Chronic Disease Self-Management. North West CCAC

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1 Chronic Disease Self-Management 1

2 What is Self-Management? Self-Management is... The active participation of individuals in achieving their own best health & wellness. Definitions from Ontario Diabetes Strategy, Ministry of Health Self- Management working group, 2010 This involves gaining confidence, knowledge and skills to manage physical, social and emotional aspects of life, in partnership with health care teams and community supports. Self-Management Support is... A range of organizational, community, and provider strategies to support the active participation of individuals in achieving their best health & wellness. 2

3 The Stanford Self-Management Model Stanford University licensed Programs, extensively researched and evaluated - In the past 20 years, the Stanford Patient Education Research Center has developed, tested, and evaluated self-management programs for people with chronic health problems. The first program was the Arthritis Self-Management Course, which became the prototype for all Stanford self-management programs. The Chronic Disease, Diabetes, and Chronic Pain are all different versions of the Self-Management program. The NW CCAC currently holds the license for CDSMP and DSMP. 3

4 Group sessions of 8 to 16 participants The Stanford Chronic Disease Self-Management Model 2.5 hours per week for 6 weeks Co-led by 2 trained facilitators Highly interactive workshop with goal setting, problem solving and weekly modules following standardized topics such as exercise, pain management, working with your health care provider, difficult emotions & fatigue Empowers patients and teaches them the skills to manage their disease 4

5 Why Self-Management? Time spent over 1 year: GP visits per year = 1 hour Visits to specialists = 1 hour Nurse, PT, OT, Dietitian = 10 hours Total = 12 hours 364½ days managing on their own 5

6 Important Realizations - Clinicians are present for only a fraction of the patient s life - Nearly all outcomes are mediated through the patient s behaviour - Motivation is not enough. People also need self-confidence, and certain skills that can be modeled and taught in group sessions or via one-on-one interactions 6

7 Who can benefit from CDSMP? Patients appropriate for the Chronic Disease Self- Management Program: Any condition lasting 3 months or more that is noncommunicable can be considered a chronic disease. Some of these conditions might be arthritis, asthma, heart disease, lung disease, diabetes, crohn s & colitis, fibromyalgia, or depression. Caretakers or family members of someone with a chronic condition can also attend. Keep in mind that a person has to be willing and able to learn self-management strategies; setting & following their weekly action plans. 7

8 When is it appropriate? When the patient asks about the program When a caretaker asks about the program When a person is on a waitlist for other programs When a person has taken a disease education program When a person is not managing their disease When a person is managing their disease Pre-diabetic or other pre-risk chronic disease groups 8

9 Chronic Disease Self-Management Workshop Topics Session 1 Differences between acute and chronic conditions Using the mind for symptom management Making Action Plans Session 3 Better Breathing Muscle Relaxation Pain and Fatigue Management Endurance Exercise Session 5 Medications Making Treatment Decisions Depression Management Positive Thinking Guided Imagery Session 2 Difficult emotions Intro to physical activity Session 4 Healthy Eating Future Plans for Health Care Communication Problem Solving Session 6 Working with your health care professional Working with the health care system Looking back and planning for the future 9

10 Workshop Benefit : Learning to Break the Symptom Cycle Disease Fatigue Pain Depression SYMPTOM CYCLE Difficult Emotions Tense Muscles Stress/Anxiety Shortness of Breath 10

11 1. Something YOU want to do 2. Achievable 3. Action-specific 4. Answer the questions: What? How much? When? How often? Workshop Benefit : Making an Action Plan 5. Confidence level that you will complete the ENTIRE action plan (0 = not at all confident, 10 = totally confident ) 11

12 Why the Stanford model? Research Shows Self-Management Workshops are Effective Treatment subjects when compared with control subjects demonstrated improvements at 6 months in: Weekly minutes of exercise Frequency of cognitive symptom management Communication with physicians Self-reported health Health distress Fatigue, disability, and Social/role activities limitations. They also had fewer hospitalizations and days in the hospital. Source: Lorig et al. Evidence Suggesting That a Chronic Disease Self-Management Program Can Improve Health Status While Reducing Hospitalization: A Randomized Trial. Medical Care. 37(1):5-14, Jan

13 Where is CDSMP/DSMP now? Gold = Active Leaders with some outreach to neighboring communities & videoconference capacity Sandy Lake Webequie Pikangikum Pickle Lake Fort Hope Red Lake Kenora Vermillion Bay Sioux Lookout Armstrong Nakina Dryden Ignace Geraldton Longlac Rainy River Emo Fort Frances Atikokan Nipigon Schreiber Terrace Bay Manitouwadge Thunder Bay Marathon 13

14 Refer clients to FREE Healthy Change workshops in the community To refer: Provide an informational brochure Invite the client/family to call the program s central toll free number: Register locally How can you support clients & families in Self-Management -Your Role- or visit to register on line Develop and practice a range of self-management support strategies within your conversations with clients & families. 14

15 Questions on the Self-Management Program?? Please follow up with me! Call (807) or Ext Other helpful resources: 15

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