mobilising community assets to help people achieve personal health...
TRANSCRIPT
Mobilising community assets to help people achieve personal health outcomes
Margaret Hannah, Director of Public Health
Fife Health Board, Scotland
Helen Crisp, Assistant Director of Research
The Health Foundation
Conflicts of interest
None to declare
Margaret Hannah, employed by Fife Health Board,
Scotland
Helen Crisp, employed by the Health Foundation, UK
Giving this presentation is part of my work for the
Foundation
Valuing health and wellbeing
Take 3 – 4 minutes to talk to 2 or 3 people sitting
near you about:
What do you value in your life that
keeps you healthy and well?
Context in the NHSA growing consensus about the need for
health and care services to embrace and
support the role of individuals and
communities in their health and care –
and a growing understanding of the value
of doing so.
Person and community centred approaches
What does the evidence tell us?
Key Objectives
•Making the case for person and community
centred care
• Evaluating the impact of key evidence-based
approaches and developing tools to support
their adoption and spread.
• Supporting culture change, by developing a
range of behaviour change approaches to impact
on the relationships between professionals and
people
• Aligning the system by identifying relevant
system change levers and drivers
Rita’s story
Three Horizons Framework
Increasing signs of strain and
system failures
Innovation to try and keep things
going
new context for
useful old ways
less
disruptive change
new paradigm fits and takes off
TIME
THE TURBULENT TRANSITION
HORIZON 1
HORIZON 2
HORIZON 3
VIABILITY
radically different operating
environment
NOW
www.internationalfuturesforum.com
A quick tour of Southcentral Foundation, Alaska
“Third Horizon in the present”
Fife SHINE Programme
• Find ways for older people to thrive, not just
survive at home.
• Explore what matters to people, nurturing
quality relationships.
• Co-create solutions with
and by the community
maximized.co.uk
scottish-places.info
Training exercise
• Think of an older person you know
personally. They may be still alive or not.
• What makes/would have made a
difference to their health and wellbeing?
• Take 2 minutes to talk about this person to
your neighbour.
• Other person listens without interrupting.
Deepening and embedding
the practice• “Good Conversations”
• Reflective learning sessions
• Review visits
• Clinical champions
• Revised paperwork
• Annual learning event
Claire’s Story
“It changes the relationship. I now put more of me in to the conversation. I am a daughter, a wife, a friend, a mother. I just happen to work as an OT. People are now thanking me for listening and talking with them at a person level and I am thanking them in return. It is a more enjoyable way of working, of relating to each other.”
“I was working with one lady who had been in hospital. I was there to help her with kitchen tasks to ensure she was able to make herself something to eat and drink safely. And through conversation, boiling the kettle, making a cup of tea, she talked about her friends and their support while she’d been in hospital. Sitting safely in the kitchen drinking a cup of tea from a spill-safe beaker on her own really wasn’t what she wanted. She wanted to be able to make a pot of tea and serve it to her friends in her living room. She wanted to reciprocate. It was important for me to support that.”
Evelyn’s Story
“I was referred a very elderly lady with dementia and was told to ‘keep her ticking over until we can find her a place in long term care’. But as I got to know her, her self-esteem and confidence grew. She began to talk more about things she enjoyed doing and grew less anxious about leaving the house. I began to realise that her wish to live at home had become a real possibility.”
Mary’s Story
What are we learning for
patients/clients?
• Small changes can make a big difference
• Understanding what is important to the person can change the intervention and lead to different outcomes
• Feeling useful and connected is really important
• Being listened to is even more important
What are we learning for staff?
• Supporting staff self-care and time for reflection is vital
• Staff find this way of working protective and energising
• Flexible and creative management responses can unlock complex situations
• Saves time – gets to the heart of things quicker
• Facilitates discharge – easier for staff and client to let go appropriately
Changing the culture of care
• Looks like failure in first 1-2 years
• Change in practice is “subtle but profound”
• Supporting infrastructure takes time to
build
• Learning every step of the way
Engaging Patients
in their own HealthSweden 2016 B9
Diana Dowdle
Delivery Manager
Dr David Codyre
Campaign Clinical Lead
New Zealand
Learning from New Zealand
Where is Ko Awatea?
