Making self management support a reality: learning from practice Learning event
13 May 2015
#selfmgt #thfpcc
http://personcentredcare.health.org.uk
• 25% LTC• 70% GP• 70% inpatient• 65% outpatient• 50% adherence
• Financial crisis• Rights• Gratitude• Legislation, Policy
• Initiatives• Professional bodies• Voluntary sector• Commissioning
• 5% written care plan
• 43% GP• 47% nurse
Context
Population Climate
GapLeadership
#selfmgt and #thfpcc
NB : People may also be accessing a wide variety of other support e.g. from within their communities
Life with a long term condition: the person’s perspective
Interactions with the service: planned or unplanned
‘Every system is perfectlydesigned to get the results it gets’
#selfmgt and #thfpcc
http://personcentredcare.health.org.uk
5
What is person-centred care?
There is no single agreed definition of the concept: it is used to refer to many different principles and activities
#selfmgt and #thfpcc
http://personcentredcare.health.org.uk
What is self-management support?
Should I take that pill today?
Am I going to stick to
that exercise regime?
Do I really want that
heart operation?
A portfolio of techniques and tools that help patients choose healthy behaviours and a fundamental transformation of the patient-caregiver relationship into a collaborative partnership.
Source: Bodenheimer T, MacGregor K, Shafiri C (2005).Helping Patients Manage Their Chronic Conditions, California: California Healthcare Foundation.
…supporting people to make informed and personally relevant decisions about managing their own health and healthcare that they can enact.
#selfmgt and #thfpcc
http://personcentredcare.health.org.uk
8
Moving to self-management support
Based upon: In Brief: Person-centred care: from ideas to action
Current Practice Person-Centred care
Roles and beliefs
Patients passive People active partners and managers of their health
Clinical expert gives advice, fixes, cares for and promotes dependency
Expertise used to support the person’s journey to living well in the presence/absence of symptoms
Knowledge creates behaviour change
Knowledge, skills, confidence create behaviour change
Model Primarily medical Biopsychosocial
Values clinical outcomes Values outcomes that matter to people
Who Workforce = clinicians Workforce = clinicians + peer support workers + navigators + health coaches + …
How Clinician shares results and information during consultation
Person receives results and information at appropriate time
Training Communication skills for agreement to clinician determined goals
Skills to support people to determine and enact their own goals
Mode Compliance with clinically determined goals and treatment plans
Collaborative care and support planning with adherence to co-produced goals
#selfmgt and #thfpcc
Person-centred care and support
Service provision that
embeds the systems, tools and processes to enable PCC
A model for change
Based upon the Year of Care in Diabetes House of Care
An integrated, whole system approach
Workforce with knowledge, skills and
confidence for technical tasks and to support people to have
agency over their health
and well-being
Population with
knowledge, skills and
confidence to have agency
over their health and well-being
System stewardship and regulation that facilitates and holds services to account
“More than medicine”Informal and formal sources of support and care
#selfmgt and #thfpcc
http://personcentredcare.health.org.uk
11
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
#selfmgt and #thfpcc
http://personcentredcare.health.org.uk