Engaging Patients in their own Health -...
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Engaging Patients in their own Health Sweden 2016 B9 Diana Dowdle Delivery Manager Dr David Codyre Campaign Clinical Lead New Zealand
Transcript of Engaging Patients in their own Health -...
Engaging Patients
in their own Health Sweden 2016 B9
Diana Dowdle
Delivery Manager
Dr David Codyre
Campaign Clinical Lead
New Zealand
Learning from New Zealand
Where is Ko Awatea?
20 District
Health Boards
Across NZ
Counties Manukau Health • 512,000 people • 11% of NZ Population • NZ’s largest deprived populations • NZ’s largest Pacific population • 1-2 % growth per year • 950 Middlemore Hospital beds • 7,000 staff
Case for Change
Counties Manukau Health
• Emergency Care sees
nearly 100,000 people per
year
• Unsustainable growth in
demand
• Full hospital
• Increasing people with long
term conditions
Christchurch earthquakes February 2011
67,020 People with Long Term
Conditions (2013)
• 38,860 with Diabetes
• 16,600 with Cardiovascular
Disease (CVD)
• 5,750 with Chronic Obstructive
Pulmonary Disease (COPD)
• 4,590 with Coronary Heart
Failure (CHF)
• 18,440 with Gout
• 4,720 with Asthma
Having LTCs means
increased risk of
Mental Health
problems,
Loss of Wellbeing
The “Zone of Delusion”
Who controls the outcomes?
Case Study – “Tavita”:
A clinician-centred perspective
• 58 y.o. man, obese, smoker, past heavy drinking
• Diabetes – poorly controlled, HbA1c over 100
• Gout – frequent flare-ups
• Poor adherence to medication
• Frequent unplanned GP appts
• Frequent unplanned ED presentations
• Many DNA’s to specialist appts
• “No matter what we say or do, he does not do it; he
does not want to be well…”
Case Study – “Tavita”:
What we do now
• Focus on his pressing medical issues
• GP visits – review, prescribe medication, try to make
him understand his health conditions, stress to him
how important it is to take his meds, prognosis if he
does not
• ED visits – re-assess, re-investigate, re-prescribe,
discharge
• Referrals to diabetes and rheumatology svcs – mostly
DNA’d
• “No matter what we do, he does not want to be well…”
Case Study – “Tavita”:
His story
• “No-one has ever listened to my story before”
• Grew up with family violence, alcohol – lifestyle of
drinking and violence through teens – BUT since 20s
he has tried to improve his life, be a good father, work
• Struggles with depression, has symptoms of PTSD,
has continued to “self medicate” with alcohol
• Ongoing worry re: kids problems – truant, getting into
trouble; finances; conflict with own family/siblings
• When doctors/nurses try to “make me understand” re
health, “can’t make sense of it”, worry
Case Study – “Tavita”:
A patient-centred perspective
• Primary issues – trauma history, PTSD, depression,
family stress, low self esteem – all meaning he feels he
has no control in his life.
• Secondary issues – diabetes, gout
• Attempts at “health education” have left him feeling
whatever he does, he will die young.
• He is thus anxious about his health, but does not know
what to do, and does not trust health professionals
who “don’t understand…”
Case Study – “Tavita”:
A different approach
• What is happening now is a “lose-lose-lose”
• He feels more and more out of control, his health is
getting worse
• He is now unable to work, address his family issues
• We get frustrated trying to help, and he is an increasing
burden on the health system
• SO HOW COULD WE DO THIS DIFFERENTLY???
• What would a “self-management support” informed
approach look like??
Case Study – “Tavita”:
A different approach to prioritising
1. Listen, hear his story, understand his perspective
and what his issues are
2. Engage him in identifying his goals and what
support works for him
3. Address mental health & psychosocial issues
4. Improve his health literacy, “self-efficacy”, and “self
management” skills – and then…
…chances are his medical issues will be easier to
manage
Moving From Defined Roles For Clinician and
Patient …
• Power imbalance
• Clinician
responsibility
• “What’s the matter
with you”
• Compliance
• Constraint
…To a Focus On Building Trust and Partnership
• Health Behaviour
• “What matters to you”
• Partnership
• Shared responsibility
• Teamwork
• Liberation
20,000 Days Campaign
The increasing demand on resources across Counties Manukau is driving the need for continuing improvements in the way that we keep our community healthy.
