HLN004 Lecture 6 - Chronic conditions self management


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  • 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.
  • 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.
  • 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.
  • 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)
  • 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 ….
  • 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.
  • 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.
  • 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.
  • In assessing a person’s ability and unique characteristics, these are some of the factors that we might look at:
  • 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
  • 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.
  • The flinders model provide a set….
  • The basic steps
  • 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.
  • 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
  • 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…..
  • 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.
  • 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…
  • To begin to build an understanding about what this future education might entail, two projects were undertaken…
  • 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.
  • 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.
  • HLN004 Lecture 6 - Chronic conditions self management

    1. 1. Queensland University of TechnologyCRICOS No. 00213JHLN004 Chronic conditionsprevention and managementLecture 6Chronic Disease Self Management
    2. 2. CRICOS No. 00213Ja university for the worldrealRWhat is self-management?“involves (the person with the chronic disease)engaging in activities that protect and promotehealth, monitoring and managing the symptomsand signs of illness, managing the impact of illnesson functioning, emotion and interpersonalrelationships and adhering to treatment regimes”“participants to make informed choices, to adapt tonew perspectives and generic skills that can beapplied to new problems as they arise, to practisenew health behaviours and to maintain or regainemotional stability”(Flinders Human Behaviour and Research Unit, 2009)
    3. 3. CRICOS No. 00213Ja university for the worldrealRPatient Self Management vsSelf Management Support• Patient Self Management= actions individuals takefor themselves• Self Management Support= facilities that health careand social care services provide to enable patients toenhance management of their health
    4. 4. CRICOS No. 00213Ja university for the worldrealRWhat is effective management ofchronic disease?Literature suggests that we need to consider thesecomponents in effective management of chronicdisease:- Collaboration- Personalised care plans- Self-management education- Adherence to treatment- Follow up and monitoring
    5. 5. CRICOS No. 00213Ja university for the worldrealRSelf ManagementAt the policy level, self management has risento prominence through:– The National Chronic Disease Strategy (NCDS)– Patient programs developed through the SharingHealth Care Initiative– Australian Better Health Initiative (moving towardpolicy reform, health system changes, supportinghealth care professionals througheducation, training, clinical audit and financialincentives)
    6. 6. CRICOS No. 00213Ja university for the worldrealRSelf management initiatives• Have been based on social, cognitive, behaviouraland self efficacy theories• Initiatives can include drug management, symptommanagement, psychosocialmanagement, psychological management, lifestylechanges, social support, goal setting and informationon how to access appropriate services(Williams, Harris, Daffurn, Davies, Pascoe and Zwar, 2007, p.121)
    7. 7. CRICOS No. 00213Ja university for the worldrealRExamples of self-managementeducation interventionsType of Intervention ExamplesIndividual Face-to-face consultation Flinders University model ofclinician-administered supportTelephone coaching Coaching patients ON AchievingCardiovascular Health (COACH)programInternet Individual course New South Wales ArthritisFoundation courseInternet group course UK National Health Service’sExpert Patients Programme onlineGroup: ongoing cycle Rehabilitation programsGroup: formal/structured Stanford University programWritten information Non-government organisationpublicationsPopulation Television/multimedia, socialmarketingBack pain beliefs campaign; Quitanti-smoking campaign
    8. 8. CRICOS No. 00213Ja university for the worldrealRThe facets of self management support for patientsand health professionals and possible modesof deliveryJordan, Briggs, Brand and Osborne, 2008
    9. 9. CRICOS No. 00213Ja university for the worldrealRPatient Self ManagementCurrent evidence suggests that patients with effective selfmanagement 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 contentprovides greatest health impact
    10. 10. CRICOS No. 00213Ja university for the worldrealRCapacity to self-manage• Ability to self-manage will influence the preferredmodel 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. 11. CRICOS No. 00213Ja university for the worldrealRCritical Components for individuals to participate in themanagement 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. 12. CRICOS No. 00213Ja university for the worldrealRCommon Models and ApproachesModels (cognitive behaviour)• Flinders: assessment and care planning, behaviouralchange- goal setting• Stanford: generic skills- goal setting, problemsolving, symptom management• United Kingdom National Health Service ExpertPatients Program (based on the Stanford model)• The United States Institute for HealthcareImprovement’s model and tools for self-managementsupport
