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 & poorly coordinated Delayed decision making Wasted visits & time System focus rather than Disease focus rather than what ‘patient’ focus matters to you?
10 characteristics of high performing 3 chronic care systems 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 10. Whole system approach and whole system change 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
Determinants of Health 5 Environment Healthcare 5% 10% Social circumstances 15% Genetics Environment 30% Social circumstances Behaviour choices Genetics Behaviour choices Clnical care 40% 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.
“All New Zealanders live well, 6 stay well, get well” (MOH)
Self Management Support 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. 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, • Includes health literacy • Builds on resilience & development of life skills • Most needed for high needs populations
Self-care is 24/7 What do you do when becoming unwell? – most say, ring the doctor or nurse HOWEVER Over 70% of the week is outside normal working hours so having a care plan to guide “What to do when…” is very important! Virtually everyone can be encouraged & supported to self care/manage some aspect of their health more successfully
Why is self care important? NHS – Supporting people with LTC to Self Care – Department of Health, UK.
Enabling whānau to have the knowledge, confidence & resources to: Be proactive Make better help Shift from passive recipients of seeking choices care to active, engaged & More able to manage motivated whanau a) minor ailments & b) Exacerbations & know what to do when Focus on what can change Share in decision-making Nearly everyone can improve Focused on the values, some aspect of their health priorities & preferences of with the right tools, patients/clients/service users knowledge and support Improve health Improve patient experience and their whanau outcomes . When engaged, sharing in decision-making & proactively When patients feel listened to managing one’s health, customer and their priorities addressed, experience improves. wellbeing, immune function & adherence tends to improve.
Principles of self-management 1. K now & understand your condition 2. Be actively I nvolved with the health practitioners to make decisions & navigate the system 3. Follow the C are plan that is agreed upon with the GP & other health practitioners 4. M onitor symptoms associated with the condition(s) & R espond to, manage & cope with the symptoms 5. Manage the physical, emotional & social I mpact of the condition(s) on your life 6. Live a health L ifestyle 7. Readily access S upport services. Battersby, Flinders Programme 2013
Ways to support self-care The Health Foundation. Helping people help themselves. A review of the evidence considering whether it is worthwhile to support self- management. May 2011.
13 Care planning .
Care Planning 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: • problems • goals • actions and tasks • timeframes & • accountability of all involved to prevent complications & deterioration of long-term health conditions. (Battersby 2007)
Principles & Benefits of Care Planning Principles • “Same Page” “Joined Up Care” Single plan shared by everyone • Health Literacy and communicating in a way patient understands is critical • Patients as partners • Share decision making • Equip, Engage, Empower, Enable Needs dedicated time – 15 minutes doesn’t work well
• Level 5 - Advanced Multidisciplinary 1.5 80 / 20 rule Care Planning across wider healthcare End of % team Life • Level 4 – Comprehensive Care Plan & 8.5 Complex/High Health Summary to facilitate 20% % Health Need multidisciplinary care & case management 10 • Level 3 – Standard Care Plan & % Health Summary – care planning Moderate LTC(s) predominantly within primary care & shared with specialist services to facilitate same page care • Level 2 – Simple Care At risk & Mild - 1 or 2 risk 30% factors or well controlled long- Plan or Action Plan term conditions with minimal completed with GP, nurse impact or allied health provider 80% • Level 1 – Wellness Healthy (approx. 50% of population) 50% Care Plan (optional) Bycroft, J. Health Navigator NZ, 2015
Year of Care – a UK Model www.diabetes.org.uk/upload/Professionals/Year%20of%20Care/Getting%20to%20Grips%20with%20the%20Year%20of %20Care%20A%20Practical%20Guide.pdf
ABCs – Care planning model Pre-visit preparation 4.Develop 5.Early 2. 3.Create 6.Follow skills & warning 1. Assess Balance goal & support signs & up & agree action plan network acute plan
Take Charge Resources www.healthnavigator.org.nz/clinicians/s/self-management-support-project/training-resources/taking-charge/
What matters to you? 1. Assess
Which are patient goals vs clinician driven goals? C – Collaborative goal setting & action • “I will walk for 30 minutes 5 x per week” planning • “I will go to the library and attend the internet classes once a week so I can learn how to skype with my grandchildren.” • “I will get my HbA1C down from 84 to 70 by 1 Sept 15.” • “Quit smoking and lose 5% body weight.” • “Take all your medicines as prescribed.” • “I will take my asthma preventer at least 6 mornings a week and mark it on the calendar to help me remember.”
Refer to self-management programmes 4. Develop skills & support www.healthnavigator.org.nz/healthy-living/self-care/programmes-courses/
Online self-help programmes 4. Develop skills & support https://myjournal.depression.org.nz/ www.beatingtheblues.co.nz/
E - Early Warning Signs & Follow-Up 5.Early warning Plan ahead for exacerbations signs & follow up Red Flags/Early Warning Signs and Crisis plan Use Closing the Loop/Teach-Back to check understanding Phone call within 1-2 weeks post visit Principles • Consultations in which clinicians use Closing the Loop do not take longer and significantly improve adherence and communication • Planned, proactive follow-up makes a difference to goal attainment • Use a coaching approach
Follow Up Phone Calls & Portals www.chcf.org/publications/2008/08/video-on-coaching-patients-for-successful-selfmanagement
Gone Fishing – back at 6pm! John – 6 months earlier • Very sick • House bound • Pain++ • 7 heart attacks • Feeling overwhelmed and lost hope • Sisters caring for him Credits: Waikohu Health Centre nurse-led project reuniting unwell hard-to-reach patients with general practice
29 Self-management support toolkit .
30 www.healthnavigator.org.nz/clinicians/s/self-management-support-project/
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