The document provides an overview of the Journey Into Well-Being chronic disease self-management program. It discusses the importance of self-management skills in chronic disease management compared to more traditional acute disease education approaches where the professional directs care. The program teaches problem-solving, action planning, and other self-management skills to increase patients' self-efficacy and ability to independently manage their conditions. It is a 6-week group program based on the Stanford model and has been shown to reduce healthcare utilization while improving health outcomes. The document also notes opportunities to integrate this program into community health centers.

1. Journey Into Well-Being:
The Path to Positive Self
Management of Chronic Disease

2. OBJECTIVES:
1.To understand the concept of self management in Chronic
Disease Management
2. To learn the tasks and skills required to self manage
3. To introduce NYGH ‘s Chronic Disease Self Management
Program, Journey Into Well-Being
4. To experience elements of group skill mastery
5. To discover how CDSMP fits into the Community Health Centre

3. Reflect…..
Knowledge =?= Behavior Change

4. ACUTE DISEASE
abrupt onset
short term
single cause
diagnosis certain
intervention usually effective
outcome cure common
uncertainty minimal
knowledge of professional
important

5. Chronic Disease
gradual onset
long term
many causes, interrelated
delayed diagnosis
multiple interventions, side
effects, no effects
no cure…..management
uncertain future
knowledge of patient and
professional important

6. Traditional Education Self Management
Education
Professional is expert in Patient is the expert in their
disease lives
Professional tells patient Patient sets goals with
what to do and sets goals professional
Professional solves the Patient identifies problems
problems Patient learns strategies to
Goal is for patient to comply solve problems
to professional to achieve Patient internally motivated
benefits and uses problem solving,
Behaviour changed by goals to achieve benefits
external motivation that are meaningful
Minimal behavior change Maximal behaviour change
occurs. occurs

7. Self Management Tasks
Medical management
of condition(s)
Managing changing life
roles
Dealing with difficult
emotions

8. Self Management Skills
Problem solving
Decision making
Resource utilization
Patient/ health care
provider partnership
Taking action
(achieving meaningful
goals)

9. Action Planning
1. Something YOU want to do
2. Achievable
3. Action specific
4. Answers the questions:
What?
How much?
When?
How often?
5. Confidence level of 7/10 or more
(Stanford CDSMP)

10. Benefits of Self Management programs
Increased use of
healthy behaviours
relaxation, exercise, healthy
eating, stress management
Improved health status
Reduced health care
utilization
1:9

11. Why do self management programs work?
Self Efficacy Theory:
When patients have the
confidence to do
something, they will
probably do it (Bandura)
skills mastery
modelling
reinterpretation of
symptoms
social persuasion

12. Ontario’s CDPM Framework
INDIVIDUALS
AND FAMILIES
Healthy
Public Personal
Policy Skills & Self-
Management HEALTH CARE
Supportive Support
Environments
ORGANIZATIONS
Delivery Information
Community System Provider Systems
Action Design Decision
Support
Productive interactions and relationships
Informed,
Activated Prepared,
activated
communities & proactive
individuals
prepared, proactive practice
& families
community teams
partners
Improved clinical, functional
and population health outcomes

13. Journey Into Well-being
The Chronic Disease Self Management Program
Stanford (Lorig) model
Licensed program
No doctor’s referral needed
Target: 50+ with any chronic disease
diabetes, asthma, hypertension, arthritis, osteoporosis,
depression
6 weeks, 2 ½ hours
Relaxation, nutrition, exercise, action plans

14. $25 (Reference book)
2 leaders: 1 Lay leader,
1 Health Care
Professional
(4 day training for
leaders)
Scripted sessions –
emphasis on group
process, setting and
achieving goals, learning
from others

15. CDSMP in the CHC
Need for CDM programming
Community – staff relationship
Locations
Existing programs
Ongoing support
Disease specific information
Exercise
Other opportunities