About Co-creating Health

Natalie GrazinAssistant DirectorThe Health Foundation

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DiabetesThe

Whittington Hospital

and Haringey

and Islington

PCTs

Guys & St Thomas

and Southwark PCT

COPDAddenbrokes and

Cambridgeshire PCT

NHS Arran and Ayrshire

DepressionSW London MH Trust and Wandsworth PCT

Torbay Care Trust and PCT

Chronic

PainCalderdale

and Huddersfie

ld Trust and

Kirkees PCT

A model for all LTCs

A model for all long-term conditions

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What is needed for effective self-management?

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What is needed for effective self-management?

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The Integrated CCH Model

©The Health Foundation 2007

An Integrated Approach

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Programme Who Role change Focus

Patient

From passive patient to self-management

Activation and partnership: confidence and skills

Clinician

From expert who cares to enabler who supports self-management

Building the knowledge, skills and attitudes needed to provide effective self-management support

Service

From clinician-centred services to services that have self-management support as their organising principle

Embedding the 3 enablers into everyday practice by building them into systems and care pathways

Self-management Programme

Practitioner Development Programme

Service Improvement Programme

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Agenda setting– Identifying issues and problems

– Preparing in advance

– Agreeing a joint agenda

Goal setting– Small and achievable goals

– Builds confidence and momentum

Goal follow-up– Proactive – instigated by the system

– Soon – within 14 days

– Encouragement and reinforcement

Becoming an active partner

Making change

Maintaining change

The Three Enablers

Self Management Programme outcomes

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... producing statistically significant changes in:• positive engagement with life• constructive attitude/approach towards condition• more positive emotional well being• using self-management skills and techniques

“I used to go to the doctor only when they summoned me, and then say ‘What are you going to do to fix my problem?’. But now I’m saying like, ‘I’m not sure these particular painkillers are working the way we hoped, can we try something else? What could I do myself? ’ “

Person living with along-term condition

Skills developed ....

• Setting the agenda

• Setting goals

• Problem solving

• Develop the confidence

• Understand their condition

• Develop skills

Practitioner Development Programme outcomes

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Practice positively influenced:

• patients’ confidence to self manage • agenda setting • setting own goals• collaborative problem solving• goal follow up• patients’ experience

Community matron

Clinician tutor

“It’s a change from the traditional approach where say ‘You need to do this”, and the patient says “you’re the boss”, but doesn’t actually do it. We used to wonder why that wasn’t working”

“Now I use agenda setting with my patients and I start by asking ‘what do you want us to do today?’ Patients appreciate this different approach because you are giving them the power. You work out the goals and the steps together and they are empowered to carry on and work on it on their own. So you may need to see them a bit more at first, but in the long run you need to see them less often.”

Patient Confident in Self

Management

Organisational Changes

Pre-visit changes

During visit changes

Post-visit changes

Primary Drivers Secondary Drivers

Outcome

Service Improvement Programme

IMPROVEMENT

The 3 Enablers

Agenda Setting

Goal Setting

Goal Follow Up

Adapted from Robert Lloyd and Richard Scoville, Better Quality through Better Measurement

11©The Health Foundation

Conclusion

Person living with a long-term condition

‘I’d like to thank you both for giving me back the life I thought I’d lost, its made me realise I was holding myself back’

More information

Visit our self management support resource centre on the Health Foundation’s website:

www.health.org.uk/sms

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