1. Introduction to Co-Creating Health
Preparatory Workshop

2. Welcome and Introductions
Tutors
All in group
Name and area of work
House keeping;
-Manage self
-All teach, all learn
-Toilets
-Fire alarm & exits
-Refreshments
-Mobile phones

3. Aims Preparatory Workshop
During this workshop you will have the opportunity to;
Understand the contextual background regarding the challenges for today’s healthcare economy with regard to Long Term Conditions (LTCs)
Explore your knowledge, beliefs and understanding of Self Management (SM) and Self Management Support (SMS)
Raise your awareness of the evidence base to support this approach
Consider what you already do that works well to support SM
Find out how to signpost people living with a long term condition to the parallel skills training programme for patients
Understand the support tools available to help you change processes
Start to develop your team’s action plan for SMS

4. Pre-training questionnaire
Please complete the pre training questionnaire (or other chosen version) and return to the facilitator.
This questionnaire will be repeated at the end of the last workshop and will enable you to assess your development and will contribute to the programme evaluation
Thank you

5. The Challenge – Long term Conditions (LTC’s)
15.4 million people in UK living with at least one LTC
People with LTCs are far higher users of health and social care
Accounts for; approx 69% primary and acute care budget in England
Includes; 50% General Practitioner consultations, 65% of out-patient appointments and 70% of inpatient bed days
Aging population and rising numbers
At current rate of growth, expenditure on LTCs would increase by 94% by 2022 (with minimal real potential increase in NHS budget)
Increasing pressure to improve quality and cost
Our healthcare system is not currently configured to cope with the increased demand

6. Meeting the Challenge No decision about me without me
Equity and excellence: Liberating the NHS: The 2010 NHS white paper
82% people living with a LTC want more support to self care
Half those identified with LTC unaware of treatment options & no care plan
GP Patient Survey 2008/9 - 61% surveyed felt discussion of care plan would result in better care
The Co-Creating Health Programme; improve quality of healthcare services, increase personalisation and reduce costs

7. Reflective exercise Exploring your philosophy – What do you think?
Work in groups of two or three
Discuss statements on the handout/next slide
Score how much you agree with them on a scale of (0=strongly disagree, 10=strongly agree)
Each group start with a different statement
Move onto the other statements
Come back as a large group
Discuss and debrief

8. Statements
The person with a long term condition is in charge of their own life and managing their condition(s)
The person with a long term condition is the main decision-maker in terms of how they live with and manage their condition(s)
The person with a long term condition is more likely to act upon the decisions they make themselves rather than those made for them by a professional
The person with a long term condition and the health care professional are equals and experts
The Year of Care Consultation Skills and Philosophy Toolkit © Year of Care v7 08/07/10

9. Why Self-Management Support?
Life with a long term condition: the person’s perspective
Interactions with the service: planned or unplanned
NB : People may also be accessing a wide variety of other support e.g. from within their communities 9

10. What is Self-Management?
What is SM? (Interactive discussion)
Self-management, by definition, is led, owned and done by people themselves
The NHS cannot do self management to people, however it can create an environment where people feel supported and have increased confidence to self-manage
This is not just about a change in service provision, but a cultural change, allowing people with long term conditions to be partners in their care, supporting them to decide what is important to them, what support they need, when they need it and how it should be available

11. What is Self-Management Support?
What is SMS? (Interactive discussion)
“Self-management support is what health services do in order to aid and encourage people living with long term-conditions to make daily decisions that improve health-related behaviours and clinical outcomes. It can be viewed in two ways: as a portfolio of techniques and tools; and as a fundamental transformation of the patient-caregiver relationship into a collaborative partnership” Tom Bodenheimer CHF 2005
Personal Care Planning (is a process that) empowers individuals, promotes independence and helps people to be more involved in decisions about their care. It centres on listening to individuals, finding out what matters to them and finding out what support they need.
They are verbs not nouns!

