1. Campaspe PCP Chronic Disease Management Introduction
Campaspe Primary Care Partnership
The aim of this presentation is to provide an introduction chronic disease management and many of the underlying principles of consumer self management. Self management is the main factor to consider in chronic disease management. The many services available within the community only support the individual in their own journey of living with a chronic disease for the rest of their life. They are not in care but managing at home with the support networks available and minimal admissions for acute care.

2. Objectives To introduce the principles of ICDM
To increase understanding of goal setting and where it fits the consumer self management
To introduce opportunities for workforce capacity building 2

3. Integrated Chronic Disease Management - Principles
Person centred care
Consumers active partners
Increasing choice and control
Providing right care in the right place at the right time
Proactively promoting health
Chronic disease self management requires the consumers to make many changes in their lives. While many clients make changes in the short term, most find it hard to maintain these changes.
To support consumers to make lasting changes, health professionals need additional skills in CDSM. The Health Professional is there to support the consumer rather than tell the consumer what they must do. This requires a different way of thinking for many HP who have been trained in the acute medical model.
The principles of CDSM are person centred care. The consumer is the main player with the HP as the support.
Consumers participate in all the decisions about their own care. Must consider what the consumer sees as a problem and what they want to achieve.
This gives them some choice in what they do. By having some control over the choices they make gives the consumer by in to the process. More likely to achieve something if it is their own choice.
By supporting the consumer to get the right care at the right place at the right time may seem idealistic but that is the aim. In rural services some times that cannot be provided within our local service but if the consumer is actively engaged they may be supported in overcoming the barriers and obtaining that elsewhere.
All of these concepts aim to support the consumer to be as well as possible and manage their on going health issues.

4. Chronic Disease Self Management
CDSM support
Philosophy or approach to working with people
Not any one specific intervention
CDSM is an approach to working with people rather than a specific intervention.
Working with consumers in the community requires the health professional to move away from the traditional acute model that many professions are based on. The consumer should be encouraged to make changes in their own life to give them the skills to manage their ongoing health issues.
Many things the consumer must do every day may seem simple but can have great outcomes on their overall health. Learning to take medications correctly, eating well, and getting some regular planned exercise are or seemingly simple things that will allow the consumer to manage their own health.
For the HP CDSM is a philosophy or ideal. It is the general approach to working with people rather than one specific intervention. It is not what the HP does for the consumer but what they can support the consumer to do for themselves.
It is not just directing consumers to make the changes in their lifestyle. Rather it is facilitating the consumer to choose to make these changes. Educating the consumer to give them the knowledge to choose to make the changes for themselves.
It is important to remember that not all consumers or HP are at the same stage in ability or willingness to make these changes. Each consumer is an individual and as such may all need to be treated differently. The right care in the right place at the right time.

5. Definitions Chronic disease Long term (remainder of consumers life)
No cure
Self management
Living with ongoing chronic disease – consumer management
Chronic disease.- a long term disease that has gradual onset, no expected cure and will last for the remainder of the consumers life, e.g. diabetes, arthritis, asthma and COPD
Self management- the consumer must learn to manage the multiple symptoms they experience on a daily basis.
The consumer must learn to live and cope with the multiple symptoms of the disease. Client centred care as each individual is unique so they will have their own issues to overcome. It is not the health professional doing for them rather they must learn to manage for themselves.

6. 8,766 hours Management hours
This is a reminder of how many hours in a year a person with a chronic illness must manage their own illness, i.e. 24 hours a day 365 days a year.
How many hours do they spend with a health professional?
This is why the person must learn to make any lifestyle changes that will help them manage their own health.

7. Behavioural Goal Setting
Identified/ agreed issues
Gradual process
Making small sustainable changes
To learn to manage their own health conditions the consumer must make many alterations to their current lifestyle.
The health professional has a role in helping the consumer identify what these changes may need to be and supporting them in the planning to achieve these changes.
For the consumer to actively participate in their own self management they must consider the issues to be important enough to make some changes.
Smoking is a good example. As a health provider we would consider giving up smoking a high priority but unless the consumer regards this as an issue they will not consider this necessary. They need to see this as an issue before they can consent to a service. Another example would be, not every consumer will think they need a clean and tidy house, so why do they need home care? It may always have been like this?

