Mobilising community assets to help people achieve personal health outcomes

Margaret Hannah, Director of Public Health

Fife Health Board, Scotland

Helen Crisp, Assistant Director of Research

The Health Foundation

Conflicts of interest

None to declare

Margaret Hannah, employed by Fife Health Board,

Scotland

Helen Crisp, employed by the Health Foundation, UK

Giving this presentation is part of my work for the

Foundation

Valuing health and wellbeing

Take 3 – 4 minutes to talk to 2 or 3 people sitting

near you about:

What do you value in your life that

keeps you healthy and well?

Context in the NHSA growing consensus about the need for

health and care services to embrace and

support the role of individuals and

communities in their health and care –

and a growing understanding of the value

of doing so.

Person and community centred approaches

What does the evidence tell us?

Key Objectives

•Making the case for person and community

centred care

• Evaluating the impact of key evidence-based

approaches and developing tools to support

their adoption and spread.

• Supporting culture change, by developing a

range of behaviour change approaches to impact

on the relationships between professionals and

people

• Aligning the system by identifying relevant

system change levers and drivers

Rita’s story

Three Horizons Framework

Increasing signs of strain and

system failures

Innovation to try and keep things

going

new context for

useful old ways

less

disruptive change

new paradigm fits and takes off

TIME

THE TURBULENT TRANSITION

HORIZON 1

HORIZON 2

HORIZON 3

VIABILITY

radically different operating

environment

NOW

www.internationalfuturesforum.com

A quick tour of Southcentral Foundation, Alaska

“Third Horizon in the present”

Fife SHINE Programme

• Find ways for older people to thrive, not just

survive at home.

• Explore what matters to people, nurturing

quality relationships.

• Co-create solutions with

and by the community

maximized.co.uk

scottish-places.info

Training exercise

• Think of an older person you know

personally. They may be still alive or not.

• What makes/would have made a

difference to their health and wellbeing?

• Take 2 minutes to talk about this person to

your neighbour.

• Other person listens without interrupting.

Deepening and embedding

the practice• “Good Conversations”

• Reflective learning sessions

• Review visits

• Clinical champions

• Revised paperwork

• Annual learning event

Claire’s Story

“It changes the relationship. I now put more of me in to the conversation. I am a daughter, a wife, a friend, a mother. I just happen to work as an OT. People are now thanking me for listening and talking with them at a person level and I am thanking them in return. It is a more enjoyable way of working, of relating to each other.”

“I was working with one lady who had been in hospital. I was there to help her with kitchen tasks to ensure she was able to make herself something to eat and drink safely. And through conversation, boiling the kettle, making a cup of tea, she talked about her friends and their support while she’d been in hospital. Sitting safely in the kitchen drinking a cup of tea from a spill-safe beaker on her own really wasn’t what she wanted. She wanted to be able to make a pot of tea and serve it to her friends in her living room. She wanted to reciprocate. It was important for me to support that.”

Evelyn’s Story

“I was referred a very elderly lady with dementia and was told to ‘keep her ticking over until we can find her a place in long term care’. But as I got to know her, her self-esteem and confidence grew. She began to talk more about things she enjoyed doing and grew less anxious about leaving the house. I began to realise that her wish to live at home had become a real possibility.”

Mary’s Story

What are we learning for

patients/clients?

• Small changes can make a big difference

• Understanding what is important to the person can change the intervention and lead to different outcomes

• Feeling useful and connected is really important

• Being listened to is even more important

What are we learning for staff?

• Supporting staff self-care and time for reflection is vital

• Staff find this way of working protective and energising

• Flexible and creative management responses can unlock complex situations

• Saves time – gets to the heart of things quicker

• Facilitates discharge – easier for staff and client to let go appropriately

Changing the culture of care

• Looks like failure in first 1-2 years

• Change in practice is “subtle but profound”

• Supporting infrastructure takes time to

build

• Learning every step of the way

Engaging Patients

in their own HealthSweden 2016 B9

Diana Dowdle

Delivery Manager

Dr David Codyre

Campaign Clinical Lead

New Zealand

Learning from New Zealand

Where is Ko Awatea?

