Self-Management and Complex Care Planning. Workbook

Transcription

1 Self-Management and Cmplex Care Planning Wrkbk Prduced by the Self-Management Sub Grup f the Alberta Health Services Team Based Care Planning Wrking Grup June 2010

2 Objectives The care planning prcess dcument: 1. describes a prcess that will enhance the cllabrative nature f the care planning prcess 2. prvides sample interview questins that will facilitate patient invlvement in cmpleting the Cmprehensive Care Plan dcument (03.04J) 3. supprts the health care prvider t evke and enhance the patient s intrinsic mtivatin t change health behaviurs, and t strengthen the patient s cmmitment t adhere t the treatment plan 4. prvides an pprtunity fr health care prviders t enhance their skills in patientcentred care Ding care planning cllabratively is imprtant because it: enhances patient mtivatin t make changes increases patient adherence t their care plan invlves patients in decisin making has the prvider act as a cach and a guide Mtivatinal Interviewing Apprach Partnership between tw experts Mirrr Oppsite Apprach One expert prvider wh knws what is best fr the patient Strength-based assumes that the patient has the resurces and mtivatin t make changes, and the prvider s jb is t draw them ut. Deficit-based assumes that the client lacks key knwledge, insight r skills necessary fr change t ccur, and the prvider must give them t the patient. Autnmy prvider affirms the patient s right and capacity fr self-directin and chice the patient makes decisins; is patient-centred Authrity the prvider tells the patient what he must d the prvider makes decisins is healthcare prvider-centred

3 Cmplex Care Plan Template (03.04J) Patient: (Affix Label) Date: Diagnses: Cmplex patient means multiple cmplex health needs including chrnic disease and ther cmplicatins. The patient must have at least tw diagnses frm Grup A OR at least ne frm Grup A and ne frm Grup B. GROUP A GROUP B Hypertensive disease (401) Diabetes Mellitus (250) COPD (496) Asthma (493) Heart Failure (428) Ischaemic Health Disease ( ) Mental Health ( ) Obesity(278) Addictins ( ) Tbacc (305.1) Much f this infrmatin will cme frm the medical recrd; hwever yu will want t invlve the patient in the discussin by asking questins such as: Tell me abut the health cnditins that yu have What d yu knw abut yur <health cnditins>? What might happen t yu if yu d nt keep yur <health cnditin> under cntrl?

4 Part 1: Histry (Nte: if the required infrmatin already exists in anther frmat, the physician may attach a hard cpy instead f cmpleting the required fields. The frm must still include apprpriate signatures.) Prblem List: (allergies, medical cnditins, imprtant medical histry, barriers, prblems etc.) Much f this infrmatin will cme frm the medical recrd. Patients wh feel they have been heard and understd are mre likely t take wnership f their care plan and fllw it. Invite the patient t tell yu their stry by using questins such as: What ther cncerns r health cnditins d yu have? What prevents yu frm making r attending yur medical appintments? Hw cmfrtable are yu talking with yur dctr / nurse abut yur medical cnditins? Tell me abut the symptms yu experience / hw yu keep track f them / hw yu manage them.

5 Lifestyle issues and ther relevant infrmatin Caffeine N Yes Daily Cnsumptin Smking N Yes Pack/Years Alchl N Yes Cnsumptin (day/wk/m.) Recreatinal Drugs N Yes Specifics Physical Activity N Yes Specifics Other N Yes Specifics *Be cautius: asking clse-ended questins that are inherently judgmental in nature can generate resistance n the part f the patient, and may discurage patients frm engaging in a frthright discussin f risk behaviurs. Discussins abut engaging in risk behaviurs can be facilitated by: 1. starting yur discussin with a nrmalizing statement prir t asking abut specific behaviurs: All f us at sme time r anther d things that aren t gd fr us. It might be smething like nt wearing a seatbelt, r perhaps drinking mre than we shuld What behaviurs have yu been ding that might put yu at risk? OR 2. beginning the discussin by inviting patients t tell yu what psitive things they are already ding. What d yu d t keep yurself as healthy as pssible? Once yu have acknwledged, cngratulated and affirmed their actins (building self-efficacy), mve n t discver current issues by asking: What things d yu d that culd make yur health wrse?

6 Current Medicatins Medicatin Prblem Dsage By engaging yur patient in a cnversatin abut their medicatins, and why and hw they take them, yu will gain insight int whether they are willing and able t take their medicatins in the mst effective way. Tell me hw and why yu take yur medicatins What are sme ther treatments that yu are using nw, r have tried in the past? What side effects have yu experienced frm taking yur medicatins? Many patients have prblems taking their medicatins perhaps they cst t much, r it is hard t remember t take them n time. What prblems have yu had with taking yur medicatins?

