improving outcomes by helping people take control the theory and practice of co-creating health
TRANSCRIPT
Improving Outcomes by Helping People Take Control
The theory and practice of Co-creating Health
Care pathways: providingspecific interventions
Care planning: A system of regular scheduled appointments, providing proactive structured support
NB : People may also be accessing a wide variety of other support e.g. from within their communities
Life with a long term condition: the person’s perspective
Interactions with the service: planned or unplanned Problem solving: Time limited consultation/s providing motivational support
Why support self-management?
3
“Self management support can be viewed in two ways: as a portfolio of techniques and tools that help patients choose healthy behaviours; and a fundamental transformation of the patient-caregiver relationship into a collaborative partnership.”
Bodenheimer T, MacGregor K, Shafiri C (2005). Helping Patients Manage Their Chronic Conditions. California: California Healthcare Foundation.
What is supportedself-management?
4©The Health Foundation
Co-creating Health
Achieve measurable improvements in the quality of life of people living with long term conditions and improve their experience of health services by embedding self management support within mainstream health services.
The problems:
• Lack of care coordination • Lack of active follow-up• Patients inadequately trained to
manage their illnesses
‘Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible.’
Supporting people on
their journey of activation
Supporting people on
their journey of activation
Understanding have role; confident and capable in role
The Chronic Care Model
Developed by the MacColl InstituteACP-ASIM Journals and Books 5
6
Evidence for supporting self management grows every year.
• Research is up to date
• Internationally, studies are consistently positive
• Research has used a range of methodologies.
• Studies are from small to large scale.
It shows that supporting self-management can improve:
• self confidence / self efficacy
• self management behaviours
• quality of life
• clinical outcomes
• patterns of healthcare use
The evidence
7
Active support works best
Research shows that more active support focused on self-efficacy (confidence) and behaviour works best to improve outcomes.
Source: Prof Judy Hibbard, University of Oregon
Information and knowledge alone are not enough.
Approaches that focus on whether people are ready to change work well.
8
• Self monitoring and agenda setting reduce hospitalisations, A&E visits, unscheduled visits to the doctor and days off work or school for people with asthma (Gibson et al 2004).
• Goal setting for older women with heart conditions reduces days in hospital and overall healthcare costs (Wheeler et al 2003).
• Telephone support may improve self care behaviour, glycaemic control, and symptoms among vulnerable people with diabetes (Piette et al 2000).
• Motivational interviewing improve self efficacy, patient activation, lifestyle change and perceived health status (Linden et al 2010).
• Individual education and group sessions improve symptoms for people with high blood pressure (Boulware et al 2001).
Examples of improvement
9
The Co-creating Health model
©The Health Foundation
10
Agenda setting– Identifying issues and problems
– Preparing in advance
– Agreeing a joint agenda
Goal setting– Small and achievable goals
– Builds confidence and momentum
Goal follow-up– Proactive – instigated by the system
– Soon – within 14 days
– Encouragement and reinforcement
Becoming an active partner
Making change
Maintaining change
The Three Enablers
11
An Integrated Approach
Programme Who Role change Focus
Patient
From passive patient to self-management
Activation and partnership: confidence and skills
Clinician
From expert who cares to enabler who supports self-management
Building the knowledge, skills and attitudes needed to provide effective self-management support
Service
From clinician-centred services to services that have self-management support as their organising principle
Embedding the 3 enablers into everyday practice by building them into systems and care pathways
Self-management Programme
Advanced Development Programme
Service Improvement Programme
Self Management Programme outcomes
12
... producing statistically significant changes in:• positively engagement with life• constructive attitude/approach towards condition• more positive emotional well being• using self-management skills and techniques
“I used to go to the doctor only when they summoned me, and then say ‘What are you going to do to fix my problem?’. But now I’m saying like, ‘I’m not sure these particular painkillers are working the way we hoped, can we try something else? What could I do myself? ’ “
Person living with along-term condition
Skills developed ....
• Setting the agenda
• Setting goals
• Problem solving
• Develop the confidence
• Understand their condition
• Develop skills
13
Practitioner Development Programme outcomes
Practice positively influenced:
• patients’ confidence to self manage • agenda setting • setting own goals• collaborative problem solving• goal follow up• patients’ experience
Community matron
Clinician tutor
“It’s a change from the traditional approach where say ‘You need to do this”, and the patient says “you’re the boss”, but doesn’t actually do it. We used to wonder why that wasn’t working”
“Now I use agenda setting with my patients and I start by asking ‘what do you want us to do today?’ Patients appreciate this different approach because you are giving them the power. You work out the goals and the steps together and they are empowered to carry on and work on it on their own. So you may need to see them a bit more at first, but in the long run you need to see them less often.”
Patient Confident in Self
Management
Organisational Changes
Pre-visit changes
During visit changes
Post-visit changes
Primary Drivers Secondary Drivers
Outcome
Service Improvement Programme
IMPROVEMENT
The 3 Enablers
Agenda Setting
Goal Setting
Goal Follow Up
Adapted from Robert Lloyd and Richard Scoville, Better Quality through Better Measurement
15
DiabetesThe
Whittington Hospital and
Haringey and
Islington PCTs
Guys & St Thomas and Southwark PCT
COPDAddenbrokes and
Cambridgeshire PCT
NHS Arran and Ayrshire
DepressionSW London MH Trust and
Wandsworth PCT
Torbay Care Trust and PCT
Chronic PainCalderdale
and Huddersfield Trust and
Kirkees PCT
A model for all LTCs
A model for all long-term conditions
Improving lives in chronic pain?
P intensity P Interference PAM PSEQ0
10
20
30
40
50
60
Pre SMP
6 Months Post SMP
Ou
tco
me
me
as
ure
Sc
ore
p = 0.001p = 0.01 p = 0.02 p = 0.05
Pre and 6 Months Post Self-Management Programme scores for Pain in-tensity, Pain Interference, Pain Activation and Pain Self Efficacy
17©The Health Foundation
Conclusion
Person living with a long-term condition
‘I’d like to thank you both for giving me back the life I thought I’d lost, its made me realise I was holding myself back’