20 District

Health Boards

Across NZ

Counties Manukau Health

• 512,000 people

• 11% of NZ Population

• NZ’s largest deprived

populations

• NZ’s largest Pacific population

• 1-2 % growth per year

• 950 Middlemore Hospital beds

• 7,000 staff

Case for Change

Counties Manukau Health

Emergency Care sees nearly

100,000 people per year

Unsustainable growth in

demand

Full hospital

Increasing people with long

term conditions

Christchurch earthquakes February 2011

67,020 People with Long Term

Conditions (2013)

• 38,860 with Diabetes

• 16,600 with Cardiovascular

Disease (CVD)

• 5,750 with Chronic Obstructive

Pulmonary Disease (COPD)

• 4,590 with Coronary Heart

Failure (CHF)

• 18,440 with Gout

• 4,720 with Asthma

Having LTCs means

increased risk of

Mental Health

problems,

Loss of Wellbeing

The “Zone of Delusion”

Who controls the outcomes?

Case Study – “Tavita”: A clinician-centred perspective58 y.o. man, obese, smoker, past heavy drinking

Diabetes – poorly controlled, HbA1c over 100

Gout – frequent flare-ups

Poor adherence to medication

Frequent unplanned GP appts

Frequent unplanned ED presentations

Many DNA’s to specialist appts

“No matter what we say or do, he does not do it; he

does not want to be well…”

Case Study – “Tavita”: What we do nowFocus on his pressing medical issues

GP visits – review, prescribe medication, try to make

him understand his health conditions, stress to him

how important it is to take his meds, prognosis if he

does not

ED visits – re-assess, re-investigate, re-prescribe,

discharge

Referrals to diabetes and rheumatology svcs –

mostly DNA’d

“No matter what we do, he does not want to be

well…”

Case Study – “Tavita”: His story“No-one has ever listened to my story before”

Grew up with family violence, alcohol – lifestyle of

drinking and violence through teens – BUT since 20s

he has tried to improve his life, be a good father,

work

Struggles with depression, has symptoms of PTSD,

has continued to “self medicate” with alcohol

Ongoing worry re: kids problems – truant, getting into

trouble; finances; conflict with own family/siblings

When doctors/nurses try to “make me understand” re

health, “can’t make sense of it”, worry

Case Study – “Tavita”: A patient-centred perspectivePrimary issues – trauma history, PTSD, depression,

family stress, low self esteem – all meaning he feels

he has no control in his life.

Secondary issues – diabetes, gout

Attempts at “health education” have left him feeling

whatever he does, he will die young.

He is thus anxious about his health, but does not

know what to do, and does not trust health

professionals who “don’t understand…”

Case Study – “Tavita”: A different approachWhat is happening now is a “lose-lose-lose”

He feels more and more out of control, his health

is getting worse

He is now unable to work, address his family

issues

We get frustrated trying to help, and he is an

increasing burden on the health system

SO HOW COULD WE DO THIS DIFFERENTLY???

What would a “self-management support” informed

approach look like??

Case Study – “Tavita”: A different approach to prioritising1. Listen, hear his story, understand his

perspective and what his issues are

2. Engage him in identifying his goals and what

support works for him

3. Address mental health & psychosocial issues

4. Improve his health literacy, “self-efficacy”, and

“self management” skills – and then…

…chances are his medical issues will be easier

to manage

Moving From Defined Roles For Clinician and Patient …

Power imbalance

Clinician responsibility

“What’s the matter with

you”

Compliance

Constraint

…To a Focus On Building Trust and Partnership

Health Behaviour

“What matters to you”

Partnership

Shared responsibility

Teamwork

Liberation

20,000 Days Campaign

The increasing demand on

resources across Counties Manukau is

driving the need for continuing

improvements in the way that we keep

our community healthy.

To meet the predicted 5.5% increase

in bed days, we needed to save 20,000

days by 1 July 2013.