7 Befre cmpleting the interventins sectin f the care plan, it is necessary t identify which issues need t be addressed. Althugh the health care prvider will knw which medical issues need attentin, the patient s cmmitment t fllw the care plan will depend n their level f invlvement in negtiating hw these issues are priritized n the care plan. This is accmplished by 1) having the patient d a self-assessment f hw well they are ding in managing their cnditin 2) having the prvider assess hw well the patient is managing, based n what the patient has tld them, and n what the medical indicatrs shw 3) having bth parties negtiate which items will be dealt with, in what rder, when, and what supprt will be prvided t the patient by each member f the health care team. PATIENT ASSESSMENT OF SELF-MANAGEMENT Give yur patients an pprtunity t assess hw well they are self-managing by having them answer the fllwing questins. This can be dne by handing them the questins t write ut an answer, r by asking the questins in an pen-ended and nn-judgmental way. Hw well d yu understand yur health cnditin(s) and treatment(s)? Hw well d yu keep track f and respnd t changes in yur symptms? Hw well d yu cmmunicate with yur family and yur health care prviders abut yur health cnditin? Hw des yur health cnditin change yur life -- physically? emtinally? scially? Hw healthy is yur lifestyle -- healthy eating? physical activity? stress management? Is there anything yu wuld like t change abut yur lifestyle?

8 PROVIDER ASSESSMENT OF ISSUES After the patient has cmpleted the self-assessment, have a discussin abut these questins with the patient and d yur wn assessment f hw well the patient is managing in these key areas. Based n that discussin and the clinical infrmatin in the patient s medical recrd, yu are nw be ready t negtiate with the patient abut which f these areas shuld g nt the care plan. The tw f yu must agree n which issues the patient and the health care team can wrk n tgether t achieve better utcmes. NOTE: There may be issues that the prvider feels are imprtant t address but that the patient is nt willing t cmmit t right nw. If that is the case, ask the patient s permissin t list them n the care plan t be dealt with at a future time, whenever the patient is ready. Re-visit thse parts f the care plan during each care plan review. MUTUALLY AGREED UPON IDENTIFIED ISSUES Issue Interventin Encurage patients t chse which target behaviurs t wrk n first. This will strengthen patients cmmitment t take actin. They are mst likely t chse thse issues that they are mst cnvinced are imprtant, that they are mst cnfident that they are capable f ding, and which are therefre the issues where they are mst ready t take actin t make a change. Therapies/Interventins Therapies/Interventins # Per Year Scheduled services are t be shwn under respective mnths listed belw Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nv Dec Invlvement f Health Care Prfessinals Prfessinal Active r Planned A r P Specialist Pharmacist Dietician Nurse Physician Assistant Psychlgist Scial Wrker Other Cntact Infrmatin (If available) Additinal Infrmatin (rles, gal linkages, next appintment, etc.)

9 End f Life / Advance Care Planning discussed: Yes N N/A If yes, prvide details Part 2: Gals Must be clearly defined and agreed upn between the patient and/r the patient s agent and the physician. This sectin is t be cmpleted by the patient in partnership with the physician and/r care team. May include cncerns abut medical cnditins, prblems, barriers r next steps, and are fllwed by actin, slutins, bservatins, the current status f the gals and expected utcmes, etc. Gal Actin Wh is Respnsible Expected Outcme Result It may be helpful t begin this discussin by first having the patient define what their verarching gal fr their health is. This may be stated in the frm f a medium t lng-term life gal. Peple have many different reasns fr wanting t stay as healthy as pssible. It may be that they are lking frward t glfing in their retirement, watching their grand children grw up, staying well enugh t travel Tell me why it is imprtant t yu that yu manage yur health well. What things wuld yu like t be able t d regularly, that yur health prblems are keeping yu frm ding nw? Sub-Gals: What things will yu have t d, t achieve yur life gal? Examples might be, get my diabetes under cntrl s I dn t get any cmplicatins, stp smking t prevent my COPD frm getting wrse, manage my pain meds well s I can think clearly and still functin well Actin Plans: What wuld yu like t fcus n first, t get yu started n achieving that gal? Fr example, if the gal is t cntrl yur diabetes, yur actin plan might be t see the dietitian abut healthy eating, have a medicatin review with the pharmacist, increase physical activity by walking the kids t schl in the mrning. Actin plans shuld be SMART: specific, measurable, achievable, rewarding and timely. What I will d: Hw much I will d: When I will d it : Hw many times I will d it befre we meet again:

10 Rlling With Resistance Yu may find that the patient ffers resistance t the care planning prcess at sme pint. Resistance is a prduct f the relatinship between the prvider and the patient. There are things that prviders can d t decrease resistance: listen attentively clarify using reflective listening express empathy strengthen self-efficacy and things we can d which increase it: be directive r prescriptive argue fr change shame warn disagree with the patient Think f resistance as a signal fr the prvider t listen mre carefully, slw dwn, prceed with cautin, r stp ging in that directin. The interactin between prvider and patient shuld feel like dancing nt like wrestling. Declaratin We (the physician and patient/patient agent) have discussed this care plan and the patient/patient agent has received a written cpy f it. A similar dcument has nt been cmpleted with anther physician in the past twelve mnths. Patient &/r Agent (please print) Signature Date Physician Name(please print) Signature Date Adapted frm: