Engaging primary care in selfmanagement support a combined presentation prepared by Carolyn Chew-Graham Professor of General Practice Research and Christos Lionis Professor of General Practice and Primary Care
Content (a combined approach) Definitions, policy and context Supporting self-management what is happening now? Encouraging behaviour change what is happening now? Introducing compassionate care- is it effective? Do we need a patient-centered and integrated care strategy? The reality of the ten-minute consultation (UK) and the lack of patient-centered care (Greece)
Definitions Self-management / Self-care: the care taken by individuals towards their own health and well being: it comprises the actions they take to lead a healthy lifestyle; to meet their social, emotional and psychological needs; to care for their long term condition; and to prevent further illness or accidents DoH, 2005
Self-management Regulatory self-care (eating, sleeping, bathing) Preventative self-care (exercise, diet, brush teeth) Reactive self-care (respond to symptoms without clinician intervention) Restorative self-care (behaviour change and compliance with treatment regimens)
Supported self-management collaboratively helping individuals and their carers to develop the knowledge, skills and confidence to care for themselves and their condition effectively DoH, 2005
Behaviour change Behaviour plays an important role in people's health Interventions to change behaviour have potential to alter current patterns of disease Interventions at patient level - underpinned by psychological theory NICE, 2007
Supported self-management and behaviour change Activities have to occur in the primary care consultation Do they?
The Theory of Planned Behaviorwho teaches it? Attitude towards the behavior is determined by one person s evaluation of the outcomes associated with the behavior. Subjective norms refer to the extent to which a person believes that significant individuals or groups (e.g. parents, spouse, close friend, co-workers, doctor or accountant) will approve or disapprove of their performing the behavior. 8 Ajzen, 1991 Perceived behavioral control refers to the extent to which the individual believes they can control their behavior and this includes beliefs about factors that will affect the difficulty of the behavior and the perceived power of these factors.
9 Theories and models of behaviour and behaviour change-the health beliefs model
Motivational interviewing to Do we need: -a more directive - person-centered counseling style for behaviour change? elicit behaviour change-i http://titan.uoc.gr/ Smoking Example 10
Motivational interviewing to elicit behaviour change-ii Do we have evidence in using low-intensity motivational interviewing interventions in primarycare setting in maintaining changes in life style related factors? Promising results New and challenging area fir family practice research 11 Hardcasstle, et al, 2013 Practical issues and barriers
Whole System Informing Self-management Engagement
WISE Approach Patient Professional NHS System Aim Make better use of self care support Provide better self care support Improve access to self care support Method Relevant Information and Support based on: Current need Personal priorities Negotiated plan Changed professional response: Assessment Sharing decisions Supporting change Self care support options Improving: Staff training Data on local resources Patient access to support Tools PRISMS Menu of options Management plan PRISMS Menu of options Management plan Computer template Explanatory model Computer template Menu of options Online Directory of support groups
Components Developed for WISE RCT cluster trial in Salford Primary Care Trust, England Training package for practices Two 3 hour sessions (Maximum feasible in UK primary care) Session 1 all practice staff Session 2 clinical staff (including consultation skills training/role play) Delivered by two facilitators employed by the PCT Guidebooks (IBS, COPD, Diabetes) Shared-decision making tool PRISMS Online directory of support services
Results and discussion No effect on any measure (process, outcome) Design strengths Size External validity Low attrition Range of conditions and outcomes Design limitations Potential recruitment bias
Process measures Attendance at training sessions 90% (n=179) session 1 82% (n=85) session 2 Training rated positively Mean > 2.5 out of 5 point by 76% session 1 and 89% session 2 Self reported implementation (response rate 48%) Guidebooks (92% clinicians used, 51% regularly ) PRISMS tool (70% reporting no or seldom use) Guidebooks - all clinicians 8 9 51 32 PRISMS - all clinicians 13 42 17 28 Not at all Seldom A little Regularly Not at all Seldom A little Regularly