20 District
Health Boards
Across NZ
Counties Manukau Health
• 512,000 people
• 11% of NZ Population
• NZ’s largest deprived
populations
• NZ’s largest Pacific population
• 1-2 % growth per year
• 950 Middlemore Hospital beds
• 7,000 staff
Case for Change
Counties Manukau Health
Emergency Care sees nearly
100,000 people per year
Unsustainable growth in
demand
Full hospital
Increasing people with long
term conditions
Christchurch earthquakes February 2011
67,020 People with Long Term
Conditions (2013)
• 38,860 with Diabetes
• 16,600 with Cardiovascular
Disease (CVD)
• 5,750 with Chronic Obstructive
Pulmonary Disease (COPD)
• 4,590 with Coronary Heart
Failure (CHF)
• 18,440 with Gout
• 4,720 with Asthma
Having LTCs means
increased risk of
Mental Health
problems,
Loss of Wellbeing
The “Zone of Delusion”
Who controls the outcomes?
Case Study – “Tavita”: A clinician-centred perspective58 y.o. man, obese, smoker, past heavy drinking
Diabetes – poorly controlled, HbA1c over 100
Gout – frequent flare-ups
Poor adherence to medication
Frequent unplanned GP appts
Frequent unplanned ED presentations
Many DNA’s to specialist appts
“No matter what we say or do, he does not do it; he
does not want to be well…”
Case Study – “Tavita”: What we do nowFocus on his pressing medical issues
GP visits – review, prescribe medication, try to make
him understand his health conditions, stress to him
how important it is to take his meds, prognosis if he
does not
ED visits – re-assess, re-investigate, re-prescribe,
discharge
Referrals to diabetes and rheumatology svcs –
mostly DNA’d
“No matter what we do, he does not want to be
well…”
Case Study – “Tavita”: His story“No-one has ever listened to my story before”
Grew up with family violence, alcohol – lifestyle of
drinking and violence through teens – BUT since 20s
he has tried to improve his life, be a good father,
work
Struggles with depression, has symptoms of PTSD,
has continued to “self medicate” with alcohol
Ongoing worry re: kids problems – truant, getting into
trouble; finances; conflict with own family/siblings
When doctors/nurses try to “make me understand” re
health, “can’t make sense of it”, worry
Case Study – “Tavita”: A patient-centred perspectivePrimary issues – trauma history, PTSD, depression,
family stress, low self esteem – all meaning he feels
he has no control in his life.
Secondary issues – diabetes, gout
Attempts at “health education” have left him feeling
whatever he does, he will die young.
He is thus anxious about his health, but does not
know what to do, and does not trust health
professionals who “don’t understand…”
Case Study – “Tavita”: A different approachWhat is happening now is a “lose-lose-lose”
He feels more and more out of control, his health
is getting worse
He is now unable to work, address his family
issues
We get frustrated trying to help, and he is an
increasing burden on the health system
SO HOW COULD WE DO THIS DIFFERENTLY???
What would a “self-management support” informed
approach look like??
Case Study – “Tavita”: A different approach to prioritising1. Listen, hear his story, understand his
perspective and what his issues are
2. Engage him in identifying his goals and what
support works for him
3. Address mental health & psychosocial issues
4. Improve his health literacy, “self-efficacy”, and
“self management” skills – and then…
…chances are his medical issues will be easier
to manage
Moving From Defined Roles For Clinician and Patient …
Power imbalance
Clinician responsibility
“What’s the matter with
you”
Compliance
Constraint
…To a Focus On Building Trust and Partnership
Health Behaviour
“What matters to you”
Partnership
Shared responsibility
Teamwork
Liberation
20,000 Days Campaign
The increasing demand on
resources across Counties Manukau is
driving the need for continuing
improvements in the way that we keep
our community healthy.
To meet the predicted 5.5% increase
in bed days, we needed to save 20,000
days by 1 July 2013.
