Self-management support, experiences from Päijät-Häme, Finland • Päijät-Häme district Municipalities 15 Inhabitants 212 000 Area 6072 km2Risto KuronenMedical AdvisorJoint Authority for Päijät-Häme Social and Health CareLahti, Finland
• Goal* groupcounseling – Primary prevention – Intervention in lifestyle counseling process – Routine care in every health center in Päijät-Häme region• Telecoaching (Terva-program) – Secondary prevention – Study-programm – Implementation going on *Goal = Good Ageing in Lahti region = Ikihyvä
Lifestyle counselling process Identification of Lifestyle Follow-up,those who may be counselling evaluation at higher risk
Identification of those in high risk in primary health care1. Obesity, increased waist circumference or family history of diabetes2. Client is asked to complete the risk test (FINDRISC)3. Score < 15: Self-care material (diet and exercise)4. Score ≥ 15 (under 40y ≥ 12): Referral to an OGTT and lipid tests. Lifestyle counseling in primary health care
Lifestyle counseling• Group-based, task-oriented lifestyle counselling in six sessions• Motivating communication• Active self-monitoring• Educated group leaders• Consistent guidance material (manual)• 80% of the lifestyle counseling in groups
Goal groupcounselling Evidence based• Type 2 diabetes prevention in the "real world": one-year results of the GOAL Implementation Trial. Absetz P, Valve R, Oldenburg B, Heinonen H, Nissinen A, Fogelholm M, Ilvesmäki V, Talja M, Uutela A. Diabetes Care. 2007 Oct;30(10):2465-70.• Type 2 diabetes prevention in the real world: three-year results of the GOAL lifestyle implementation trial. Absetz P, Oldenburg B, Hankonen N, Valve R, Heinonen H, Nissinen A, Fogelholm M, Talja M, Uutela A. Diabetes Care. 2009 Aug;32(8):1418-20.
Follow-up and evaluation• Lifestyle counseling continues as ”open groups” e.g. twice a year• For risk control, advice to contact health care every 1-3 years (OGTT etc.)• Systematic registration of data for the evaluation of the process and its effectiveness
Data collectionMeasurements In the beginning After 6 sessions Follow-up (~6months) (1-3 years)Diabetes risk XtestWeight X X XBMI X X XBlood pressure X X XWaist X X XOGTT X XLipids X X
Final report• Group facilitator fills into structured patient record• Test scores for diet (before/after) – Quality of fat – Intake of fiber – Intake of salt – Servings of vegetables• How many times participated in the group sessions 1-6
Lifestyle counselling process Conclusions• In every group small positive changes have happened in all the indicators• In near future data to see if T2D is prevented• Educated GOAL group leaders are motivated and ready to work if possibility is given – Motivating communication! – No return to the old way of working• Routine care in every health center but – volume? – 200 participants in Päijät-Häme / year – Challenge to organize continuous functioning of the process – Treatment of diseases still so often overtakes prevention• Structured registration of the data and making use of it is still a challenge – Motivation of the group leaders, is feedback given? – Are the chief professionals interested what’s going on in their organization and its effectiveness?
Health coaching…• ...is targeted at patients with long-term conditions or life-style risks• ...is comprehensive and personal guidance done by a trained health coach• ... outcomes are regularly monitored and reported, and• ... aims to empower the patient and enhance his/her self-care capabilities
Tele-coaching in disease management (the TERVA program)• A 12-month structured, telephone-based program supported by tailored technology.• To promote patients motivation, knowlegde and skills in disease self management and to improve their adherence to clinical care.• Intervention: two calls for engagement and assessment, and a median number of 12 outbound, structured coaching calls under a one- year period.• Health coaches also had access to patient records in both primary and secondary care, and an opportunity to consult the patients’ physician/nurse.• All Health coaches worked in one call-centre.• RCT: 1000 patients were randomized to receive a personal Health coach and 500 participated in a control group, 75% T2DM patients CHANGES IN CHANGES IN LIFESTYLE AND HEALTH HEALTH CARE SERVICE SELF-CARE IMPROVEMENTS COST SAVINGS UTILIZATION CAPABILITIES
Patients were satisfied with the Health coaching*• 89,5 % were satisfied on the Health coaching they received.• 86 % agreed that they learned new things from their Health coach and this helped them to take care of themselves better.• 83 % felt that the content of the Health coaching answered to their needs.• 78 % felt that Health coaching has increased their ability to cope with their condition.• 71 % felt that Health coaching has improved their health status.• 70 % had done positive changes in their lifestyles due to the Health coaching. * Patient survey after the Health coaching period ( = 266)
Results: Smoking (%) Intervention Group Control Group T1 T2 T1 T2 - Daily smoking 10.6 (66) 9.6 (60) 9.7 (28) 9.7 (28) -Nicotine dependency (How quickly after waking up 1st cigarette) - < 5 min 22 15 22 22 - 6-30 min 53 62 41 37 - 31-60 min 13 13 15 11 - after 60 min 12 10 22 30 9% quit rate, NNT=11Patja K. et al. Manuscript in progress
Intervention quality improvement Phase I Phase II Intervention Control Intervention Control Hb1Ac 23,1% 29,4% 40,0% 26,1% Waist circumference 8.5 % 3.1 % 11.2 % 6.8 % Systolic blood pressure (mmHg) 30.3 % 33.3 % 35.5 % 37.3 % Diastolic blood pressure (mmHg) 44.7 % 33.3 % 46.2 % 40.7 % Serum total 27.5 % 50.0 % 34.3 % 25.0 % (N=12) cholesterol(mg/mmol) (N=8)Proportion of those T2DM patients who reached the target after coachingPhase 1 before 15.3.2008 and phase II after 15.3.2008 among type 2 diabetic patientsPatja K. et al. Manuscript in progress
TERVA program Conclusions 1 Health Coaches• No significant differences between the Health coaches in the outcomes of the Health coaching –program• Changes were better within the patients who started Health coaching program in the later stage compared to those, who started the program in the early stage.• A quality control, which based on a content of the Health coaching, follow- up and development of Health coaches’ work, helped Health coaches to learn a new working model• It took one and a half year to change working model from paternalistic and directive to motivating and empowering.
TERVA-program Conclusions 2• As a non-target intervention, effect moderate• Although the changes found during the intervention are small, many of them favour the intervention group – primary endpoints: rather short follow up?• Professional’s working model can change if an opportunity is given• Quality control had an effect• Integration to standard care: better outcomes?• Tele-based health coaching has potential as a feasible means for self-management support.
Conclusions• Is the focus of Finnish primary care in prevention and treatment of longterm conditions and diseases? - self-management support, underused potential to get health gain• Self-management support is the key element in patient-centred care• Patient-centred care means a change in culture?• Health care professionals can learn the new way of practicing• Self-management support must be made possible for the health care professionals: delivery system design• In the future, Chronic Care Model could provide a framework for development and organizing of effective, patient-centred health care in Päijät-Häme.