Kia Kaha: Manage Better, Feel

Stronger

Aim: To achieve 25% reduction in

unplanned hospital & general practice

use for 125-150 individuals with medical

& mental health

co-morbidities engaged in the programme

by 1 July 2014

Manaaki Hauora-Supporting Wellness Campaign

To provide self management

support for 50,000 people living with

long term conditionsacross Counties

Manukau by

1 December 2016

Kia Kaha Ki Te Hauora: Be Strong in Wellness

To engage, activate & connect patients/ whaanau & GP clinics with

patient-centered processes / programmes, and a self-management

“wheel of support”.

Aim:

To enable 5000 East

Tamaki Healthcare

patients with long-term

conditions in the Otara

locality to engage in

self-management

support by 1

December 2016.

Select

Topic

Expert

Meetings

Identify

Change

Concepts

Pre work

LS 1

S

P

A D

LS 2

Supports: emails/ phone / one on one site visits & regular

meetings

P

A D

S

The Breakthrough Series: Institute for Healthcare

Improvement Collaborative Model

LS 0LS 3

Spread

across

Services,

Sector,

Community

PA D

S

Collaborative Teams

P

A D

S

P

A D

S

P

A D

S

Learning Sessions – Face to face

Inspiring Stories ….

Co-Design

Initial FindingsNot all of the high users seen identified themselves as having

a “mental health issue”

What we identified was high psychological distress and

psychosocial complexity

Engagement was the biggest challenge

We trialed the use of peer support workers to engage with the

most hard to reach patients

Along the way, we recognised more and more the value of

peer support as an “intervention” in itself

Initial FindingsSome interesting themes emerged in the “stories” that sat

behind these patients:

• Patient perspective – “no-one listens… sick of everyone

telling me what to do… they don’t understand…”

• Clinic perspective – “no matter what we do they don’t

change, they miss appointments – they don’t want to be

well…”

Most of these people are disempowered and feeling hopeless

BUT want their lives to be better, want to be well, and have

been so grateful to be heard, and provided help in a way that

works for them.

Peer specialist pilot

starts

% m

akin

g first a

pp

oin

tment

OUTCOME: Activated patient - Activated Services

Total cohort n=69

Number

Ag

e g

rou

pin

g

Results – Primary Aim Exceeded!

Results – Improved Mental Health

PHQ-15 – Somatisation rating scale GAD-7 – Anxiety rating scale PHQ-9 –

Depression rating scale

2. SME SupportGroup/Individual

Peer Led

3. Wellness/Care Plan

With activated patient

and whanauPeer/Professional

4. Connect to Primary Care

Teamwith option

to get furthersupport

1. AssessmentProfessional/Peer

Kia Kaha

End of Phase I – Change Package

Aim:

To enable

5000 East

Tamaki

Healthcare

patients with

long-term

conditions in

the Otara

locality to

engage in

self-

management

support by 1

December

2016.

Driver Diagram: Kia Kaha Ki Te Hauora

Engagement 7 Types of

Professional-peer

self-management

support

Measures:

Qualitative & Quantitative

Within the locality

Change IdeasPrimary

DriversSecondary Drivers

Aim &

Measures

With other services

Co-design

Within the team

Huddles with other teams

Connection

Activation

Referral pathways

Organisational/

Professional

attitudes

Peer-led self-management training

Empower ETHC ARI team with support and tools

Streamline Admin Processes

Weekly Mentoring

sessions

Engage with Management

Ongoing community connection

Provide consultancy to other collaboratives

Professional peer led visits (group care

plans) Co-designing

Peer Health Coaches

Referrals to Community Health Workers

Support groups

Telephone-based peer support

Online peer support

Training and cross-

training

Implementing

Testing

Implementing

Testing

Co-designing

Co-designing

Testing

Implementing

Testing

Testing

What has the Manage Better

Course done for you?

