HLN004 Lecture 6 - Chronic conditions self management
- 1. Queensland University of Technology CRICOS No. 00213J HLN004 Chronic conditions prevention and management Lecture 6 Chronic Disease Self Management
- 2. CRICOS No. 00213Ja university for the worldreal R 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)
- 3. CRICOS No. 00213Ja university for the worldreal R 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
- 4. CRICOS No. 00213Ja university for the worldreal R 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
- 5. CRICOS No. 00213Ja university for the worldreal R 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)
- 6. CRICOS No. 00213Ja university for the worldreal R 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)
- 7. CRICOS No. 00213Ja university for the worldreal R 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
- 8. CRICOS No. 00213Ja university for the worldreal R The facets of self management support for patients and health professionals and possible modes of delivery Jordan, Briggs, Brand and Osborne, 2008
- 9. CRICOS No. 00213Ja university for the worldreal R 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
- 10. CRICOS No. 00213Ja university for the worldreal R 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
- 11. CRICOS No. 00213Ja university for the worldreal R 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
- 12. CRICOS No. 00213Ja university for the worldreal R 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
- 13. CRICOS No. 00213Ja university for the worldreal R Flinders Model
- 14. CRICOS No. 00213Ja university for the worldreal R 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
- 15. CRICOS No. 00213Ja university for the worldreal R 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
- 16. CRICOS No. 00213Ja university for the worldreal R 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
- 17. CRICOS No. 00213Ja university for the worldreal R 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
- 18. CRICOS No. 00213Ja university for the worldreal R 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
- 19. CRICOS No. 00213Ja university for the worldreal R 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
- 20. CRICOS No. 00213Ja university for the worldreal R Stanford Model (or Lorig Course)
- 21. CRICOS No. 00213Ja university for the worldreal R 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
- 22. CRICOS No. 00213Ja university for the worldreal R 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.
- 23. CRICOS No. 00213Ja university for the worldreal R 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
- 24. CRICOS No. 00213Ja university for the worldreal R Common Models and Approaches Approaches • Motivational Interviewing • Health Coaching • The COACH Program • Better Health Self-Management • Group Education
- 25. CRICOS No. 00213Ja university for the worldreal R Advancing chronic disease self management in Australia
- 26. CRICOS No. 00213Ja university for the worldreal R 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
- 27. CRICOS No. 00213Ja university for the worldreal R 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,
- 28. CRICOS No. 00213Ja university for the worldreal R (Jordan and Osborne, 2006) Barriers to and enablers for the integration of chronic disease self-management education programs into the Australian health care system
- 29. CRICOS No. 00213Ja university for the worldreal R 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.
- 30. CRICOS No. 00213Ja university for the worldreal R 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
- 31. CRICOS No. 00213Ja university for the worldreal R 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
- 32. CRICOS No. 00213Ja university for the worldreal R 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
- 33. CRICOS No. 00213Ja university for the worldreal R • 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
- 34. CRICOS No. 00213Ja university for the worldreal R AliveConnect transmitter with meter
- 35. CRICOS No. 00213Ja university for the worldreal R 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
- 36. CRICOS No. 00213Ja university for the worldreal R 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
- 37. CRICOS No. 00213Ja university for the worldreal R 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
- 38. CRICOS No. 00213Ja university for the worldreal R 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
- 39. CRICOS No. 00213Ja university for the worldreal R
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- 41. CRICOS No. 00213Ja university for the worldreal R
- 42. CRICOS No. 00213Ja university for the worldreal R 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
- 43. CRICOS No. 00213Ja university for the worldreal R 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
- 44. CRICOS No. 00213Ja university for the worldreal R 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)
- 45. CRICOS No. 00213Ja university for the worldreal R 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
- #5: 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.
- #6: 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.
- #7: 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.
- #8: 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)
- #9: 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 ….
- #10: 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.
- #12: 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.
- #13: 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.
- #14: In assessing a person’s ability and unique characteristics, these are some of the factors that we might look at:
- #15: 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
- #16: 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.
- #17: The flinders model provide a set….
- #20: The basic steps
- #24: 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.
- #27: 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
- #29: 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…..
- #30: 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.
- #31: 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…
- #39: To begin to build an understanding about what this future education might entail, two projects were undertaken…
- #41: 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.
- #42: 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.