure and
systems to ensure appropriate uptake and utilisation
by key stakeholders eg patients, carers, health
professionals and health care organisations.
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Examples of initiatives that are being undertaken in
Australia
Government policymakers; funding providers
• Inclusion of self-management support in national strategic
frameworks (eg. National Service Improvement Framework)
• Sharing Health Care Initiative
• Australian Better Health Initiative
• Early Intervention in Chronic Disease in Community Health
(Victoria)
• Systematic evaluation for state-based chronic disease self-
management courses (Western Australia)
• Medicare Benefits Schedule (chronic disease management
items, Team Care Arrangements)
• Self-management interventions incorporated into national
clinical practice guidelines
Jordan, Briggs, Brand and Osborne, 2008
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Examples of initiatives that are being undertaken in
Australia
Non-government and broader community organisations
• Chronic disease self-management education programs
• Disease-specific information
• Telephone helplines
• Support groups
Health care professionals and professional associations
• Medicare Benefits Schedule
• Self-management curricula for undergraduate medical, allied health
disciplines and postgraduate ongoing professional development programs
• Self-management interventions incorporated into clinical practice guidelines
Health care system managers and organisations
• Primary Care Partnerships (Vic)
• Self-management interventions incorporated into clinical practice guidelines
Jordan, Briggs, Brand and Osborne, 2008
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Case Manager:
monitors and triages
reports and alerts
Health Provider:
Collaborative goal
setting
Electronic
Health Record
Self-Monitoring:
e.g. Blood Glucose
testing, symptoms
monitoring
TLC (Telephone
Linked Care):
Educates, monitors,
supports and
produces alerts and
reports
Australian TLC Diabetes
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• Directly from caller’s home to TLC database
• Just before weekly call to TLC Diabetes
• Improving accuracy of TLC feedback on BG testing
AliveConnect: a new device to upload BG
results
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AliveConnect transmitter with meter
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Chronic Disease Self management and
the skills of the health workforce
The Australian Department of Health
and Ageing, through the Australian
Better Health Initiative determined
that education and training of the
existing and future health workforce
was a key element in assisting
patients to better manage their
chronic conditions
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Continued..
2 projects were undertaken:
a) The development of a curriculum framework for self
management support education of the future
workforce
b) Determine the skills required for prevention and
self-management support of chronic conditions by
the current PHC workforce
– 19 core capabilities have been defined and confirmed as
necessary for the Primary Health Care Workforce to
successfully support patients and carers within the self
management continuum
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Best Practice for Delivering Prevention and
Chronic Condition Self-Management Support
Has been based on the Chronic Care Model. This model can be applied to PHC
settings as part of implementing care across the prevention, early risk factor
identification and Chronic Care Self-Management support continuum
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Core Skills for the PHC Workforce
General Patient-Centred
Capabilities
Behaviour Change
Capabilities
Organisational/Systems
Capabilities
1. Health promotion
approaches
2. Assessment of health risk
factors
3. Communication skills
4. Assessment of self-
management capacity
(understanding strengths
and barriers)
5. Collaborative care
planning
6. Use of peer support
7. Cultural awareness
8. Psychosocial
assessment and support
skills
9. Models of health behaviour
change
10. Motivational interviewing
11. Collaborative problem
definition
12. Goal setting and goal
achievement
13. Structured problem solving
and action planning
14. Working in multidisciplinary
teams/interprofessional
learning and practice
15. Information, assessment
and communication
management
16. Organisational change
techniques
17. Evidence-based knowledge
18. Conducting practice based
research/quality improvement
framework
19. Awareness of community
resources
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Best Practice for Delivering Prevention
and Chronic Condition
Self Management
• Patient-centred skills for effective engagement and
communication between patients, PHC workers and health
systems
• Skills to support behaviour change by patients (and staff)
• How to work collaboratively in teams and systems that
actively use a range of technology and evidence-based
practices to achieve optimal patient outcomes
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Continued…
• How to plan care that accesses a range of skills and
resources within and across disciplines and within
the community; and
• An understanding of the social determinants of
health and health promotion approaches to achieve
population health outcomes
Australian Government Department of Health
and Ageing, 2009
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Summary
1) Develop health literacy within the whole population
2) Invest in research and evaluation
3) Increase engagement of patients, clinicians and
organisations with self-management programs
4) Drive integration of self management into
clinical, educational and workplace contexts
5) Optimise self-management programs through
incorporation of best educational practice and
insights from psychological sciences
(Glasgow, Jeon, Kraus and Pearce-Brown, 2008)
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References
• Australian Government Department of Health and Ageing. (2009). Capabilities for
Supporting Prevention and Chronic Condition Self-Management: A Resource for
Educators of Primary Health Care Professionals. Commonwealth of Australia:
Canberra.
