Transcript Go for your Life* Health Promoting Communities

Campaspe PCP
Chronic Disease Management
Introduction
Campaspe Primary Care Partnership
Objectives
To introduce the principles of ICDM
To increase understanding of goal setting and
where it fits the consumer self management
To introduce opportunities for workforce
capacity building
Integrated Chronic Disease
Management - Principles
Person centred care
Consumers active partners
Increasing choice and control
Providing right care in the right place at the
right time
Proactively promoting health
Chronic Disease Self
Management
CDSM support
oPhilosophy or approach to working with
people
oNot any one specific intervention
Definitions
 Chronic disease
o Long term (remainder of consumers life)
o No cure
Self management
o Living with ongoing chronic disease –
consumer management
Management hours
8,766 hours
Behavioural Goal Setting
Identified/ agreed issues
Gradual process
Making small sustainable changes
Goal Setting
Linked to problem/issue
Written in positive
Written in the consumers words
SMART
Can be maintenance goals
Should not be interventions
Setting Goals and Action
Planning
Something the consumer wants to do
Achievable
Action specific
Answer what, how much, when, how often?
Confidence level 7 or more
Goal setting – practice example
Overall aim to lose weight
Goal
Specific- aim to help lose weight by increasing the amount
of walking
Measurable- walk for 30 minutes
Achievable- confident that could manage to walk for that
long
Realistic- need to take the dog for a walk so will be the
motivation I need
Timely- will walk 3 times per week in the afternoon
What is Care Planning?
Dynamic process
Involves negotiation, decision making and
goal setting
Relies on good communication between
consumer, service providers and GPs
Benefits of Care Planning
 Assist consumers to set goals
 Encourages consumer involvement and selfmanagement
 Manages and monitors long term care
 Provides a checklist
 Documents information e.g. action plans
 Encourages team approaches
 Is proactive rather than reactive
 Increase consumer awareness of services
Person-Centred Practice Principles
 Partnership approach
 Holistic
 Open communication
 Respect and privacy
 Inclusive of family and carers
 Supports self-management and responsibility
 Participation in decision making
 Supports autonomy
Communication
Communication skills
Interviewing
open ended questions
allow consumer to express issues
Active listening
what the consumer is actually saying
Workforce Development
Courses available
Better Health Self Management
Motivational interviewing
Flinders model
Health Coaching
Active Service Model
HACC initiative
People to live
independently
autonomously
Work force development
Online CDSM learning package
o Heart Research Centre
Motivational interviewing CD
o Heart Foundation
Service Coordination self paced training
module CD
o PCP
Consumer Courses
Recognised programs for consumers
Better Health Self-Management
Diabetes prevention programs
• LIFE
• RESET
Cardiac rehabilitation
Conclusion
Role of health professional is to enable the
consumer to develop the individual skills they
require to manage their own health