Manage Better, Together Group Care Planning

Charlene Pretorius & Leona Didsbury We are health psychologists and self- management trainers working in Nirvana Healthcare, Auckland, New Zealand. We are currently involved in testing and co-designing a peer group care planning process which will be potentially led by a professional/peer team using the Flinders My Health Story.

Rationale This testing is being done within the context of a primary care initiative, Kia kaha ki te Hauora-Be Strong in Wellness, to address the biopsychosocial needs of patients with long term conditions. As part of this initiative we are striving to decrease unplanned hospital presentations and increase positive health outcomes, which include mental wellness, through self-management support.

Self-Management Support for 50,000 Our collaborative is supported by Manaaki Hauora-Self-Management Support for 50,000 which is a Counties Manukau District Health Board and Ko Awatea led campaign in Auckland, New Zealand.

Self-Management Support We are interested in this addition to the various types of self-management support that we are currently offering as we  have found that  engagement in a clinician-patient relationship using the Flinders programme works extremely well when: 1) clinicians have the time allocated to train and deliver this process appropriately, and 2) when patients feel comfortable in the patient- clinician interaction and there are no particular cultural or language barriers.

Barriers found Clinical time is always limited Many of our patients who are most in need of a self-management care planning have language or cultural barriers which exclude them from experiencing a satisfactory process.

Our peer health workers Kia Kaha Ki Te Hauora has a growing number of patients who have become Stanford trained peer leaders and are part of our team, some as staff and some as volunteers  We also have peer support specialists who are cross training into peer health coaching roles. 

Trained professional-peer alliance We would like to include a group care planning process delivered by a trained professional-peer alliance, or ‘teamlet’, as one of the self-management options that we can offer our patients of various culture and languages.  

Aim To co-design a group care planning process using the Flinders My Health Story that can be facilitated by a health professional and trained patient/peer with a group of patients in two half-day or one whole day session(s). We would like to co-design this process with our patients, peers and clinicians to create a process that we can test within our overall self-management support project within the primary care setting. 

Drivers To enhance patient engagement and activation in their care plans through increased accessibility, peer and ethnic support and confidence building  interactions.  To connect staff working with ‘complex patients’ to the “power of a self- management care plan process” by bringing the steps and relationships closer together. 

Purpose  To have a self-management support tool that is culturally appropriate, suitable for people with various health literacy levels, able to be used in collaboration with the client by peer support workers to formulate a self-management care plan that captures self-management, psychosocial, family/whanau/community and carer support. Medical management is overseen and provided by the GP in partnership with the patient/client. 

To date we have held two co-design workshops Method  Co-design workshops Quality improvement methodologies   To date we have held two co-design workshops  

Results – Participant Feedback Feedback was 100% positive Participants were confident to suggest changes to booklet and wording  

Results – Our observations: As SME facilitators and psychologists, we found the level of participation encouraging and the “group magic” exciting for future options  We were able to see that more planning and further testing is required to have confidence in the process and the possibilities, this will be addressed in our 3rd PDSA cycle

Thank you! Malcolm Battersby, Professor of Psychiatry and Director of Flinders Human Behaviour and Health Research Unit Dr David Codyre, Mental Health Lead, Consultant Psychiatrist at East Tamaki Healthcare Flinders team and ETHC team, volunteers and peer workers East Tamaki Healthcare