Care Planning and Goal setting in Diabetes management How can we provide self-management support to people with chronic conditions? Professor Malcolm Battersby Flinders University Flinders Human Behaviour and Health Research Unit
Overview What is self-management? Health professional capabilities in selfmanagement support Goal setting Care planning Flinders Program Diabetes care planning
Why is self-management support important? - Adherence Asthma, Diabetes, Hypertension McLellan et al JAMA 243; 1689, (2000). Drug treatments are effective Compliance with medications poor - diabetes = 60%, - asthma and hypertension 40% Behaviour change is poor with 30% adherence to advice for lifestyle changes Relapse over 12 months requiring care - 30-50% diabetes - 50-70% asthma and hypertension Worse for lower socio economic groups
Funded by the Australian Department of Health and Ageing Based on being able to deliver the 6 elements of the Chronic Care Model (Wagner et al) Capabilities of health professionals for supporting chronic condition selfmanagement http://som.flinders.edu.au/fusa/cctu/pdf/what's%20new/capabilities%20self- Management%20Resource.pdf Flinders University, University of South Australia, AGPN, Australian Psychological Society
Chronic Care Model Community Resources and Policies Self- Management Support Health System Health Care Organization Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes
Self-management (CCSM) Having knowledge of the condition and/or its management Adopting a self-management care plan agreed and negotiated in partnership with health professionals, significant others and/or carers and other supporters Actively sharing in decision-making with health professionals, significant others and/or carers and other supporters Monitoring and managing signs and symptoms of the condition
Self-management Managing the impact of the condition on physical, emotional, occupational and social functioning Adopting lifestyles that address risk factors and promote health by focusing on prevention and early intervention Having access to, and confidence in the ability to use support services
Self-management support Self-management support is what health professionals, carers and the health system do to assist the person to manage their disease or condition, in order to promote health and prevent illness, detect, treat and manage early signs of disease, and minimise the disabling impact of existing conditions and complications
Capabilities of health professionals for self-management support General person centred skills Behaviour change skills Organisational/system skills
General person centred skills 1. Health promotion approaches 2. Assessment of health risk factors 3. Communication skills 4. Assessment of self management capacity (understanding strengths and barriers) 5. Collaborative care planning 6. Use of peer support 7. Cultural awareness 8. Psychosocial assessment and support skills
Behaviour change skills 9. Have knowledge of models of health behaviour change 10. Motivational Interviewing 11. Collaborative problem definition 12. Goal setting and goal achievement 13. Structured problem solving and action planning
Organisational/Systems Skills 14. Working in multidisciplinary teams / Interprofessional learning and practice 15. Information, assessment and communication management systems 16. Organisational change techniques 17. Evidence based knowledge 18. Conducting practice based research/ quality improvement framework 19. Awareness of community resources
Current Models of Self- Management Support Disease Specific Generic Coaching Motivational interviewing Arthritis Self-Management, Diabetes, Cardiac Rehab, teaches patients knowledge of disease, disease self-management Stanford 6 week course teaches patients skills in self-management Health/ Telephone coaching, teaches health professionals a range of engagement and motivational techniques where the client has identified goals Teaches health professionals stages of change, explores ambivalence, focus on a targeted behaviour to change
Current Models of Self- Management Support 5As: Assess, Advise, Agree, Assist, Arrange: usually targeted at risk factors Flinders program: taught to health professionals to use with individual patients Most are complementary Most teach patients goal setting and problem solving as the core patient skills
Goal setting A goal is the object or aim of an action Ryan ( 70) Motivation through conscious goal setting Locke (1996) Higher self-efficacy enhances goal commitment Social cognitive theory (Bandura, 1997) Locke E, Motivation through conscious goal setting, Applied and Preventive Psychology 1996 Locke, Latham, Building a practically useful theory of goal setting, American Psychologist 2002
Goal attainment 1. The more difficult the goal the greater the attainment 2. The more specific the goal the greater the attainment 3. Both difficult and specific (progress is possible) 4. Difficult goals require commitment 5. Highest commitment when the goal is important and achievable
Goal attainment 1. Self-efficacy 2. Feedback 3. Goals affect the direction, effort and persistence 4. Goals require plans 5. Goals mediate the effects of personality
Increasing commitment - external 1. Leadership 2. Rationale 3. Authority 4. Rewards 5. Modelling 6. Feedback
Increasing commitment - internal Values Importance of the outcomes Specific goals to achieve the outcomes Training eg self-management skills Cognitive effort Success in sub-goals Self-efficacy
5 functions of the Flinders Program of chronic care management Generic chronic condition management Case management and coordination Self-management support Systemic and organisational change Clinician change
Background - SA HealthPlus SA HealthPlus Coordinated Care Trial 1997 1999 Patients with chronic and complex illnesses 8 projects in 4 regions of South Australia 4,500 patients randomised into Intervention (3000) and Control (1500) groups in the 8 projects Battersby et al, BMJ, March 2005
BACKGROUND -Year 1 review Problems and Goals worked well for most patients However the system designed to allocate coordination time according to level of severity (H/M/L) wasn t being used WHY? Because some people who had severe complicated conditions, but were good self-managers, and did not need coordinated care Service coordination was provided based on whether a person was a good self-manager or not Self management was not defined or operationalised
Learning Self-management capacity is affected by the illness personal attributes attributes of health providers cultural and social factors Self-management skills need to be assessed before the right intervention is offered Not all consumers need self-management support and those who do will respond to a wide range of learning methods, some group, some individual (Battersby et al, Milbank Quarterly, Dec 2006)
Care Plans Should be derived from a self-management assessment including Knowledge Behaviours Attitudes Impacts of the condition Lifestyle risk Factors Barriers to selfmanagement Strengths.
