Sel elf-Manag Manageme ement nt Sup upport port & & - - PowerPoint PPT Presentation
Sel elf-Manag Manageme ement nt Sup upport port & & Ca Care re Planning nning Dr Janine Bycroft, Associate Clinical Director, ProCare, Clinical Director, Health Navigator NZ The problem that needed solving 2 Care is fragmented
Dr Janine Bycroft, Associate Clinical Director, ProCare, Clinical Director, Health Navigator NZ
2
Care is fragmented & poorly coordinated Wasted visits & time Disease focus rather than what matters to you? System focus rather than ‘patient’ focus Delayed decision making
3
1. Universal coverage 2. Low cost or free care 3. Focus on prevention not just treatment 4. Priority given to self-management support for patients to self manage their conditions with support from carers and families 5. Priority is given to primary health care, particularly multi- disciplinary team work in chronic care led by nurses 6. Population management & risk stratification by clinical risk 7. Integrated care with easy access to specialist advice and support for primary care 8. Information technology is used to facilitate communication across wider team members, support at home (eg telehealth) 9. Care is effectively coordinated across health and social sector and people given own budgets or allowed to make direct payments for services
Ham, C, 2010 as presented by Prof Nicholas May in Report To Treasury Jan 2013
4 Slide from Rodenburg, H. Self-Management Workshop, May 2015
5
Environment 5% Social circumstances 15% Behaviour choices 40% Genetics 30% Healthcare 10%
Environment Social circumstances Behaviour choices Genetics Clnical care
McGinnis, J. M., Williams-Russo, P., & Knickman, J. R. (2002). The case for more active policy attention to health promotion. Health affairs, 21(2), 78-93.
6
It requires: Paradigm shift in control – patient/client/whanau have central role in managing their health day to day, expert about their values, priorities, roles and preferences Structured approach, with a range of tools & resources to match stage of change, values & priorities of patient/family Collaboration between patient and care provider, Provider is a coach as well as clinician and, Is what we, as clinicians and a health system (along with whanau, community and peers) do to support, encourage and enable people to manage the often complex medical, psychological and emotional roles of living with a long-term illness/condition more effectively.
NHS – Supporting people with LTC to Self Care – Department of Health, UK.
Improve patient experience
When patients feel listened to and their priorities addressed, wellbeing, immune function & adherence tends to improve.
Make better help seeking choices
More able to manage a) minor ailments & b) Exacerbations & know what to do when
Share in decision-making
Focused on the values, priorities & preferences of patients/clients/service users and their whanau .
Be proactive
Shift from passive recipients of care to active, engaged & motivated whanau
Focus on what can change
Nearly everyone can improve some aspect of their health with the right tools, knowledge and support
Enabling whānau to have the knowledge, confidence & resources to:
Improve health
When engaged, sharing in decision-making & proactively managing one’s health, customer experience improves.
Battersby, Flinders Programme 2013
The Health Foundation. Helping people help themselves. A review of the evidence considering whether it is worthwhile to support self-
13
Health/Care planning is the process of proactively developing a structured, comprehensive plan by the patient and their significant others, carers & health professionals(s). It defines:
to prevent complications & deterioration of long-term health conditions.
(Battersby 2007)
plan shared by everyone
in a way patient understands is critical
Needs dedicated time – 15 minutes doesn’t work well
Care Planning across wider healthcare team
End of Life
Health Summary to facilitate multidisciplinary care & case management Complex/High Health Need
Health Summary – care planning predominantly within primary care & shared with specialist services to facilitate same page care Moderate LTC(s)
Plan or Action Plan completed with GP, nurse
At risk & Mild - 1 or 2 risk factors or well controlled long- term conditions with minimal impact
Care Plan (optional) Healthy (approx. 50% of population)
1.5
%
8.5 % 10 % 30% 50% Bycroft, J. Health Navigator NZ, 2015
20% 80%
www.diabetes.org.uk/upload/Professionals/Year%20of%20Care/Getting%20to%20Grips%20with%20the%20Year%20of %20Care%20A%20Practical%20Guide.pdf
2. Balance & agree 3.Create goal & action plan
4.Develop skills & support network 5.Early warning signs & acute plan
6.Follow up
Pre-visit preparation
www.healthnavigator.org.nz/clinicians/s/self-management-support-project/training-resources/taking-charge/
C – Collaborative goal setting & action planning
www.healthnavigator.org.nz/healthy-living/self-care/programmes-courses/
skills & support
https://myjournal.depression.org.nz/ www.beatingtheblues.co.nz/
skills & support
5.Early warning signs & follow up
Principles
longer and significantly improve adherence and communication
www.chcf.org/publications/2008/08/video-on-coaching-patients-for-successful-selfmanagement
Credits: Waikohu Health Centre nurse-led project reuniting unwell hard-to-reach patients with general practice
John – 6 months earlier
and lost hope
29
30
www.healthnavigator.org.nz/clinicians/s/self-management-support-project/
31
Enhanced user experience
Our content is regularly updated and peer reviewed: Content is also provided by approved content providers vetted for their quality standards
Self care focus
As well as a comprehensive library of health conditions and medicines topics, we have a strong focus on prevention and self-care information.
Relevant to New Zealand
We save health organisations time and money localising international content. Our content is written by New Zealanders, for New Zealanders. .
Improving health literacy
Our content is developed based
people from the age of 10 and above can read, understand and use it.
Easy to read
Excellent use of plain language, white space, bullet points, sub headings and short sentences to improve understanding.
We are dedicated to providing quality content and resources for New Zealanders
Peer review
We take advantage of international trends in user experience (UX), ensuring visitors to our site keep returning and sharing our content with friends and family.
www.healthnavigator.org.nz/clinicians/s/self-management-support-project/
32
www.healthnavigator.org.nz/clinicians/s/self-management-support-project/training-resources/
33
34
35
Bennett, H. Coleman E. Parry C. Bodenheimer T. Chen E. Health Coaching for Patients. Sept/Oct 2010 www.aafp.org/fpm FAMILY PRACTICE MANAGEMENT
36
37
37 https://www.vitl.net/sites/default/files/documents/Summit/Summit14/e-Patient_Dave_45_minutes_2014.pdf
Consumers equal partners from the beginning
38
38
39
Thanks to ADHB Performance Improvement team for sharing, Feb 2018
40
41
www.healthnavigator.org.nz OR www.hn.org.nz
42
43
www.healthnavigator.org.nz/apps/
44
45
46
Health information needs of Zealanders
Crown Enterprises
Committee
Board
PHARMAC
Specific campaigns
Professional Organisations
DHBs
Services,
etc
Academic institutions
Publishers
PHOs
NGOs & Community groups
Arthritis NZ
focused NGOs
etc
General Practices BPAC
companies
alternative health providers
companies
Pathways groups
Health Directories
Individuals, Authors, Research groups Clinical Networks Regional, national, virtual groups
Health Navigator NZ
Medsafe NZ Formulary
KidsHealth
47
48
At each stage of the journey: What can we do to enable people to have the skills, confidence and right support to manage well at home and maximise their health and wellbeing?
Contact Dr Janine Bycroft
janine@healthnavigator.org.nz facebook.com/healthnavigatornz www.healthnavigator.org.nz