Making self management support a reality: learning from practice Learning event 13 May 2015 #selfmgt...

Making self management support a reality: learning from practice Learning event

13 May 2015

#selfmgt #thfpcc

http://personcentredcare.health.org.uk

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The Health Foundation

• 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’



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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



Presentation title set in header

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Conflicts of interest

The well

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.



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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


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



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Co-creating Health#selfmgt and #thfpcc


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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



Making self management support a reality: learning from practice Learning event 13 May 2015 #selfmgt...

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