Care Plans Should contain Client defined problems Clients defined goals Medical management A prioritised action plan Community education or resources Community services Planned review and follow-up
Care Plans Should Facilitate the persons engagement in their own healthcare and treatment Enhance the client / provider relationship Enhance the clients self-efficacy for selfmanagement and health outcomes Enhance the clients ability to maintain changes / improvements.
Care Planning Should enhance clients skills in Problem definition Goal setting Goal attainment skills Action Planning Problem solving Pain management Psychosocial management
The Flinders Program of Care Planning for Self-Management Support The Flinders Program is: Bio psycho-social Motivational Outcomes based Patient-centred Integrates medical and self-management Communication tool
Seven Principles of Self-Management 1. Know your condition 2. Have active Involvement in decision making with the GP or health workers 3. Follow the Care plan that is agreed upon with the GP and other health professionals
Seven Principles of Self-Management 4. Monitor symptoms associated with the condition(s) and Respond to, manage and cope with the symptoms. 5. Manage the physical, emotional and social Impact of the condition(s) on your life. 6. Live a healthy Lifestyle 7. Have access to Services
Principles of Self-Management K Knowledge I Involvement C Care plan MR Monitor and Respond I Impact L Lifestyle S Services
The Flinders Program Assess Self-Management + Problems and Goals Self- Management Healthcare Management Community / Family Support Psychosocial Support Action Plan Agreed Issues Agreed Interventions Shared Responsibilities Review Process
Assessment of Self- Management Capacities Partners in Health Scale (PIH) 12 questions self assessed and scored on 9 point scale Cue and Response Interview (C&R) 12 questions with cues explores the strengths and barriers HP assessed and scored on 9 point scale Leads to collaboratively identified issues
CUE & RESPONSE INTERVIEW V10 JUNE 2010
Problems & Goals Assessment Identifies what the client sees as the biggest problem and Identifies the goal(s) the client wants to achieve
Problem Statements 3 parts to a problem statement The Problem What happens to the client because of the problem? How this makes the client feel?
Problem Measurement Problem Statement Because I m so tired from looking after my grandkids, I don t do the exercise I should and I feel like a failure. Rating Scale How much of a problem is this for me? 0 1 2 3 4 5 6 7 8 Not at Very little Somewhat A fair bit a lot all
Goal Statements Goals are linked to the problem statement Achieving goals may result in improved problem rating because of changes to - The problem - What happens because of the problem - How the problem makes the client feel
Goal Statements Repeated and S.M.A.R.T. Specific Measurable Action based Realistic Time-framed (how long / how often)
Care Plans for Chronic Condition Management Identifies medical needs /management aims Evidence based guidelines Planned Appointments Planned tests Medication list May be individualised but may be templates
Care Plans for Self-Management Contains: Identified issues from the C&R Interview & P&Gs Agreed goals / management aims Agreed interventions Sign off Review dates Supports: Self efficacy Empowerment
The Flinders Program Certificate of Competence Part of a Quality Assurance Process Submit a minimum of 3 care plans Results in a licence to use the Flinders Program of Self Management Support.
Achievement of Goal 1 Figure 2.15. Extent of Achievement of Goal 1 by project, end of trial. EP Diabetes n= 347 S somatisation n= 76 S COPD n=140 S. Aged n= 525 EP Chronic and complex n=831 W COPD n= 212 W Diabetes n= 154 Central cardiac n= 194 0% 20% 40% 60% 80% 100% Positive % No change % Negative %
Eyre Peninsula Aboriginal Diabetes Project Self-management program that is culturally sensitive and flexible, promotes self management principles through goal setting, care planning lifestyle changes access to preventative services 60 participants - 12 months follow up Sustainability through the care planning item numbers
Eyre Peninsular Diabetes Improved scores on PIH self management at 12 months Problem improved 6.22 5.28 (p <0.01) Goal improved 7.26 5.42 (p <0.001) Improved HbA1c 8.74-8.09 (p< 0.01 ) BP 139/84-136/83 No change in SF-12 (difficulty with questions)
Education and Training Flinders Program on-line Communication and motivation workshop Revised (shorter) version of FP Flinders Graduate Certificate and Diploma in chronic condition management Master of Primary Health Care (chronic condition management) Sharon.lawn@health.sa.gov.au
Thank You Contact: Prof Malcolm Battersby Flinders Human Behaviour and Health Research Unit, Flinders University Phone: 8404 2608 Fax: 8404 2101 Email: malcolm.battersby@flinders.edu.au Paula.harris@flinders.edu.au http://som.flinders.edu.au/fusa/cctu/home.html