12. People who optimally self manage are;
Optimistic
Determined
Contextually informed (health information that ‘makes sense to me’)
Confident
Problem solvers, decision makers
People who inhabit rich social networks
Chicken and egg – however;
All of these are amenable to change – often with simple interventions

13. Active support works best
There is a continuum.
─ There are many ways to support self management.
─ Some approaches are passive and focus on improving technical knowledge.
─ Other ways are more active and focus on changing confidence and behaviours.
Research shows that more active support focused on confidence and behaviour works best to improve outcomes. 13

14. Self management works
Research shows that supporting self management can improve:
self confidence / self efficacy
self management behaviours
quality of life
clinical outcomes
patterns of healthcare use
A review of almost 600 studies found that when people are supported to look after themselves, they feel better, enjoy life more and have fewer emergency visits to GPs and hospitals.
There is a lot of evidence from systematic reviews and randomised trials and much of the research is good quality. 14

15. Diabetes had at least one check up in the last 12 months and
discussed ideas about the best way to manage their diabetes
agreed a plan to manage their condition over the next 12 months
discussed their goals in caring for their diabetes
From ‘Managing Diabetes’ Healthcare Commission: 2007 15

16. Self management of warfarin and INR
Self management of warfarin and INR. Cochrane review Heneghan et al April 2010
Clinician management of warfarin and INR
Self monitoring of INR and clinician advice re: warfarin dose
Self management of INR and warfarin
Compared to groups 1 and 2, group 3 have
same risk of bleeding
50% fewer thrombotic episodes
36% lower mortality

18. Co-creating Health: What are we trying to achieve?
Our aim is to support people with long term conditions to develop the knowledge, skills and confidence to manage their own health and healthcare (to become activated). Co-creating Health supports people with long term conditions on their journey of activation Compared with people at low levels of activation, people at high levels of activation tend to live a higher quality of life, have better clinical outcomes and make more informed decisions about accessing medical services.

19. Levels of activation

20. The CCH Integrated Model

21. Health behaviour modeling
Biological
Biological
Social / Behavioural
Emotions / Thoughts

22. An Integrated Approach
Self-management Programme
Development Programme
Practitioner
Service Improvement Programme
Programme
Who
Role change
Focus
Patient
From passive patient to self-management
Activation and partnership: confidence and skills
Clinician/workforce
From expert who cares to enabler who supports self-management
Building clinicians’ skills and addressing attitudes
Service/processes
From clinician-centred services to services that have self-management support as their organising principle
Embedding the 3 enablers into everyday practice by building them into systems and care pathways 22 22

23. Becoming an active partner
The Three Enablers
Agenda setting
Identifying issues and problems
Preparing in advance
Agreeing a joint agenda
Exploring ambivalence, decisional balance
Goal setting & action planning
Small and achievable goals
Builds confidence and momentum
Goal follow-up
Proactive – instigated by the system
Soon – mutually agreed and ideally within 14 days
Encouragement and reinforcement
Becoming an active partner
Making change
Maintaining change
Faded background of the middle circle of the three rings diagram 23 23

24. Practitioner Development Programme
Three x 3 hour skills development workshops Time interval between for practice Adult learning methods Co-facilitation lay and clinical tutor equal partnership Pre course reading Interactive exercises Large and small group discussion Based on three enablers – agenda setting, goal setting and follow up Experiential role play with simulated patient Goal setting and action planning between sessions Clinical communication skills, motivational interviewing, CBT approach Mapped to KSF & Appraisal/revalidation Evaluation Ongoing support & continued development Continuous improvement measurement tools

25. PDP skills list Reflection/Empathy Explore agenda - something else
- priority & expectation
- clarify boundaries
Explore beliefs self management
Explore importance
Explore confidence
Support autonomy & choice
Explore ambivalence
Invite goals
Ask before advise
Problem solving
Action planning
Follow up

26. Self management programme for Patients (SMP)
Skills development programme
Co-facilitation lay and clinical tutor equal partnership
Combination of education, interactive learning and role play
Based on three enablers – agenda setting, goal setting and follow up
Each session follows up goals set for the week and sets new goals for the following week
Seven 3 hour workshops at weekly intervals
Follow up support, but aims to build effective peer support.
Skills descriptor list

27. SMP Skills list Goal setting and action planning Problem solving
Follow up
Pacing and balancing life
Communication – with family, friends and effectively with clinicians
Agenda Setting
Making choices, deals and decisions.
Relaxation & mindfulness
Managing setbacks
Handling and challenging difficult emotions
Planning to stay well

28. Self Management Programme outcomes
Produces statistically significant changes in:
positive engagement with life
constructive attitude/approach towards condition
more positive emotional well being
using self-management skills and techniques
“I used to go to the doctor only when they summoned me, and then say ‘What are you going to do to fix my problem?’. But now I’m saying like, ‘I’m not sure these particular painkillers are working the way we hoped, can we try something else? What could I do myself? ’ “
Person living with a
long-term condition 28 28