Kia Kaha: Manage Better, Feel
Stronger
Aim: To achieve 25% reduction in
unplanned hospital & general practice
use for 125-150 individuals with medical
& mental health
co-morbidities engaged in the programme
by 1 July 2014
Manaaki Hauora-Supporting Wellness Campaign
To provide self management
support for 50,000 people living with
long term conditionsacross Counties
Manukau by
1 December 2016
Kia Kaha Ki Te Hauora: Be Strong in Wellness
To engage, activate & connect patients/ whaanau & GP clinics with
patient-centered processes / programmes, and a self-management
“wheel of support”.
Aim:
To enable 5000 East
Tamaki Healthcare
patients with long-term
conditions in the Otara
locality to engage in
self-management
support by 1
December 2016.
Select
Topic
Expert
Meetings
Identify
Change
Concepts
Pre work
LS 1
S
P
A D
LS 2
Supports: emails/ phone / one on one site visits & regular
meetings
P
A D
S
The Breakthrough Series: Institute for Healthcare
Improvement Collaborative Model
LS 0LS 3
Spread
across
Services,
Sector,
Community
PA D
S
Collaborative Teams
P
A D
S
P
A D
S
P
A D
S
Learning Sessions – Face to face
Inspiring Stories ….
Co-Design
Initial FindingsNot all of the high users seen identified themselves as having
a “mental health issue”
What we identified was high psychological distress and
psychosocial complexity
Engagement was the biggest challenge
We trialed the use of peer support workers to engage with the
most hard to reach patients
Along the way, we recognised more and more the value of
peer support as an “intervention” in itself
Initial FindingsSome interesting themes emerged in the “stories” that sat
behind these patients:
• Patient perspective – “no-one listens… sick of everyone
telling me what to do… they don’t understand…”
• Clinic perspective – “no matter what we do they don’t
change, they miss appointments – they don’t want to be
well…”
Most of these people are disempowered and feeling hopeless
BUT want their lives to be better, want to be well, and have
been so grateful to be heard, and provided help in a way that
works for them.
Peer specialist pilot
starts
% m
akin
g first a
pp
oin
tment
OUTCOME: Activated patient - Activated Services
Total cohort n=69
Number
Ag
e g
rou
pin
g
Results – Primary Aim Exceeded!
Results – Improved Mental Health
PHQ-15 – Somatisation rating scale GAD-7 – Anxiety rating scale PHQ-9 –
Depression rating scale
2. SME SupportGroup/Individual
Peer Led
3. Wellness/Care Plan
With activated patient
and whanauPeer/Professional
4. Connect to Primary Care
Teamwith option
to get furthersupport
1. AssessmentProfessional/Peer
Kia Kaha
End of Phase I – Change Package
Aim:
To enable
5000 East
Tamaki
Healthcare
patients with
long-term
conditions in
the Otara
locality to
engage in
self-
management
support by 1
December
2016.
Driver Diagram: Kia Kaha Ki Te Hauora
Engagement 7 Types of
Professional-peer
self-management
support
Measures:
Qualitative & Quantitative
Within the locality
Change IdeasPrimary
DriversSecondary Drivers
Aim &
Measures
With other services
Co-design
Within the team
Huddles with other teams
Connection
Activation
Referral pathways
Organisational/
Professional
attitudes
Peer-led self-management training
Empower ETHC ARI team with support and tools
Streamline Admin Processes
Weekly Mentoring
sessions
Engage with Management
Ongoing community connection
Provide consultancy to other collaboratives
Professional peer led visits (group care
plans) Co-designing
Peer Health Coaches
Referrals to Community Health Workers
Support groups
Telephone-based peer support
Online peer support
Training and cross-
training
Implementing
Testing
Implementing
Testing
Co-designing
Co-designing
Testing
Implementing
Testing
Testing
What has the Manage Better
Course done for you?