    13. 13. CRICOS No. 00213Ja university for the worldrealRFlinders Model
    14. 14. CRICOS No. 00213Ja university for the worldrealRFlinders Model• Generic set of tools and processes  enables clinicians andclients 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. 15. CRICOS No. 00213Ja university for the worldrealRAim of the Flinders ModelTo provide a consistent, reproducible approach to assessing thekey 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 sustainedbehaviour change– Allows measurement over time and tracks change– Has a predictive ability i.e. improvements in self-managementbehaviour as measured by the PIH scale, related to improved healthoutcomes
    16. 16. CRICOS No. 00213Ja university for the worldrealRFlinders ModelFormat• Detailed one-to-one assessment and care planning• Use of standardised forms and tools• Requires health professionals to complete a 2 day trainingand approval of 3 case studiesAdvantages• Individualised and client-centred (using clients’ goals)• Differentiates between care for chronic conditions vs acuteconditions• Promotes systems change within organisations to enhancechronic condition care and self-management
    17. 17. CRICOS No. 00213Ja university for the worldrealRThe Flinders Model1. Assess– Use partners in Health Scale– Use Cue and Response Interview– Problems and Goals Assessment2. Agree on Care Plan– Identification of Issues and Goal Setting– Agreed goals– Agreed interventions3. Useful tools– Symptom Action Plan– Doctor visit checklist– Patient Handbook4. Monitor and Review
    18. 18. CRICOS No. 00213Ja university for the worldrealRFlinders Model - Principles of Self-Management1. Know the condition you have2. Involve yourself in the decision making with healthpractitioners3. Care plan adherence as agreed4. Monitor symptoms5. Respond to symptoms as learnt in order to enhancemanagement of the condition6. Impact of the condition(s) on your life (physically,emotionally and socially) need to be managed7. Lifestyle is important, so live a healthy one
    19. 19. CRICOS No. 00213Ja university for the worldrealRBarriers 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 equipsthem to assess and plan, it does not provide themechanisms for supporting ongoing selfmanagement and behaviour change
    20. 20. CRICOS No. 00213Ja university for the worldrealRStanford Model (or Lorig Course)
    21. 21. CRICOS No. 00213Ja university for the worldrealRStanford ModelFormat• Group based structured course (10-15 participants)– 6 week duration• Requires a health professional and a peer leader to lead thecourse (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. 22. CRICOS No. 00213Ja university for the worldrealRStanford Model (Lorig course)Subjects covered include:1) Techniques to deal with problems such asfrustration, fatigue, pain and isolation2) Appropriate exercise for maintaining and improvingstrength, flexibility, and endurance3) Appropriate use of medications4) Communicating effectively with family, friends, andhealth professionals5) Nutrition, and,6) How to evaluate new treatments.
    23. 23. CRICOS No. 00213Ja university for the worldrealRStanford ModelBarriers• Group environments do not suit everyone• Reduced capacity to address individual needs• Structured content makes it difficult to addressindividual learning needs, learning styles andlearning speeds• Participants need to find ongoing peer contact afterthe six week courseMore information:http:/patienteducation.stanford.edu/programs/cdsmp.html
    24. 24. CRICOS No. 00213Ja university for the worldrealRCommon Models and ApproachesApproaches• Motivational Interviewing• Health Coaching• The COACH Program• Better Health Self-Management• Group Education
    25. 25. CRICOS No. 00213Ja university for the worldrealRAdvancing chronic disease selfmanagement in Australia
    26. 26. CRICOS No. 00213Ja university for the worldrealRChronic Disease Self Management and theNational Chronic Disease Strategy• Recognised in the NCDS that it is essential thatsupport is put in place at all levels of the healthsystem to optimise people’s ability to self manage• Making self management key action area recognisesthat many health behaviours required to effectivelymanage chronic disease daily responsibility ofpeople themselves
    27. 27. CRICOS No. 00213Ja university for the worldrealRAdvancing CDSM programs inAustralia• Increasing focus on self management programs aswell as self management support systems inAustralia• CDSM programs are increasingly recognised as partof secondary prevention of chronic disease• The 2008-2009 federal budget placed a renewedemphasis on preventive health care,
    28. 28. CRICOS No. 00213Ja university for the worldrealR(Jordan and Osborne, 2006)Barriers to and enablers for the integration of chronic disease self-managementeducation programs into the Australian health care system
    29. 29. CRICOS No. 00213Ja university for the worldrealRSelf Management Supportin Australia• Currently lack of coordination of initiatives in area ofCDSM support• To improve integration, self management supportneeds to be incorporated as an integral aspect ofhealth service redesign in terms of infrastructure andsystems to ensure appropriate uptake and utilisationby key stakeholders eg patients, carers, healthprofessionals and health care organisations.