8. Goal Setting Linked to problem/issue Written in positive
Written in the consumers words
SMART
Can be maintenance goals
Should not be interventions
Goal setting is an important component in self management and as service provider we need to ensure:
Goals should be linked to a problem statement
Should be client stated gaols (not health professionals)
Should be written in the positive
Can be a maintenance gaols for good self-managers however avoid one off goals such as “I want to be happier, skinnier, etc”
Goals should be SMART
Specific - doing something
Measureable - observable
Achievable - can they do it?
Realistic - not reliant on other
Timely - how long and how often
Goals are not interventions such as a referral or a blood test, but should be more about changing behaviours.

9. Setting Goals and Action Planning
Something the consumer wants to do
Achievable
Action specific
Answer what, how much, when, how often?
Confidence level 7 or more
Goal setting is an important self-management skill for consumers to learn. We can support consumers to learn this skill and to break their goals down into smaller achievable steps and to develop their own plan of action.
Many Life Style Modification Programs such as LIFE or Better Health Self Management use goal setting to support consumers through a series of steps to ensure the goal is:
Something YOU want to do, not what someone else thinks you should do, or that you think you should do
Achievable, something you can expect to be able to do in the immediate future
Action specific, for example losing weight is not an action or behaviour, but avoiding snacks between meals is, losing weight is the RESULT of actions
Answer the questions:
What? (For example, walking or avoiding snacks)
How much? (for example walking 4 blocks)
When? (e.g. after dinner Monday, Wednesday & Friday)
How often? (e.g. 4 times, try to avoid everyday as this lowers the likelihood of success)
5. Confidence level of 7 or more (Ask yourself on a scale of 0=no confidence to 10=total confidence, how confident am I that I will complete the entire action plan?)

10. Goal setting – practice example
Overall aim to lose weight
Goal
Specific- aim to help lose weight by increasing the amount of walking
Measurable- walk for 30 minutes
Achievable- confident that could manage to walk for that long
Realistic- need to take the dog for a walk so will be the motivation I need
Timely- will walk 3 times per week in the afternoon
Goal setting with consumers can be a challenge but it is about making small changes in behaviour that when a consumer is successful may lead to beneficial outcomes.
For example. A consumers overall aim may be to lose weight.
but this is not a goal. It needs to be more specific in that need to identify some things the consumer is going to do to lose weight. Actions they will take. Such as walking the dog.
Take some time to consider the consumers that you see and the types of goals they may need to consider.

11. What is Care Planning? Dynamic process
Involves negotiation, decision making and goal setting
Relies on good communication between consumer, service providers and GPs
Once consumer issues or goals have been identified this information may be integrated into the consumers care plan.
Care Planning is a component of service coordination. Many HP may be involved in this process as a support to the consumers they see.
Care Planning is a dynamic process that includes care coordination, case management, referral, feedback, review, re-assessment, monitoring and exiting.
The process involves discussion negotiation and decision making between service providers and consumer to define their goals and strategies, then identify services to meet those goals.
This may include linking the consumer to a range of services and identifying how self-management support, education and health promotion will be provided.
The process relies on good communication between the consumer and participants involved in their care and with their general practitioner.
It is the documentation for what many Hp do on a regular basis. 11 11

12. Benefits of Care Planning
Assist consumers to set goals
Encourages consumer involvement and self-management
Manages and monitors long term care
Provides a checklist
Documents information e.g. action plans
Encourages team approaches
Is proactive rather than reactive
Increase consumer awareness of services
Why do we care plan and what are the benefits to our consumers?
Assists the consumer in setting and achieving goals
Encourages the consumer to be involved in their care, and incorporates self-management support, where possible.
Manages long term care in a clear and concise way.
Provides an essential checklist to ensure continuity of care.
Provides a way of documenting essential information to be shared by others, including life saving actions for emergencies (action plans)
Encourages a team approach to care, with the consumer at the centre.
Focuses on being proactive rather than reactive.
Increase consumer and carer awareness of support service available, and how and when to access them.
Ensures effective monitoring of the consumer’s health. 12 12

