Presentation given by: Pippa Hague toSummer School 2004
Date: 4 August 2004
Chronic disease self management
the potential role of the active patient in wider engagement
Chronic Disease Management
Improving the quality of life for people living with chronic disease, reducing interventions
and bringing care closer to home.
The Context for CDMYoung
and healthy
Options, convenience
access
Planned and systematic disease management
Promoting and supporting self management
Choice
Development of chronic conditions
Increasingly dependant
Joined up health and social care
Taken from Sue Roberts - National Lead for Diabetes presentation to the CDM conference 18 May 2004
Managing the complexities ...
Diabetes
Heart Fai lure
Dement ia
COPDChoice
Expert patients
Medicines Management
Case finding and intensive case management
Tertiary, primary, community, acute etc
Living with a chronic disease (SS, housing, tr
ansport, employment etc)
Chronic Disease Progression
Time
Wellness Stage 1: 80% people
Stage 2: 15% people
Stage 3: 5% people
Adapted from Pieter Degeling presentation to NSC SHA 27 July 04
Resource usage
High
Low
Chronic DiseaseManagement andShared Care
Highly complex patients
High risk patients
70-80% of CDM population
self care
Professional care
Chronic Care Systems Model
Improved Outcomes
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Health SystemHealth Care Organization
DeliverySystemDesign
Decision
Support
ClinicalInformation
Systems
Self-Management
Support
Resources and Policies
Wagner et al.
Community
Health systems must take advantage of community-based programmes that enhance chronic illness care
Successful self-management programmes rely on a collaborative process between patients and providers
Improved Outcomes
Informed,ProactivePatient
ProductiveInteractions
Prepared,ProactivePractice Team
Health SystemHealth Care Organization
DeliverySystemDesign
Decision
Support
ClinicalInformation
Systems
Self-Management
Support
Resources and Policies
Wagner et al.
Community
Effective chronic illness management requires more than simply adding interventions to an existing system focussed on acute care. Basic changes in delivery system design are required for effective care management
Practice teams require evidence-based protocols to guide their decisions about patient care
Effective information systems can measure the success of treatment across populations and deliver reminders about care for individual
Changes in the health system will only improve chronic illness care if active informed patients work together with provider teams
Too many initiatives what goes where ?
PPI
CDMChoice
CDSM
Empowered Patients…Are patients who take responsibility for managing their condition with respect to:
• Knowledge of their disease • Self monitoring • Therapeutic interventions • Diet • Exercise • Smoking
Paradoxically: this requires structured support from service providers
Empowered Patients…
The Expert Patients Programme is a Chronic Disease Self Management programme
available through the NHS
Other support programmes (DAPHNE for diabetes) are becoming more widespread -
focused on medicines management, but with an emphasis also on the active patient
But then what?
Once we have let the genies out of the lamps you can’t ask them to go back in!
So ?
People living with long term conditions
have a vested interest in helping the
NHS and social care get CDM right!
People living with long term conditions are ideally placed to tell us where it is
wrong!
So how do we do it ?
www.dh.gov.uk
Strengthening accountability - involving patients and the public:
practice guidance
Section 11 of the Health and Social Care Act 2001