Transcript Supporting people to self-manage their long term condition(s)

Supporting people to self manage their
long term condition(s).
Session Outline
• Hear what has helped people to manage
their long term condition.
• Share practical tips in relation to supporting
people to manage their condition
• Identify what interventions have helped to
support people on their self management
journey.
• Reflection - what action is needed to make
this happen for you/your organisation?
• Take home messages – key points to take
away with you
Self Management
Support
Self management support is the assistance that
caregivers give to people with long term conditions in
order to encourage daily decisions that improve health
related behaviours and clinical outcomes. It can be
viewed in two ways:
• A portfolio of tools and techniques that help
patients choose healthy behaviours
• A fundamental transformation of the patient
caregiver relationship into a collaborative
partnership”
Bodenheimer T, McGregor K and Sharifi C (2005) Helping patients manage
their chronic conditions California Healthcare Foundation, Oakland, USA
‘a person-centred approach in which the
individual is empowered and has ownership
over the management of their life and
conditions. The role of the health and social
care professionals, services and treatment is to
support the person’s journey towards living
well in the presence or absence of symptoms’
Gaun Yersel!
The Self Management Strategy for Long Term
Conditions in Scotland 2008
4
Self Management Support
What does it look like to you?
What are the challenges?
What do you/we need to
change?
My self management journey
Ann Jackson from Marsden, West Yorkshire
Steve Donaldson from Ayrshire and Aaron
The Self Management Journey
Most people do not become confident selfmanagers overnight. They embark on a journey
where self management may not be seen as
important and confidence levels vary.
4 Stages:
• Beginning the journey
• Finding a way
• Travelling
• Staying on track
Beginning the Journey
Does not see self management as
an important part of living with a long
term condition
Finding a Way
Recognises their role in managing
health and well-being but has low
confidence in their ability
Travelling
Recognises their role in managing
health and well-being but has low
confidence in their ability.....trying
some skills, looking for ideas
Staying on Track
High confidence for many
skills and can problem solve
new challenges
Self Management Support
Patients cannot do it alone. They need support,
information and skills to develop their self
management capabilities
Agenda Setting
http://personcentredcare.health.org.uk
Agenda Setting
It is important that:
• the patient and clinician jointly
agree the agenda otherwise the
clinician might not know what
changes the person is willing to
make
• patients who succeed in making
one health behaviour change will
apply that learning to other areas
http://personcentredcare.health.org.uk
Setting & Negotiating the
Agenda
Role Play:
Sam is a person living with a long
term condition and is visiting his /
her GP.
(medications are fictional)
Goal Setting
Goal Setting
• Though goal setting is a collaborative
process between the individual and
clinician, behavioural change and better
health care outcomes are more likely
if the patient sets the goals.
• This is because the goal(s) will be
relevant and important to them, at the
time and take account of their situation.
• Follow up of goals
http://personcentredcare.health.org.uk
Goal Setting: Importance & Confidence
Exploring importance and confidence can help
clarify significance of change to the patient and
increase importance and confidence levels. For
example..
http://personcentredcare.health.org.uk
Goal Setting - SMART
Goals should be SMART
• Specific - What are you going to do?
• Measurable - How much and how often will you
do it?
• Appropriate - How important is this to you? (010 scale)
• Realistic - How confident are you? (0-10 scale)
• Time Based - When will you do it?
http://personcentredcare.health.org.uk
Goal Follow Up
Self Management Programme
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•
•
•
weekly goal follow up
Peer support and encouragement
Learning how to set SMART goals
Peer supported problem solving
Post Self Management Programme
• Reunion sessions (Support Network)
• Peer support groups
• Health practitioners?
http://personcentredcare.health.org.uk
Reflection from Ann & Steve
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•
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•
Confidence
Agenda Setting
Goal Setting
Goal Follow up
http://personcentredcare.health.org.uk
Top Tips for Implementing
Self Management Support
1. Flexible and relevant patient self
management support options
necessary
2. Identify and fully utilise volunteer
patient ‘champions’ from the start.
3. Commitment from influential
leaders vital (Clinical and
Managerial)
http://personcentredcare.health.org.uk
Take Home Messages
What 3 key messages will you take from
the session?
Think about what is needed in your
locality / field of work to make Self
Management Support a reality?
http://personcentredcare.health.org.uk
Questions
http://personcentredcare.health.org.uk
Session Outline
• Hear what has helped people to manage
their long term condition.
• Share practical tips in relation to supporting
people to manage their condition
• Identify what interventions have helped to
support people on their self management
journey.
• Reflection - what action is needed to make
this happen for you/your organisation?
• Take home messages – key points to take
away with you
http://personcentredcare.health.org.uk