    30. 30. CRICOS No. 00213Ja university for the worldrealRExamples of initiatives that are being undertaken inAustraliaGovernment policymakers; funding providers• Inclusion of self-management support in national strategicframeworks (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 managementitems, Team Care Arrangements)• Self-management interventions incorporated into nationalclinical practice guidelinesJordan, Briggs, Brand and Osborne, 2008
    31. 31. CRICOS No. 00213Ja university for the worldrealRExamples of initiatives that are being undertaken inAustraliaNon-government and broader community organisations• Chronic disease self-management education programs• Disease-specific information• Telephone helplines• Support groupsHealth care professionals and professional associations• Medicare Benefits Schedule• Self-management curricula for undergraduate medical, allied healthdisciplines and postgraduate ongoing professional development programs• Self-management interventions incorporated into clinical practice guidelinesHealth care system managers and organisations• Primary Care Partnerships (Vic)• Self-management interventions incorporated into clinical practice guidelinesJordan, Briggs, Brand and Osborne, 2008
    32. 32. CRICOS No. 00213Ja university for the worldrealRCase Manager:monitors and triagesreports and alertsHealth Provider:Collaborative goalsettingElectronicHealth RecordSelf-Monitoring:e.g. Blood Glucosetesting, symptomsmonitoringTLC (TelephoneLinked Care):Educates, monitors,supports andproduces alerts andreportsAustralian TLC Diabetes
    33. 33. CRICOS No. 00213Ja university for the worldrealR• Directly from caller’s home to TLC database• Just before weekly call to TLC Diabetes• Improving accuracy of TLC feedback on BG testingAliveConnect: a new device to upload BGresults
    34. 34. CRICOS No. 00213Ja university for the worldrealRAliveConnect transmitter with meter
    35. 35. CRICOS No. 00213Ja university for the worldrealRChronic Disease Self management andthe skills of the health workforceThe Australian Department of Healthand Ageing, through the AustralianBetter Health Initiative determinedthat education and training of theexisting and future health workforcewas a key element in assistingpatients to better manage theirchronic conditions
    36. 36. CRICOS No. 00213Ja university for the worldrealRContinued..2 projects were undertaken:a) The development of a curriculum framework for selfmanagement support education of the futureworkforceb) Determine the skills required for prevention andself-management support of chronic conditions bythe current PHC workforce– 19 core capabilities have been defined and confirmed asnecessary for the Primary Health Care Workforce tosuccessfully support patients and carers within the selfmanagement continuum
    37. 37. CRICOS No. 00213Ja university for the worldrealRBest Practice for Delivering Prevention andChronic Condition Self-Management SupportHas been based on the Chronic Care Model. This model can be applied to PHCsettings as part of implementing care across the prevention, early risk factoridentification and Chronic Care Self-Management support continuum
    38. 38. CRICOS No. 00213Ja university for the worldrealRCore Skills for the PHC WorkforceGeneral Patient-CentredCapabilitiesBehaviour ChangeCapabilitiesOrganisational/SystemsCapabilities1. Health promotionapproaches2. Assessment of health riskfactors3. Communication skills4. Assessment of self-management capacity(understanding strengthsand barriers)5. Collaborative careplanning6. Use of peer support7. Cultural awareness8. Psychosocialassessment and supportskills9. Models of health behaviourchange10. Motivational interviewing11. Collaborative problemdefinition12. Goal setting and goalachievement13. Structured problem solvingand action planning14. Working in multidisciplinaryteams/interprofessionallearning and practice15. Information, assessmentand communicationmanagement16. Organisational changetechniques17. Evidence-based knowledge18. Conducting practice basedresearch/quality improvementframework19. Awareness of communityresources
    39. 39. CRICOS No. 00213Ja university for the worldrealR
    40. 40. CRICOS No. 00213Ja university for the worldrealR
    41. 41. CRICOS No. 00213Ja university for the worldrealR
    42. 42. CRICOS No. 00213Ja university for the worldrealRBest Practice for Delivering Preventionand Chronic ConditionSelf Management• Patient-centred skills for effective engagement andcommunication between patients, PHC workers and healthsystems• Skills to support behaviour change by patients (and staff)• How to work collaboratively in teams and systems thatactively use a range of technology and evidence-basedpractices to achieve optimal patient outcomes
    43. 43. CRICOS No. 00213Ja university for the worldrealRContinued…• How to plan care that accesses a range of skills andresources within and across disciplines and withinthe community; and• An understanding of the social determinants ofhealth and health promotion approaches to achievepopulation health outcomesAustralian Government Department of Healthand Ageing, 2009
    44. 44. CRICOS No. 00213Ja university for the worldrealRSummary1) Develop health literacy within the whole population2) Invest in research and evaluation3) Increase engagement of patients, clinicians andorganisations with self-management programs4) Drive integration of self management intoclinical, educational and workplace contexts5) Optimise self-management programs throughincorporation of best educational practice andinsights from psychological sciences(Glasgow, Jeon, Kraus and Pearce-Brown, 2008)
    45. 45. CRICOS No. 00213Ja university for the worldrealRReferences• Australian Government Department of Health and Ageing. (2009). Capabilities forSupporting Prevention and Chronic Condition Self-Management: A Resource forEducators of Primary Health Care Professionals. Commonwealth of Australia:Canberra.• Glasgow, N., Jeon, Y, Kraus, S. and Pearce-Brown, C. (2008). Chronic DiseaseSelf-management support: the way forward for Australia. Medical Journal ofAustralia. 189(10 Supplementary); S14-S16)• Fisher et al, Ecological approaches to self-management: the case ofdiabetes. 2005 Am J Public Health 95:1523-1535• Jordan, J., Briggs, A., Brand, C. and Osborne, R. (2008). Enhancing patientengagement in chronic disease self-management support initiatives in Australia:the need for an integrated approach. Medical Journal of Australia. 189(10Supplementary): S9-S13.• Jordan, J. and Osborne, R. (2006). Chronic disease self-management educationprograms: 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 ademonstration project. Australian Journal of Primary Health. 13(2): 121-127.