29. Self management programme signpost process and information leaflet
Describe your local signposting process with examples of relevant documentation
The lay co-facilitator can share their experience of the SMP together with any key messages
Describe local data for total numbers, completed and outcomes
Update this information regularly

30. Does CCH improve diabetes control?
Results from The Whittington Hospital, 2010 30

31. Patient Activation and Self Efficacy
Results Pre and Post SMP from NBT and CHFT, August 2010

32. Examples of improvement
─ A Cochrane review of 36 trials found that self monitoring and agenda setting reduced hospitalisations, A&E visits, unscheduled visits to the doctor and days off work or school for people with asthma (Gibson et al 2004).
─ A US trial found that personalised goal setting for older women with heart conditions reduced days in hospital and overall healthcare costs (Wheeler et al 2003).
─ A trial found that telephone support may improve self care behaviour, glycaemic control, and symptoms among vulnerable people with diabetes (Piette et al 2000).
─ US researchers found that motivational interviewing helped improve self efficacy, patient activation, lifestyle change and perceived health status (Linden et al 2010).
─ A large meta analysis found that individual education and group sessions improved symptoms for people with high blood pressure (Boulware et al 2001). 32

33. Act Plan Study Do Model for Improvement What are we trying to
Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
Model for Improvement
What are we trying to
accomplish?
How will we know that a
Measuring processes and outcomes
change is an improvement?
What change can we make that
will result in improvement?
What have others done?
Act
Plan
Study Do
Langley G, Nolan K, Nolan T, Norman C, Provost L, (1996), The improvement guide: a practical approach to enhancing organisational performance,
Jossey Bass Publishers, San Francisco
What hunches do we have? What can we learn as we go along?

34. Patient Confident in Self Management Organisational Changes
Agenda Setting
Patient Confident in Self Management
Goal Follow Up
Goal Setting
Organisational Changes
Pre Visit Changes
During Visit Changes
Post Visit Changes
Patient / Clinician Engagement
The 3 Enablers
Primary Drivers
Secondary Drivers
Ideas for Change
Outcome

35. In your consultation today:
Appendix 2
Self Management Questionnaire
To help us to continually improve our services we would be grateful if you would kindly answer the following 6 questions.
HAVE YOU ATTENDED A SELF-MANAGEMENT PROGRAMME? YES/ NO (please circle)
In your consultation today:
(please circle)
1. Did you Discuss what was most important to You in managing your own health?
YES/ N0
2. Did you Get support to set a short-term goal for yourself?
3. Did you Arrange to discuss your progress on your short-term goal?
4. How supported did you feel in managing your health?
Totally Not at all
supported supported
“I am confident that I can manage my health condition”
Strongly Strongly
agree disagree

36. Evaluation & measuring success
Practitioner longitudinal questionnaire
Workshop evaluation
Patient feedback questionnaire – The self management questionnaire,
CARE measure
Measurement tools for continuous service improvement (PDSA)
Referral rates to SMP
You may also wish to consider measuring;
Qualitative data capture
Health economic data such as length of stay, reduced emergency
admissions, increased referral and completion rates for disease
specific programmes such as pulmonary rehabilitation and diabetes
programmes

37. Examples of Activating interventions
Patient held record
Patient access to record
Results sharing
Agenda setting sheets
Access to information
Self management programmes
Peer support groups
‘Buddy system’
Negotiated agenda setting
Information sharing
Supported goal setting
Supported problem solving
Follow up on goals

38. Implementing activating intervention(s);
Which activating intervention can you develop in your team or practice that will impact activation and confidence for people living with a long term condition(s)?
Agree one which you will work on before the next session
Nominate an improvement lead who will co-ordinate goal setting and action planning for this
All contribute and all support

39. Activating intervention- goal setting and action planning
Work in groups of three
On a scale of 0-10 consider how important it is that you/your team support your chosen activation intervention? (0=no importance 10=maximal importance
Set a SMART goal and develop your action plan to progress implementation of your chosen activating intervention between now and the next session.
On a scale of 0-10 how confident are you that you/your team can do this?
(0=no confidence 10=maximal confidence)
Explore what things would need to happen to increase this confidence?

40. Next steps Three skills development workshops – List dates and venues
Start to use the ‘Self Management Questionnaire’ with people that you see who are living with a long term condition.
Agree action plan for activating intervention activity between now and next workshop.
Consider how you will embed signposting to Self Management Programme or how you will find out what programmes are available locally.
If there are no local programmes start considering how can you deliver Self Management skills training for your local population?