About Co-creating Health
Natalie GrazinAssistant DirectorThe Health Foundation
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DiabetesThe
Whittington Hospital
and Haringey
and Islington
PCTs
Guys & St Thomas
and Southwark PCT
COPDAddenbrokes and
Cambridgeshire PCT
NHS Arran and Ayrshire
DepressionSW London MH Trust and Wandsworth PCT
Torbay Care Trust and PCT
Chronic
PainCalderdale
and Huddersfie
ld Trust and
Kirkees PCT
A model for all LTCs
A model for all long-term conditions
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What is needed for effective self-management?
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What is needed for effective self-management?
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The Integrated CCH Model
©The Health Foundation 2007
An Integrated Approach
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Programme Who Role change Focus
Patient
From passive patient to self-management
Activation and partnership: confidence and skills
Clinician
From expert who cares to enabler who supports self-management
Building the knowledge, skills and attitudes needed to provide effective self-management support
Service
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
Self-management Programme
Practitioner Development Programme
Service Improvement Programme
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Agenda setting– Identifying issues and problems
– Preparing in advance
– Agreeing a joint agenda
Goal setting– Small and achievable goals
– Builds confidence and momentum
Goal follow-up– Proactive – instigated by the system
– Soon – within 14 days
– Encouragement and reinforcement
Becoming an active partner
Making change
Maintaining change
The Three Enablers
Self Management Programme outcomes
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... producing 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 along-term condition
Skills developed ....
• Setting the agenda
• Setting goals
• Problem solving
• Develop the confidence
• Understand their condition
• Develop skills
Practitioner Development Programme outcomes
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Practice positively influenced:
• patients’ confidence to self manage • agenda setting • setting own goals• collaborative problem solving• goal follow up• patients’ experience
Community matron
Clinician tutor
“It’s a change from the traditional approach where say ‘You need to do this”, and the patient says “you’re the boss”, but doesn’t actually do it. We used to wonder why that wasn’t working”
“Now I use agenda setting with my patients and I start by asking ‘what do you want us to do today?’ Patients appreciate this different approach because you are giving them the power. You work out the goals and the steps together and they are empowered to carry on and work on it on their own. So you may need to see them a bit more at first, but in the long run you need to see them less often.”
Patient Confident in Self
Management
Organisational Changes
Pre-visit changes
During visit changes
Post-visit changes
Primary Drivers Secondary Drivers
Outcome
Service Improvement Programme
IMPROVEMENT
The 3 Enablers
Agenda Setting
Goal Setting
Goal Follow Up
Adapted from Robert Lloyd and Richard Scoville, Better Quality through Better Measurement
11©The Health Foundation
Conclusion
Person living with a long-term condition
‘I’d like to thank you both for giving me back the life I thought I’d lost, its made me realise I was holding myself back’
More information
Visit our self management support resource centre on the Health Foundation’s website:
www.health.org.uk/sms
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