Self-management support, experiences from

Päijät-Häme, Finland

• Päijät-Häme district

Municipalities 15

Inhabitants 212 000

Area 6072 km2

Risto KuronenMedical AdvisorJoint Authority for Päijät-Häme Social and Health CareLahti, Finland

• Goal* groupcounseling

– Primary prevention

– Intervention in lifestyle counseling process

– Routine care in every health center in Päijät-Häme region

• Telecoaching (Terva-program)

– Secondary prevention

– Study-programm

– Implementation going on

*Goal = Good Ageing in Lahti region

= Ikihyvä

Identification of

those who may be

at higher risk

Lifestyle

counselling

Follow-up,

evaluation

Lifestyle counselling process

Identification of those in high risk in

primary health care

1. Obesity, increased waist

circumference or family

history of diabetes

2. Client is asked to complete

the risk test (FINDRISC)

3. Score < 15:

Self-care material (diet and exercise)

4. Score ≥ 15 (under 40y ≥ 12):

Referral to an OGTT and lipid tests.

Lifestyle counseling

in primary health care

Lifestyle counseling

• Group-based, task-oriented lifestyle

counselling in six sessions

• Motivating communication

• Active self-monitoring

• Educated group leaders

• Consistent guidance material (manual)

• 80% of the lifestyle counseling

in groups

Goal groupcounselling

Evidence based

• Type 2 diabetes prevention in the "real world": one-year results of the GOAL Implementation Trial. Absetz

P, Valve R, Oldenburg B, Heinonen H, Nissinen A, Fogelholm M, Ilvesmäki V, Talja M, Uutela A.

Diabetes Care. 2007 Oct;30(10):2465-70.

• Type 2 diabetes prevention in the real world: three-year results of the GOAL lifestyle implementation trial.

Absetz P, Oldenburg B, Hankonen N, Valve R, Heinonen H, Nissinen A, Fogelholm M, Talja M, Uutela A.

Diabetes Care. 2009 Aug;32(8):1418-20.

Follow-up and evaluation

• Lifestyle counseling continues

as ”open groups” e.g. twice a year

• For risk control, advice to contact

health care every 1-3 years

(OGTT etc.)

• Systematic registration of data for

the evaluation of the process and its

effectiveness

Data collection

Measurements In the beginning After 6 sessions

(~6months)

Follow-up

(1-3 years)

Diabetes risk

test

X

Weight X X X

BMI X X X

Blood pressure X X X

Waist X X X

OGTT X X

Lipids X X

Final report

• Group facilitator fills into structured patient record

• Test scores for diet (before/after)

– Quality of fat

– Intake of fiber

– Intake of salt

– Servings of vegetables

• How many times participated in the group sessions 1-6

Lifestyle counselling process

Conclusions

• In every group small positive changes have happened in all the indicators

• In near future data to see if T2D is prevented

• Educated GOAL group leaders are motivated and ready to work if possibility is given

– Motivating communication!

– No return to the old way of working

• Routine care in every health center but

– volume?

– 200 participants in Päijät-Häme / year

– Challenge to organize continuous functioning of the process

– Treatment of diseases still so often overtakes prevention

• Structured registration of the data and making use of it is still a challenge

– Motivation of the group leaders, is feedback given?

– Are the chief professionals interested what’s going on in their organization and its

effectiveness?

Health coaching…

• ...is targeted at patients with long-term

conditions or life-style risks

• ...is comprehensive and personal

guidance done by a trained health

coach

• ... outcomes are regularly monitored

and reported, and

• ... aims to empower the patient and

enhance his/her self-care capabilities

Tele-coaching in disease management

(the TERVA program)

• A 12-month structured, telephone-based program supported by tailored technology.

• To promote patients' motivation, knowlegde and skills in disease self management and to improve their adherence to clinical care.

• Intervention: two calls for engagement and assessment, and a median number of 12 outbound, structured coaching calls under a one-year period.

• Health coaches also had access to patient records in both primary and secondary care, and an opportunity to consult the patients’ physician/nurse.

• All Health coaches worked in one call-centre.

• RCT: 1000 patients were randomized to receive a personal Health coach and 500 participated in a control group, 75% T2DM patients

CHANGES IN

LIFESTYLE AND

SELF-CARE

CAPABILITIES

HEALTH

IMPROVEMENTS

CHANGES IN

SERVICE

UTILIZATION

HEALTH CARE

COST SAVINGS

Patients were satisfied with

the Health coaching*

• 89,5 % were satisfied on the Health coaching they received.

• 86 % agreed that they learned new things from their Health coach and this

helped them to take care of themselves better.

• 83 % felt that the content of the Health coaching answered to their needs.

• 78 % felt that Health coaching has increased their ability to cope with their

condition.

• 71 % felt that Health coaching has improved their health status.

• 70 % had done positive changes in their lifestyles due to the Health coaching.

* Patient survey after the Health coaching period ( = 266)

Results: Smoking (%)

Intervention Group Control Group

T1 T2 T1 T2

- Daily smoking 10.6 (66) 9.6 (60) 9.7 (28) 9.7 (28)

-Nicotine dependency (How quickly after waking up 1st cigarette)

- < 5 min 22 15 22 22

- 6-30 min 53 62 41 37

- 31-60 min 13 13 15 11

- after 60 min 12 10 22 30

9% quit rate, NNT=11

Patja K. et al. Manuscript in progress

Phase I Phase II

Intervention Control Intervention Control

Hb1Ac 23,1% 29,4% 40,0% 26,1%

Waist circumference 8.5 % 3.1 % 11.2 % 6.8 %

Systolic blood pressure (mmHg) 30.3 % 33.3 % 35.5 % 37.3 %

Diastolic blood pressure (mmHg) 44.7 % 33.3 % 46.2 % 40.7 %

Serum total cholesterol(mg/mmol)

27.5 % 50.0 % (N=8)

34.3 % 25.0 % (N=12)

Proportion of those T2DM patients who reached the target after coachingPhase 1 before 15.3.2008 and phase II after 15.3.2008 among type 2 diabetic patients

Intervention quality improvement

Patja K. et al. Manuscript in progress

TERVA program

Conclusions 1

Health Coaches

• No significant differences between the Health coaches in the outcomes of the Health coaching –program

• Changes were better within the patients who started Health coaching program in the later stage compared to those, who started the program in the early stage.

• A quality control, which based on a content of the Health coaching, follow-up and development of Health coaches’ work, helped Health coaches to learn a new working model

• It took one and a half year to change working model from paternalistic and directive to motivating and empowering.

TERVA-program

Conclusions 2

• As a non-target intervention, effect moderate

• Although the changes found during the intervention are small, many of them

favour the intervention group

– primary endpoints: rather short follow up?

• Professional’s working model can change if an opportunity is given

• Quality control had an effect

• Integration to standard care: better outcomes?

• Tele-based health coaching has potential as a feasible means for self-management

support.

Conclusions

• Is the focus of Finnish primary care in prevention and treatment of longterm conditions and

diseases?

- self-management support, underused potential to get health gain

• Self-management support is the key element in patient-centred care

• Patient-centred care means a change in culture?

• Health care professionals can learn the new way of practicing

• Self-management support must be made possible for the health care professionals:

delivery system design

• In the future, Chronic Care Model could provide a framework for development and

organizing of effective, patient-centred health care in Päijät-Häme.

Thank You!