• Glasgow, N., Jeon, Y, Kraus, S. and Pearce-Brown, C. (2008). Chronic Disease
Self-management support: the way forward for Australia. Medical Journal of
Australia. 189(10 Supplementary); S14-S16)
• Fisher et al, Ecological approaches to self-management: the case of
diabetes. 2005 Am J Public Health 95:1523-1535
• Jordan, J., Briggs, A., Brand, C. and Osborne, R. (2008). Enhancing patient
engagement in chronic disease self-management support initiatives in Australia:
the need for an integrated approach. Medical Journal of Australia. 189(10
Supplementary): S9-S13.
• Jordan, J. and Osborne, R. (2006). Chronic disease self-management education
programs: challenges ahead. Medical Journal of Australia.
• Williams, Q., Harris, M., Daffurn, K., Davies, G., Pascoe, S., Zwar, N. (2007).
Sustaining chronic disease management in primary care: lessons from a
demonstration project. Australian Journal of Primary Health. 13(2): 121-127.
Editor's Notes
The traditional model of acute care which focuses more on the illness than on the patient and is expensive and often ineffective, with the cost of care for chronic conditions exceeding billions of dollars. As such, the management of chronic conditions requires new strategies to delay health deterioration, improve function, and address the problems that people confront in their day-to-day lives.
Self-management refers to the strategies that a person with a chronic condition implementsto manage their own illness.It includes healthy lifestyle choices, informed decisions regarding ongoing treatment options, monitoring and managing symptoms and impacts of chronic health conditions and working in partnership with a team of health care workers. It requires lifelong choices, skills and strategies on the part of the individual for optimal management of their health condition in the long term. Self-management does not mean that an individual must manage their own health without any medical or healthcare treatments or support. Self-managementis a partnership between the patient and the healthcare professional with the aim of achieving desirable health outcomes.Health providers, organisations and the community and carers can provide care, support and encouragement to people with chronic conditions. Together they can help them take the central role in managing their conditions, making informed decisions about treatment and management options, and making healthy behaviour choices.The actions and support provided by healthcare practitioners is known as Self-management support, and assists a person with their self-management practices, and to support their self efficacy and ability to effectively self-manage. Self management support: can be provided through a range of strategies and approaches––individual and group based, face-to-face or by phone, as part of clinical intervention and/or as a separate interaction with the person with a chronic disease,includes not only the provision of information, but also assistance in practically applying health information in the individual context through goal setting and problem solving Is a philosophy or entire approach and not just an intervention and finally involves partnership with people with chronic diseases.
Literature suggests that there are several important components that are inherent of effective self-management programs. These include collaboration between healthcare providers and patients, care plans that are tailored to suit the needs to the individual, education to assist the patient in managing their own condition, adherence by the patient to recommended treatment, and regular systematic follow-up and monitoring. Essential characteristics of self-management support are that it: respects choices and individual circumstances of the person with a chronic disease, but assists to address barriers to self-management involves goal setting and problem solving as key components is an ongoing collaborative process between the health care practitioner and person with a chronic disease; not something that is completed in a time-limited intervention. Self-management is a lifelong practice for the individual and self-management support needs to be available when the person needs support in maintaining this approach.
NCDS identifies chronic condition self management as a priority action area and suggests that self-management principles be embedded throughout the entire continuum of chronic disease prevention and management. The NCDS identifies future directions for chronic disease self-management as requiring reorientation of the healthcare system, prioritising patient participation in healthcare planning, improving the capacity of the peer, disability and carer support sectors and tailoring self-management approaches to meet individual and community needs.The four year Sharing Health Care Initiative (SHCI) announced in the 1999 Federal Budget involved the provision of funding to conduct eight demonstration projects (one in each State and Territory), to look at a set of chronic condition self-management service delivery models in a variety of urban and rural locations. In addition, four community based indigenous projects were funded. The projects target mature adults 50 years and over (35 years and over for indigenous populations). The SHCI focuses on self-management for chronic health conditions from a restricted list including Heart disease Diabetes Arthritis Osteoporosis Respiratory disease (e.g. asthma) Depression (where it exists alongside another chronic health condition) The approaches in each location varied, ranging from a largely telephone based support system utilising health professionals in Victoria to a community controlled project in the Aboriginal communities of Katherine West in the NT.The Australian Better Health Initiative is part of the Council of Australian Government’s 4 year plan – ‘$1.1 Billion injected to health’ announced in 2006. ABHI is directly funded by the Department of Health and Ageing until June 2010. There are five focus areas: Promoting Healthy Lifestyles (e.g. through national social marketing campaigns like measure up, healthy tuckshop policies in schools)Signposting early detection of risk factors and chronic disease (e.g. screening programs)Supporting lifestyle and risk modification (referral of high risk individuals to existing programs)Encouraging active patient self management of chronic conditions (e.g. provision of resources, development of programs)Improving the communication and coordination between services (e.g. appointment of staff to specifically work to create coordinated approaches)
There are a range of initiatives that can be adopted in assisting people to self-manage their condition. As you can see, these initiatives have been based on ….
