Finding Common Ground: Supporting Change in Healthcare

and at Home

A new kind of relationship

• RuthJean Francois, Patient Advisor, Cambridge Health Alliance

What is self-management?

“The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.”

Barlow et al, Patient Educ Couns 2002;48:177

What is self-management support?

Making and refining the health care system to facilitate patients and families managing chronic health problems self-management. This includes at the level of patient-provider, patient-health care team, patient-health care system and the community.

Glasgow et al

What is Self-Management Support?

• Skills and Tools

• A change in CULTURE to a whole new relationship

– Tom Bodenheimer

Setting the Stage: PatientsSetting the Stage: Patients

Differences Between Acute and Chronic Conditions

ACUTE CHRONIC

Beginning Rapid Gradual

Cause Usually one Many

Duration Short Indefinite

Diagnosis Commonly accurate

Often uncertain

Diagnostic tests

Often decisive

Often limited value

Treatment Cure common

Cure rare

Differences Between Acute and Chronic Care Roles

ACUTE CHRONIC

Role of Professional

Select and conduct therapy

Teacher/coach and partner

Role of Patient

Lorig 2000

Follow orders Partner/ Daily manager

Symptom Cycle

Vicious Cycle

Disease

Tense musclesFatigue

Depression

Anger/Frustration/Fear

Stress/Anxiety

A philosophical shift

Professional - patient

Professional - Patient

Patient - Professional

Patient - professional

Person - professional

Person-Person

Adapted from Tom Janisse

Learning Community Journey

Pilot Collaborative

on Self-Management Support

Karen’s Story in NHP

• Quality Allies and New Health Partnerships – A bigger sea to swim in

• Finding our place as patient and family faculty

• More than “giving feedback”, bringing patient and family members in from the beginning

Participation at all levels

• Patient and family participation on the National Advisory Committee.

• Patient and family participation on the faculty team.

• Patient and family participation on the learning community teams.

Changing Practice, Changing Lives

1. Through collaborative self-management support, enhancing partnerships with patients and families.

2. Engaging patients and families in quality improvement and the redesign of ambulatory processes, practices, programs, and facilities.

The PatientThe Medical Assistant

The Provider

Leaves with scripts, referrals, and instructions

Integrated planMedical

&SMG

The Patient

The Medical Assistant

The Provider

Other Activated Patients

Typical experience with their PCP

First key service…

1) Planning and preparation- MA planned visits with goal setting

2)The Provider- taught how to negotiate a medical plan and integrate with a patient-oriented self-management goal (SMG)

BBSWAR

ACKGROUNDARRIERSUCCESSESILLINGNESS…CTION PLANEMEMBER

NON-DIRECTIVE COUNSELLING

And our Group Visits…

Patients helpingPatients…

3) The MINI-group visit4) The Open-Office Group

visit

Stressors, depressed mood, barriers, difficulty coping ALWAYS covered

Coping strategies developBoth involve goal setting

• Participation on QI teams and traveling with the team.

Clinic Patient and Family Advisory Council

Helping to develop informational and educational materials.

Teaching classes such as the Healthier Living Series.

Developing Bulletin Boards

Designing charting and documentation forms

Improving Electronic Medical Records

Patient and Family Advisors serve on the Patient Safety and Medicine Reconciliation Committees.

Patient and Family Advisors teach residents and medical and nursing students and participate in staff orientation.

Developing peer support and buddy programs, especially for newly diagnosed patients.

Family HealthCare Center, Fargo, ND

Creating a Patient Advisory Council, developing patient portals on the Center’s website, and planning, implementation, and evaluating group visits.

Humboldt Del Norte IPA, Eureka, CA

Participating on the QI team, teaching classes in the Healthier Living Series, and training peer support group facilitators.

Participating in the design of Web sites.

www.NewHealthPartnerships.org

What’s it like being involved: What’s it like being involved: Dennis MalloyDennis Malloy,,patient with COPD, Chair of Lambeth Breathe Easy Grouppatient with COPD, Chair of Lambeth Breathe Easy Group

‘You’ve given us the

lollipop and we’re not giving

it back’