To meet the predicted 5.5% increase in bed days, we needed to save 20,000 days by 1 July 2013.
Kia Kaha: Manage Better, Feel Stronger Aim: To achieve 25% reduction in unplanned hospital & general practice use for 125-150 individuals with medical & mental health co-morbidities engaged in the programme by 1 July 2014
Manaaki Hauora-Supporting Wellness
Campaign
To provide self management
support for 50,000 people living with
long term conditions across Counties
Manukau by
1 December 2016
Kia Kaha Ki Te Hauora:
Be Strong in Wellness
To engage, activate & connect patients/ whaanau & GP clinics with patient-
centered processes / programmes, and a self-management “wheel of support”.
Aim:
To enable 5000 East
Tamaki Healthcare
patients with long-term
conditions in the Otara
locality to engage in
self-management
support by 1
December 2016.
Select
Topic
Expert
Meetings
Identify
Change
Concepts
Pre work
LS 1
S
P
A D
LS 2
Supports: emails/ phone / one on one site visits & regular
meetings
P
A D
S
The Breakthrough Series: Institute for Healthcare
Improvement Collaborative Model
LS 0
LS 3
Spread
across
Services,
Sector,
Community
P A D
S
Collaborative Teams
P
A D
S
P
A D
S
P
A D
S
Learning Sessions – Face to face
Inspiring
Stories …. Co-Design
Initial Findings
• Not all of the high users seen identified themselves as
having a “mental health issue”
• What we identified was high psychological distress and
psychosocial complexity
• Engagement was the biggest challenge
• We trialed the use of peer support workers to engage with
the most hard to reach patients
• Along the way, we recognised more and more the value of
peer support as an “intervention” in itself
Initial Findings
• Some interesting themes emerged in the “stories” that sat
behind these patients:
• Patient perspective – “no-one listens… sick of everyone
telling me what to do… they don’t understand…”
• Clinic perspective – “no matter what we do they don’t
change, they miss appointments – they don’t want to be
well…”
• Most of these people are disempowered and feeling
hopeless BUT want their lives to be better, want to be well,
and have been so grateful to be heard, and provided help in
a way that works for them.
Peer specialist pilot starts
% m
akin
g fi
rst
app
oin
tmen
t
OUTCOME: Activated patient - Activated Services
Total cohort n=69
Number
Age
gro
up
ing
Results – Primary Aim Exceeded!
Results – Improved Mental Health
PHQ-15 – Somatisation rating scale GAD-7 – Anxiety rating scale PHQ-9 – Depression rating scale
2. SME Support Group/Individual
Peer Led
3. Wellness/Care Plan
With activated patient
and whanau Peer/Professional
4. Connect to Primary Care
Team with option
to get further support
1. Assessment Professional/Peer
Kia Kaha
End of Phase I – Change Package
Aim:
To enable
5000 East
Tamaki
Healthcare
patients with
long-term
conditions in
the Otara
locality to
engage in
self-
management
support by 1
December
2016.
Driver Diagram: Kia Kaha Ki Te Hauora
Engagement 7 Types of
Professional-peer
self-management
support
Measures:
Qualitative & Quantitative
Within the locality
Change Ideas Primary
Drivers Secondary Drivers
Aim &
Measures
With other services
Co-design
Within the team
Huddles with other teams
Connection
Activation
Referral pathways
Organisational/
Professional
attitudes
Peer-led self-management training
Empower ETHC ARI team with support and tools
Streamline Admin Processes
Weekly Mentoring
sessions
Engage with Management
Ongoing community connection
Provide consultancy to other collaboratives
Professional peer led visits (group care plans) Co-designing
Peer Health Coaches
Referrals to Community Health Workers
Support groups
Telephone-based peer support
Online peer support
Training and cross-
training
Implementing
Testing
Implementing
Testing
Co-designing
Co-designing
Testing
Implementing
Testing
Testing
What has the Manage Better Course done for you?