Self
Improvement
Practical
Skills
Social
Aspect
Illness
Perceptions
Confidenc
e
Change
Self-
Management
Motivation Positivity Hope
‘Not
Alone’
Social
AnxietyGroup Setting
Understandin
g
Awareness
Acceptance
Problem
Reappraisa
l
Support
PersonSkills
Information
Conceptual themes derived from
participant feedback
Run chart showing number of
Manage Better course referrals from
July 2013 to date
Median
0
10
20
30
40
50
60
70
80
90
Jul-1
3
Au
g…
Se
p…
Oct-1
3
Nov…
Dec…
Jan
-…
Fe
b…
Ma
r…
Ap
r-14
Ma
y…
Jun
-…
Jul-1
4
Au
g…
Se
p…
Oct-1
4
Nov…
Dec…
Jan
-…
Fe
b…
Ma
r…
Ap
r-15
Ma
y…
Jun
-…
Jul-1
5
Au
g…
Se
p…
Oct-1
5
Nov…
Dec…
Jan
-…
Fe
b…
Ma
r…
Ap
r-16
Ma
y…
Jun
-…
Jul-1
6
Au
g…
Se
p…
Oct-1
6
Number
Promote
SME to GPs
Integrate Peer Health
Coach into 1 clinic
In The Words of a GP:I guess the whole reason I refer my patients to the SME is that I see clinical and psychosocial evidence that it works.
Namely – patients Hb1ac are generally better, they are generally happier, proud of their achievements; also there is the companionship and sharing with other similar individuals. There is ongoing support and development.
For some patients I was seeing all the time, visiting frequency seems to have reduced.
Education is a key factor in our patient management. Unfortunately , I don’t have the time to “effectively educate and motivate” a patient in a 10-15 min consultation slot . The SME session fills in these gaps and I/We in-turn reinforce these messages.
It’s a great success - SME works for my patient’s .
Care plan groups1) Professional led visits with peer support
Manage Better Courses
2) Peer led self-management training
Peer support
4) Community
health workers
Manage Better support groups5) Support groups
Phone health coaching
6) Phone support
Health coaches3) Peer health coaching
Manage Better
Facebook Page7) Online Support
*Heisler M. Building peer support programs to manage chronic disease:
seven models for success. Oakland, CA: California Healthcare Foundation;
2006. Available from http://www.chcf.org/publications/2006/12/building-
peer-support-programs-to-manage-chronic-disease-seven-models-for-
success
Wheel of Support
Case Study - Video
“I can now control my anxiety by using all of the
techniques that were taught…my goal is to get better and
stay healthy”
I was hearing words like “terminal illness” and “you will just have
to learn to live with the pain” from the specialists. However, Kia
Kaha helped us to learn about pain management and make a
strategic plan as a family. My wife is no longer worried about me
dying, my whanau (family) is re-connected and we have a tool
box. My goal was to get healthier, I feel I have achieved that,
now I have to maintain it.
Sina’s mother said that she now
takes her medication, is more
active and much happier. She
said, “Sina looks more beautiful
when she is happy!”
Sina’s daughter said that her
mum is much happier and
stronger than before.
When I saw Sina after she started
the Manage Better Course, I couldn’t
believe I was seeing the same
person! Dr David Codyre
I now know that
this is not the end
but just the
beginning of our
health journey….
Sina
Sina’s GP practice has
noticed positive
changes
“I have noticed a
massive change since
we first met, I can see
her family has become
closer and more
supportive now.”Ula, Peer Support
0
10
20
30
PHQ15 GAD7 PHQ9
Sina's Scores on the PHQ-SADS
Sep-15 Nov-15
Sina: “Life is
extremely difficult”
11 September 2015
Sina: “Life is
not difficult at all”
11 November 2015
Lessons Learned
Committed organisational support and
inspiring project leadership is critical
Improvement Science methods “keep
you honest” and liberate you to try new
things
Co-design helps generate the right
ideas to test
Peer support via the “7 models” can be
transformational
Peer-professional partnership keeps
the patient at the centre of care
“Less is often more”
www.koawatea.co.nz
Acknowledgements
Participants of Kia Kaha
Geraint Martin, CEO Counties Manukau Health & management teams
Rakesh Patel, CEO Nirvana Health Group/East Tamaki Healthcare, senior management, & Wellness Support Team
Kia Kaha Collaborative Team
Ko Awatea Campaign Team