Self-management support and programs can be provided within a range of contexts, providing support and guidance to the individual ranging through to the population. The slide here provides a brief summary of some of the many initaitives and programs available across these levels.
So why is there such an emphasis, and active encouragement for the inclusion of chronic disease self-management principles to address chronic conditions?Read first part of slide. Cochrane reviews on self-management strategies for COPD, diabetes and arthritis have demonstrated evidence of: • decreased presentations to hospital • improved clinical indicators (such as HBA1C) • increased self-efficacy and wellbeing. In Australia specifically, the National Quality and Monitoring System for Chronic Disease Self-Management education programs has shown that 1/3 of patients who attended a community program reported substantial development of skills, techniques and self monitoring.
As I suggested before, there are a variety of approaches to assist patients in self-managing their condition. Individual ability will have an influence on the model or approach chosen for a particular individual. This ability will be influenced by the type and severity of the condition, the client’s individual characteristics, social and cultural factors for the client, and the attitudes and behaviours of the health care professional, or professionals involved in the clients care. These factors combined will determine whether we seek group-based or individual self-management support.
In assessing a person’s ability and unique characteristics, these are some of the factors that we might look at:
self-management programs are programs or services thatsimultaneously address symptom and disease management, emotional consequences and daily life with a chronic condition,provide opportunity for developing competence, vicarious learning, social persuasion and re-interpretation of symptomsteach problem solving and decision making (Bandura, 1997)instruct how to develop partnerships, set goals and introduce action planning.Self-management programs can be run many different ways using any combination of focus, consumer group, format or setting. While some programs may be run in groups, another could be offered to an individual online.Self-management programs differ from peer support groups, information/education alone, exercise alone, or cognitive behavioural therapy programs alone. FocusThe focus of self-management programs is to help people manage one or more of the following:Their condition itself – managing the symptoms, preventing new symptoms or complications, and reducing risk factors (such as improving their diet and increasing their exercise). The emotional consequences – this may include things like fear of the future, how to tell friends and family about their condition, sadness due to loss of employment, and many others.The effect of the condition on daily life – this may include things like how to change work and family activities when experiencing reduced energy, how to set personal priorities, and how to make difficult decisions.FormatThe format for a self-management program can be for an individual or group.Setting The setting for a self-management program can be in person, over the telephone or online.Complexity of condition and capacity to self-manageDepending on how complex the person's health condition might be, different self-management services, programs and approaches apply.This slide highlights some of the major models used to achieve chronic condition self management. Today we will discuss the Flinders model and the stanfor model
The flinders model is a clinician lead model that integrates self-management principles with medical management. The model emphasises the need to educate and train the primary care workforce to assist people with chronic conditions to achieve sustainable and long term gains in health.
The flinders model provide a set….
The basic steps
The stanford model focuses on peer leadership, with people with chronic diseases learning from each other via a group based approach through which experiences and collective problem solving are ahared. Programs that are based on the stanford model are potentially low-cost and individuals with chronic conditions learn how to manage and improve their own health, while reducing health care costs. Suchprograms focus on problems that are common to individuals suffering from any chronic condition, such as pain management, nutrition, exercise, medication use, emotions, and communicating with doctors.Led by a pair of trained facilitators who manage their own chronic health conditions, workshops cover materials over a six-week period. During the program, approximately 15-20 participants focus on building the skills they need to manage their conditions by sharing experiences and providing mutual support. These programs help people with diverse medical needs such as diabetes, arthritis, and hypertension develop the skills and coping strategies they need to manage their symptoms, through the Employment of action planning, interactive learning, behavior modeling, problem-solving, decisionmaking, and social support for change.Based on a review of major published studies, CDSMP results in significant, measurable improvements in the health and quality of life of people with chronic conditions. CDSMP also appears to save enough through reductions in health care expenditures to pay for itself within the first year. Studies have indicated:Cost SavingsFewer emergency room visits, inpatient stays, and outpatient visits (minimum savings of $100 per participant).Fewer hospitalizations (savings of $490 per participant).A health care cost savings of approximately $590 per participant.Health BenefitsImprovement in exercise and ability to participate in one’s own care over a two-year period.Improved health status in seven of nine variables: fatigue, shortness of breath, pain, social activity limitation, illness intrusiveness, depression, and health distress.Improved health behaviors and self-efficacy in variables related to exercise, cognitive symptom management, communication with physicians, and self-efficacy.