13. Person-Centred Practice Principles
Partnership approach
Holistic
Open communication
Respect and privacy
Inclusive of family and carers
Supports self-management and responsibility
Participation in decision making
Supports autonomy
We talk a lot about person centered, client centred practice but what does it really mean?
It is a partnership approach to care, where consumers and service providers share knowledge, values, experience and information, and collaborate to develop goals and plan actions.
A holistic approach to care.
Open and clear communication, which respects a consumers values, culture and beliefs, based on practice that is sensitive to the cultural, communication and cognitive needs of the consumer (for example, use of interpreters, translated materials, Easy-English)
Respect for privacy.
Consider and value the role of family and carers
Support consumers to identify their own needs and develop their needs and develop their own goals.
Encourage consumers to choose outcomes they define as meaningful.
Encourages consumers to participate in decision-making partnerships in treatment, program planning and policy formation.
Encourages consumers to use their own strengths and natural supports.
Respects the consumers own style of coping and bringing about change.
Supports autonomy and choice.
Encourages consumers and participants to take responsibility for their part in the plan 13 13

14. Communication Communication skills Interviewing Active listening
open ended questions
allow consumer to express issues
Active listening
what the consumer is actually saying
To facilitate the consumers Self management of their chronic illness requires the health professional to utilise many skills in interviewing and active listening.
Not a matter of an education session telling the consumer what they must do.
Aims to help the consumer identify what are their issues and what actions they may be able to take for themselves.
Many health professionals have developed these skills through experience
Depending on their work situation many Health Professionals have multiple visits in which to develop a rapport with the consumer and gradually guide them through the processes of making behavioural changes.

15. Workforce Development
Courses available
Better Health Self Management
Motivational interviewing
Flinders model
Health Coaching
If health professionals were interested to further develop their skills in consumer self management various recognised courses are available.
Motivational interviewing is a client centred directive method of enhancing motivation to change.
Health coaching is a way of working for health professionals that utilises a range of principles and techniques to assist people to make and maintain behaviour changes.
Flinders model is a comprehensive one to one self management assessment and care planning process.
Better Health Self Management is a group based course that is very structured and recognises that self management skills are common to a range of chronic diseases. To facilitate BHSM requires the HP to undertake leader training.
Even if not utilising the structured programs the HP can use the knowledge or skills they develop in their every day dealings with consumers.

16. Active Service Model HACC initiative People to live independently
autonomously
ASM is a HACC funded program aimed at the HACC target group but it is a program that involves many of the principles of self management. Many Health Professionals may be aware of this model and involved in implementing this.
The goal of the ASM model is to assist people in the HACC target group to live in the community as independently and Autonomously as possible. Independence refers to the capacity of people to manage day to day activities of daily life. Autonomy refers to making decisions about one’s life.
The aim is that consumers be as actively involved in making decisions about their life as they can be, such as the types of services they receive and the goals they wish to achieve.

17. Work force development
Online CDSM learning package
Heart Research Centre
Motivational interviewing CD
Heart Foundation
Service Coordination self paced training module CD
PCP
Some education opportunities are available within your health service.
For more general information about the principles of Chronic disease management the online CDSM learning package is beneficial but does have a cost involved.
Motivational interviewing CD is an introduction that has been distributed to each health service
Service co ordination self paced learning CD would be of benefit to many people as introduction to service coordination. New version should be released June 2012

18. Consumer Courses Recognised programs for consumers
Better Health Self-Management
Diabetes prevention programs
LIFE
RESET
Cardiac rehabilitation
Various programs are available for consumers that encourage the fundamental skills to make behaviour changes and self manage their own health.

19. Conclusion
Role of health professional is to enable the consumer to develop the individual skills they require to manage their own health