Self

Improvement

Practical

Skills

Social

Aspect

Illness

Perceptions

Confidenc

e

Change

Self-

Management

Motivation Positivity Hope

‘Not

Alone’

Social

AnxietyGroup Setting

Understandin

g

Awareness

Acceptance

Problem

Reappraisa

l

Support

PersonSkills

Information

Conceptual themes derived from

participant feedback

Run chart showing number of

Manage Better course referrals from

July 2013 to date

Median

0

10

20

30

40

50

60

70

80

90

Jul-1

3

Au

g…

Se

p…

Oct-1

3

Nov…

Dec…

Jan

-…

Fe

b…

Ma

r…

Ap

r-14

Ma

y…

Jun

-…

Jul-1

4

Au

g…

Se

p…

Oct-1

4

Nov…

Dec…

Jan

-…

Fe

b…

Ma

r…

Ap

r-15

Ma

y…

Jun

-…

Jul-1

5

Au

g…

Se

p…

Oct-1

5

Nov…

Dec…

Jan

-…

Fe

b…

Ma

r…

Ap

r-16

Ma

y…

Jun

-…

Jul-1

6

Au

g…

Se

p…

Oct-1

6

Number

Promote

SME to GPs

Integrate Peer Health

Coach into 1 clinic

In The Words of a GP:I guess the whole reason I refer my patients to the SME is that I see clinical and psychosocial evidence that it works.

Namely – patients Hb1ac are generally better, they are generally happier, proud of their achievements; also there is the companionship and sharing with other similar individuals. There is ongoing support and development.

For some patients I was seeing all the time, visiting frequency seems to have reduced.

Education is a key factor in our patient management. Unfortunately , I don’t have the time to “effectively educate and motivate” a patient in a 10-15 min consultation slot . The SME session fills in these gaps and I/We in-turn reinforce these messages.

It’s a great success - SME works for my patient’s .

Care plan groups1) Professional led visits with peer support

Manage Better Courses

2) Peer led self-management training

Peer support

4) Community

health workers

Manage Better support groups5) Support groups

Phone health coaching

6) Phone support

Health coaches3) Peer health coaching

Manage Better

Facebook Page7) Online Support

*Heisler M. Building peer support programs to manage chronic disease:

seven models for success. Oakland, CA: California Healthcare Foundation;

2006. Available from http://www.chcf.org/publications/2006/12/building-

peer-support-programs-to-manage-chronic-disease-seven-models-for-

success

Wheel of Support

Case Study - Video

“I can now control my anxiety by using all of the

techniques that were taught…my goal is to get better and

stay healthy”

I was hearing words like “terminal illness” and “you will just have

to learn to live with the pain” from the specialists. However, Kia

Kaha helped us to learn about pain management and make a

strategic plan as a family. My wife is no longer worried about me

dying, my whanau (family) is re-connected and we have a tool

box. My goal was to get healthier, I feel I have achieved that,

now I have to maintain it.

Sina’s mother said that she now

takes her medication, is more

active and much happier. She

said, “Sina looks more beautiful

when she is happy!”

Sina’s daughter said that her

mum is much happier and

stronger than before.

When I saw Sina after she started

the Manage Better Course, I couldn’t

believe I was seeing the same

person! Dr David Codyre

I now know that

this is not the end

but just the

beginning of our

health journey….

Sina

Sina’s GP practice has

noticed positive

changes

“I have noticed a

massive change since

we first met, I can see

her family has become

closer and more

supportive now.”Ula, Peer Support

0

10

20

30

PHQ15 GAD7 PHQ9

Sina's Scores on the PHQ-SADS

Sep-15 Nov-15

Sina: “Life is

extremely difficult”

11 September 2015

Sina: “Life is

not difficult at all”

11 November 2015

Lessons Learned

Committed organisational support and

inspiring project leadership is critical

Improvement Science methods “keep

you honest” and liberate you to try new

things

Co-design helps generate the right

ideas to test

Peer support via the “7 models” can be

transformational

Peer-professional partnership keeps

the patient at the centre of care

“Less is often more”

www.koawatea.co.nz

Acknowledgements

Participants of Kia Kaha

Geraint Martin, CEO Counties Manukau Health & management teams

Rakesh Patel, CEO Nirvana Health Group/East Tamaki Healthcare, senior management, & Wellness Support Team

Kia Kaha Collaborative Team

Ko Awatea Campaign Team