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