2. www.livinghealthychamplain.ca Implementing Self Management Support

3. What is encompassed by the term Self-Management Support?

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

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

6. 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

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

8. What are we trying to do?

9. 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?

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

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

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

13. 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

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

15. Survey Time

16. >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?

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

18. Action Planning

19.  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

20.  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

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

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

23.  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

24. Celebrate Success

25. Support is available Kate Nash: Training Facilitator lhcconnect@bruyere.org 613-562-6262 x 1622

26. 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

27. Thank you