1. Good Life Club Project A National Sharing Health Care Project (Chronic Disease Self-Management) Project Manager - Jill Kelly

2. Today…. Describe project model Describe project model Describe evaluation framework Describe evaluation framework Overview outcomes Overview outcomes

3. Good Life Club Consortium Inner East Community Health Service Manningham Community Health Service MonashLink Community Health Service Whitehorse Community Health Service Chinese Health Foundation of Australia Whitehorse City Council Eastern Health Whitehorse Division of General Practice (auspice)

4. Objective of project Improved self-management capacity of people over 50 years of age with diabetes living in eastern suburbs of Melbourne Sub target of older men and Chinese community

5. Major Strategies: Telephone coaching by Allied Health Practitioners & general practice nurses Telephone coaching by Allied Health Practitioners & general practice nurses Promotion of Multi-disciplinary care planning Promotion of Multi-disciplinary care planning Client Website www.goodlifeclub.info Client Website www.goodlifeclub.info Club activities Club activities Client newsletter Client newsletter & email newsletter

6. National Evaluation Framework CLIENTPROCESS Marketing/Reach/Recruitment Marketing/Reach/Recruitment Care Planning Care PlanningIMPACT Behaviour – self-efficacy Behaviour – self-efficacy Satisfaction with program Satisfaction with program

7. OUTCOME Baseline, 6 m, 12 m & 18 m Health status Health status Health related QOL Health related QOL Functional status Functional status Social functioning Social functioning Psychological distress Psychological distress Satisfaction with life (overall well-being) Satisfaction with life (overall well-being) Health Service usage (self-reported) Health Service usage (self-reported)

8. HEALTH SERVICE PROVIDER PROCESSMarketing/reachIMPACT Perceptions – key informant Perceptions – key informant interviews & focus groups of HSP & GPs HSP & GPs

9. HEALTH SERVICE SYSTEM PROCESS Infrastructure development Infrastructure development Integration IntegrationIMPACT Sustainability Sustainability

10. Project Enrolment 353 clients 353 clients 10% enrolments were Chinese-speaking 10% enrolments were Chinese-speaking 43% enrolments were men 43% enrolments were men One third of enrolled clients One third of enrolled clients referred by GPs referred by GPs High level of patient, GP satisfaction High level of patient, GP satisfaction

11. Interim 6 Month Client Outcomes (n=85) Increased confidence in managing condition Increased confidence in managing condition Increased physical activity Increased physical activity Less time being fearful/worried about health Less time being fearful/worried about health Able to turn taps (results of strength training) Able to turn taps (results of strength training) Fall in mean number of GP visits Fall in mean number of GP visits

12. Interim 12 month data (n = 49) Decreased hospital Emergency Department presentation Decreased hospital Emergency Department presentation Increased use of allied health practitioners Increased use of allied health practitioners

13. 18 month / End of project data CLIENTS Mixed bag of evidence Mixed bag of evidence Health service usage patterns trending in desired directions Health service usage patterns trending in desired directions Sustained involvement in walking exercise Sustained involvement in walking exercise Clients had a wide range of benefits including Clients had a wide range of benefits including ↑ motivation, ↑ ability to cope with diabetes, better knowledge and strong social supports ↑ motivation, ↑ ability to cope with diabetes, better knowledge and strong social supports

14. CLIENT GAINS THAT HAVE BEEN SUSTAINED CLIENT GAINS THAT HAVE BEEN SUSTAINED Self-reported symptoms of Pain, shortness of breath Pain, shortness of breath Levels of discouragement attributed to health problems Levels of discouragement attributed to health problems Fear of health problems Fear of health problems Associated worries and frustrations Associated worries and frustrations Changes in confidence not sustained Changes in confidence not sustained

15. HEALTH SERVICE PROVIDERS Implementation difficulties e.g. Competing demands Competing demands After-hours work After-hours work Difficulty contacting Difficulty contacting clients clients Av. Number of coaching Av. Number of coaching sessions per client= 6 sessions per client= 6

16. Figure 1. Mean scores for the pre-training and post-training assessments for 35 coaches

17. FIVE SUSTAINABILITY “PROJECTS” Trialled different models Trialled different models Barriers and facilitators identified Barriers and facilitators identifiedFacilitators Supportive and proactive management Supportive and proactive management Organisational and health professional behaviour change supported Organisational and health professional behaviour change supported

18. Transition Phase – 2 years Action Plans to embed CDSM Action Plans to embed CDSM Organisational support Organisational support Train the Trainers Flinders Uni model Train the Trainers Flinders Uni model Regional Practitioners network Regional Practitioners network Stanford course leader Stanford course leadertraining

19. National themes…. CLIENTS ↓ Hospital readmissions, ↓ specialist visits ↓ Hospital readmissions, ↓ specialist visits ↑ Quality of life ↑ Quality of life Difficult to engage people from CALD backgrounds Difficult to engage people from CALD backgrounds Lack of male participation Lack of male participation Those with worse health, made greatest change Those with worse health, made greatest change

20. National themes HEALTH SERVICE PROVIDERS Difficulty engaging GPs Difficulty engaging GPs CDSM not a priority in acute health sector CDSM not a priority in acute health sector HSP’s had most difficulty (competing demands, resources) HSP’s had most difficulty (competing demands, resources) Projects are clear about benefits & challenges for SM for clients, practitioners and organisations Projects are clear about benefits & challenges for SM for clients, practitioners and organisations

21. More Information www.goodlifeclub.info www.goodlifeclub.info www.goodlifeclub.info (see Health Professionals/Resources) Australian Journal of Primary Health Australian Journal of Primary Health Vol. 9 2&3 2003 Vol. 9 2&3 2003 www.chronicdisease.health.gov.au www.chronicdisease.health.gov.au www.chronicdisease.health.gov.au http://sharinghealthcare.pwcglobal.com.au./SharingHealth Care/healthcare.nsf http://sharinghealthcare.pwcglobal.com.au./SharingHealth Care/healthcare.nsf http://sharinghealthcare.pwcglobal.com.au./SharingHealth Care/healthcare.nsf http://sharinghealthcare.pwcglobal.com.au./SharingHealth Care/healthcare.nsf (PriceWaterHouse Coopers)