The document summarizes self-management support programs in the Päijät-Häme region of Finland. It describes a lifestyle counseling process that identifies those at high risk for diabetes through health screenings and refers them to group counseling sessions. The goal group counseling program has shown evidence of preventing type 2 diabetes and improving health indicators. A tele-coaching program also led to improved lifestyle behaviors and health outcomes for patients with long-term conditions. Both programs demonstrated the potential for self-management support to empower patients and enhance health, but challenges remain in making these approaches a routine part of healthcare.

1. Self-management support, experiences from
Päijät-Häme, Finland
• Päijät-Häme district
Municipalities 15
Inhabitants 212 000
Area 6072 km2
Risto Kuronen
Medical Advisor
Joint Authority for Päijät-Häme Social and Health Care
Lahti, Finland

2. • 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

3. Lifestyle counselling process
Identification of
Lifestyle Follow-up,
those who may be
counselling evaluation
at higher risk

4. Identification of those in high risk in
primary health care
1. Obesity, increased waist
circumference or family
history of diabetes
2. 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

5. 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

6. 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.

7. 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

8. Data collection
Measurements In the beginning After 6 sessions Follow-up
(~6months) (1-3 years)
Diabetes risk X
test
Weight X X X
BMI X X X
Blood pressure X X X
Waist X X X
OGTT X X
Lipids X X

9. 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

10. 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?

11. 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

12. 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

13. 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)

14. 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=11
Patja K. et al. Manuscript in progress

15. 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 coaching
Phase 1 before 15.3.2008 and phase II after 15.3.2008 among type 2 diabetic patients
Patja K. et al. Manuscript in progress

16. 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.

17. 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.

18. 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.

19. Thank You!