Self Improvement
Practical Skills
Social Aspect Illness
Perceptions
Confidence Change
Self-Management
Motivation Positivity Hope
‘Not Alone’
Social Anxiety
Group Setting
Understanding
Awareness
Acceptance
Problem Reappraisal
Support Person
Skills
Information
Conceptual themes derived from participant
feedback
Run chart showing number of Manage Better course referrals from July 2013 to date
Median
0
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40
50
60
70
80
90
Jul-1
3
Aug…
Sep…
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Nov…
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b…
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Apr-1
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May…
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Apr-1
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May…
Jun-…
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Number
Promote SME to GPs
Integrate Peer Health Coach into 1 clinic
In The Words of a GP:
• I guess the whole reason I refer my patients to the SME is that I see clinical and psychosocial evidence that it works.
• Namely – patients Hb1ac are generally better, they are generally happier, proud of their achievements; also there is the companionship and sharing with other similar individuals. There is ongoing support and development.
• For some patients I was seeing all the time, visiting frequency seems to have reduced.
• Education is a key factor in our patient management. Unfortunately , I don’t have the time to “effectively educate and motivate” a patient in a 10-15 min consultation slot . The SME session fills in these gaps and I/We in-turn reinforce these messages.
• It’s a great success - SME works for my patient’s .
Care plan groups 1) Professional led visits with peer support
Manage Better Courses
2) Peer led self-management training
Peer support
4) Community health
workers
Manage Better support groups 5) Support groups
Phone health coaching 6) Phone support
Health coaches 3) Peer health coaching
Manage Better Facebook Page 7) Online Support
*Heisler M. Building peer support programs to manage chronic disease: seven models for success. Oakland, CA: California Healthcare Foundation; 2006. Available from http://www.chcf.org/publications/2006/12/building-peer-support-programs-to-manage-chronic-disease-seven-models-for-success
Wheel of Support
Case Study - Video
“I can now control my anxiety by using all of the techniques that were taught…my goal is to get better and stay healthy”
I was hearing words like “terminal illness” and “you will just have to learn to live with the pain” from the specialists. However, Kia Kaha helped us to learn about pain management and make a strategic plan as a family. My wife is no longer worried about me dying, my whanau (family) is re-connected and we have a tool box. My goal was to get healthier, I feel I have achieved that, now I have to maintain it.
Sina’s mother said that she now takes her medication, is more active and much happier. She said, “Sina looks more beautiful when she is happy!”
Sina’s daughter said that her mum is much happier and stronger than before.
When I saw Sina after she started the Manage Better Course, I couldn’t
believe I was seeing the same person! Dr David Codyre
I now know that this is not the end but just the beginning of our health journey….
Sina
Sina’s GP practice has noticed positive changes
“I have noticed a massive change since we first met, I can see her family has become closer and more supportive now.” Ula, Peer Support
0
10
20
30
PHQ15 GAD7 PHQ9
Sina's Scores on the PHQ-SADS
Sep-15 Nov-15
Sina: “Life is extremely difficult” 11 September 2015
Sina: “Life is not difficult at all” 11 November 2015
Lessons Learned
• Committed organisational support
and inspiring project leadership is
critical
• Improvement Science methods
“keep you honest” and liberate you
to try new things
• Co-design helps generate the right
ideas to test
• Peer support via the “7 models” can
be transformational
• Peer-professional partnership keeps
the patient at the centre of care
• “Less is often more”
www.koawatea.co.nz
Acknowledgements
• Participants of Kia Kaha
• Geraint Martin, CEO Counties Manukau Health & management teams
• Rakesh Patel, CEO Nirvana Health Group/East Tamaki Healthcare, senior management, & Wellness Support Team
• Kia Kaha Collaborative Team
• Ko Awatea Campaign Team
