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

4

‘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

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 self-managers 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

http://personcentredcare.health.org.uk

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? (0-

10 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

• 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

• Confidence • Agenda Setting • Goal Setting• Goal Follow up

http://personcentredcare.health.org.uk

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)

Top Tips for Implementing Self Management Support

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