Implementing Self Management Support

What is encompassed by the term Self-Management Support?

Self-Management Support could be: Stanford Workshops Group Medical Appointments Health Coaching Motivational Interviewing Peer Support Community Health Workers Panel Management

Self-Management Support could be Patient Education Group Education Care Plans Telephone Coaching On-line Forums Shared Medical Records

Support Groups Training patients to be participants in their medical care Community Resources Family-based programs School based programs Community Associations and Neighbourhood Plans Self-Management Support could be

Self-Management Support Do we have to wait until a patient has a chronic condition?

What are we trying to do?

Improve patient outcomes Improve patient quality of life Provide a service that meets the needs of clients Improve our work satisfaction Keep long term health spending within reasonable limits What are we trying to do?

Implementation Stage 1 Trained health care professional Patient ready to make a plan Behaviour change

Implementation Stage 2 Trained health care professional Patient ready to make a plan Behaviour change Record goals Follow up with patient

Implementation Stage 3 Social Worker Health Coach Dietitian Physician Foot nurse Diabetes Educator Stanford Workshop at practice Endocrinologist Optometrist Other specialists

Implementation- Health Care Organization Individuals undertaking tasks to live well with their chronic health conditions and includes having to deal with medical management, role management and emotional management of these conditions Family Physicians Ministry of Health Health Authorities Federal Government Employers Media Researchers Non-Governmental Organizations Health Care Professionals Professional Associations Universities Community Groups Provincial Programs From Self-Management Support: A Health Care Intervention, BC Ministry of Health

Implementation- Community Patient Safe recreational space Affordable community resources Adequate housing Affordable fresh food Combatting food deserts Employment Supportive Care Team Family

Survey Time

>3 : “ I feel like the lone voice crying in the wilderness” 4-7: “We’re doing OK but I’m not sure about the rest of them” 8-10: “ Everyone in the organization thinks SMS is a good idea, but in practical terms, we can’t always put it into operation” 11-13: “ Our organization is doing everything it can to integrate SMS into routine care” 14-16: “ I think I’m in the wrong workshop” Where are we at?

Planning Next Steps Where do you realistically want to be next spring, in terms of implementing SMS?

Action Planning

 You can’t be too specific  You can’t start too small  Timing is important  Adaptability is key  Change needs to become as easy to do as not to do  Evaluation builds confidence Practical tips about change

 Institutional change……lays the groundwork for other changes  All aspects of the Chronic Care Model are necessary to improve Chronic Illness Care Lessons from the Field: California Health Foundation

 Think about team composition and workflow  Clinical and administrative champions are needed at each site  Doctors’ participation is essential System Design and Patient Flow

 On-site training, hands on experience and regular booster sessions  Providers and patients need to build confidence Training

 Measurement and reporting are critical for the organization, the providers and the patients  Organizations need to think about appropriate measures  Feedback to providers is critical, to close the loop  Keep action plans short term 6-8 weeks Measurement

Celebrate Success

Support is available Kate Nash: Training Facilitator x 1622

Self-Management Support: A study and Implementation Guide, Fraser Health Authority 2008 Self-Management Support: A Healthcare Intervention, BC Ministry of Health, June 10 th 2011 Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned California Healthcare Foundation, April 2008 Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients RNAO, September 2010 Resources and References

Thank you