Summary We set out to implement a practice-based training programme to enhance outcomes through enhanced self-management, which involved a number of steps: 1. Engaging a high proportion of practices with the programme - achieved 2. Delivering training to a high proportion of clinicians and other staff - achieved 3. Ensuring training was relevant and acceptable - achieved 4. Encouraging implementation of the training in routine practice partially achieved 5. Enhancing shared decision-making and self-management not achieved 6. Improving outcomes not achieved Kennedy A, Reeves D, Bower P, Blakeman T, Bowen RA, Chew-Graham CA, Eden M, Fulwood C, Gaffney H, Gardner C, Lee V, Morris R, Protheroe J, Richardson G, Sanders C, Swallow A, Thompson D, Rogers A. Implementation of self-management support for long-term conditions in routine primary care settings: A cluster randomized controlled trial. BMJ 2013;346:f2882 doi: 10.1136/bmj.f2882
Why was self-management support (SMS) not embedded in practices? Interviews with a sample of GPs and PNs in participating practices Findings Nothing new Not a priority Can of worms Kennedy A, Rogers A, Chew-Graham CA, Blakeman T, Bowen R, Gardner C, Lee V, Morris R, Protheroe J. Implementation of a self-management support approach (WISE) across a health system. A process evaluation of what did and didn t work for organisations, clinicians and patients. BMC Implementation Science. 2014, 9:129 doi:10.1186/s13012-014-0129-5
Nothing new Clinicians were not convinced that WISE was different enough to warrant engagement in a new way of working I don t know that it brought that much to us really. I think it gave us something, but I don t think it s an awful lot different from what everybody else has been telling us. We need to get people to self-manage everything. (nurse practice 12)
Not a priority WISE did not fit with pay-for-performance targets which did not include delivering SMS I try and do the self-care management where I possibly can, but I only have 15 minutes, and in that could have been asthma checks, it could be a BP check bloods, height, weight, BMI, depression screening, geriatric screen (nurse practice 2) They do not want to take the responsibility themselves to say... right I need to address this, this is what I need to do and this is how I m going to do it. (nurse practice 12)
Can of worms PRISMS tool was considered too disruptive in terms of QOF tasks (which the practices prioritised) and the maintenance of relationships (which nurses took pride in) I just think there would be some patients that I d probably just fear them getting their hands on a PRISMS form, for the amount of work it could create. I know that people have got all these different problems that perhaps we should bring out and try and tackle And I know that s a fairly negative philosophy on general practice, but there is some truth in it. No, I m quite fearful of the PRISMS form. (GP, Practice 22)
Behaviour change activities in CHOICE consultations Audio-recorded review consultations in routine primary care Interviews with patients (with LTCs) and practitioners TAR to guide interviews Analysis across and within cases IMPACT Audio-recorded consultations with Practice Nurses (PNs) conducting CV risk assessments in clinics Interviews with patients (with psoriasis) and practitioners TAR to guide interviews Analysis across and within cases
A focus on compassionate care: Lionis, et al, 2011 it that we missed? A six-week elective on compasssionate care It is delivered to first year medical students It has been proved highly popular It is a starting point for emphasing the important of compassionate care It needs a long term evaluation
This missing quality in the Greek primary care system-the EU-PHAMEU Project Kringos et al, 2013
Do we need a global strategy on people-centred and integrated health services? The interdependency of the five strategic directions to support people-centred and integrated health services 25 WHO Interim Report, WHO/HIS/SDS/2015.6
Do we need behaviour issue to achieve comprehensiveness? Comprehensiveness cannot be achieved without including the behavioral aspects of health. Yet comprehensiveness often is not achieved in Patient Centred Medical Home efforts because behavioral issues are not addressed. Baird, et al, 2014 Patient-centreness is still seeking a wider acceptance in concept and methods 26
An action plan for integrated care for chronic diseases in Greece We need to integrate care by bridging local policy context and needs with knowledge and experience from other European countries Chronic diseases are poorly addressed in Greece and integrated care is in a ebryonic stage. Tsiachristas, et al, 2015 It is opportunity to make substantial reforms in chronic care 27
In conclusion As a GP, I cannot support self-management activities and address behaviour change in every ten minute consultation which is driven by templates and protocols. (Carolyn) As a Primary Care Physician, I cannot support selfmanagement activities and address behaviour change since the lack of a patient-centrered and integrated care. (Christos) As a researcher, evidence that other GPs and PNs feel and do the same. (Carolyn and Christos) Primary Care is not the place for self-management or behaviour change interventions.(carolyn and Christos)
Thank you for listening Comments welcome.. c.a.chew-graham@keele.ac.uk lionis@galinos.med.uoc.gr