Motivational interviewingMotivational Interviewing focuses on exploring and resolving ambivalence and centers on motivational processes within the individual that facilitate change. The method differs from more “coercive” or externally-‐driven methods for motivating change as it does not impose change (that may be inconsistent with the person's own values, beliefs or wishes); but rather supports change in a manner congruent with the person's own values and concerns. Motivational Interviewing is grounded in a respectful stance with a focus on building rapport in the initial stages of the counseling relationship. A central concept of MI is the identification, examination, and resolution of ambivalence about changing behavior.Ambivalence, feeling two ways about behavior change, is seen as a natural part of the change process. The skillful MI practitioner is attuned to client ambivalence and “readiness for change” and thoughtfully utilizes techniques and strategies that are responsive to the client. Health coachingHealth coaching, also referred to as wellness coaching, is a process that facilitates healthy, sustainable behavior change by challenging a client to listen to their inner wisdom, identify their values, and transform their goals into action. Health coaching draws on the principles of positive psychology and the practices of motivational interviewing and goal setting.COACHThe COACH Program is the world's first evidence-based (clinically proven) program of coaching for the prevention of chronic disease and is the world leader in coaching in clinical medicine. The COACH Program is now the most widely used chronic disease management program in Australia. Coaching is directed at the patient and not at the treating doctor. The coach (a qualified health professional such as a dietitian or nurse) uses the telephone and mailouts (generated by The COACH Program software) to provide regular coaching sessions to patients over a period of 6 months. Patients are coached to know their risk factor levels, the target level for their risk factors, and how to achieve the target levels for their risk factors. Patients are persuaded to go to their usual doctor(s) and empowered to ask for appropriate prescription of medication, changes in dose, and even to change a drug if maximal dose of a particular drug has failed to achieve the target.Better health self-management A program based on the stanford model
As I said earlier, the NCDS identifies chronic condition self management as a priority action area and suggests that self-management principles be embedded throughout the entire continuum of chronic disease prevention and management. In making self-management a key action area, the strategy…..
The strong evidence suggesting the effectiveness of chronic disease selfmanagement has resulted in an increased focus on self-management programs and support in Australia, as these are increasingly recognised as effective means of seconday prevention for chronic conditions which place significant burden on a healthcare system.
There are multiple barriers and enablers for the integration of chronic disease self-management programs into the healthcare system. The current slide summarises the key barriers to the implementation of such programs, and links these with potential enablers to assist in addressing such barriers and/or effectively implementing such programs within the healthcare system. As you can see the interralationships between these is somewhat complex, so I will not read all of these out. But to give you an example of one barrier and potential enablers:In regards to the recruitment of sufficient numbers of patients into a program (the top green box on the slide) you can see that some suggested enablers to address this barrier and effectively implement a chronic disease self-management program include…
To begin to build an understanding about what this future education might entail, two projects were undertaken…
The Chronic Care Model, supported by an extensive review of the prevention and chronic condition self- management support literature and research, provided the base for the development of a survey of theskills required by the national PHC workforce. Following this survey with the national PHC workforce anda survey of existing training organisations delivering chronic condition management and self-management education, national consultation with key stakeholders from across the PHC education, training, professional accreditation and clinical delivery sectors was undertaken. Nineteen core capabilities were defined and confirmed as necessary for the PHC workforce to successfully support patients and carers within the self- management continuum. Each of these skill areas assumes an underlying knowledge and values base.
Figures 6.2.1, 6.2.2 and 6.2.3 identify the baseline knowledge, attitudes and skills required by health professionals to support patients to self-manage their health through the lifespan from maintenance of wellness and prevention of illness, early detection and risk factor modification and self-management of established chronic conditions respectively.
