Download Care Planning and Goal setting in Diabetes management

Care Planning and Goal setting in
Diabetes management
How can we provide self-management support
to people with chronic conditions?
Professor Malcolm Battersby
Flinders University
Flinders Human Behaviour and Health Research Unit
Overview
• What is self-management?
• Health professional capabilities in selfmanagement support
• Goal setting
• Care planning
• Flinders Program
• Diabetes care planning
Why is self-management support
important? - Adherence
Asthma, Diabetes, Hypertension McLellan et al JAMA 243; 1689,
(2000).
•Drug treatments are effective
•Compliance with medications poor
- diabetes = 60%,
- asthma and hypertension 40%
•Behaviour change is poor with 30% adherence to advice for
lifestyle changes
•Relapse over 12 months requiring care
- 30 -50% diabetes
- 50 -70% asthma and hypertension
•Worse for lower socio economic groups
Capabilities of health professionals for
supporting chronic condition selfmanagement
Funded by the Australian Department of Health and Ageing
Based on being able to deliver the 6 elements of the Chronic Care
Model (Wagner et al)
http://som.flinders.edu.au/FUSA/CCTU/pdf/What's%20New/Capabilities%20SelfManagement%20Resource.pdf
Flinders University, University of South Australia, AGPN, Australian Psychological
Society
Chronic Care Model
Community
Health System
Resources and
Policies
SelfManagement
Support
Health Care Organization
Delivery
System
Design
Informed, Productive
Activated Interactions
Patient
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
Self-management (CCSM)
• Having knowledge of the condition and/or its
management
• Adopting a self-management care plan agreed and
negotiated in partnership with health professionals,
significant others and/or carers and other supporters
• Actively sharing in decision-making with health
professionals, significant others and/or carers and other
supporters
• Monitoring and managing signs and symptoms of the
condition
Self-management
• Managing the impact of the condition on
physical, emotional, occupational and social
functioning
• Adopting lifestyles that address risk factors
and promote health by focusing on prevention
and early intervention
• Having access to, and confidence in the ability to
use support services
Self-management support
• Self-management support is what health
professionals, carers and the health system do
to assist the person
–
–
–
–
to manage their disease or condition,
in order to promote health and prevent illness,
detect, treat and manage early signs of disease,
and minimise the disabling impact of existing
conditions and complications’
Capabilities of health professionals
for self-management support
• General person centred skills
• Behaviour change skills
• Organisational/system skills
General person centred skills
1. Health promotion approaches
2. Assessment of health risk factors
3. Communication skills
4. Assessment of self management capacity
(understanding strengths and barriers)
5. Collaborative care planning
6. Use of peer support
7. Cultural awareness
8. Psychosocial assessment and support skills
Behaviour change skills
9. Have knowledge of models of health
behaviour change
10. Motivational Interviewing
11. Collaborative problem definition
12. Goal setting and goal achievement
13. Structured problem solving and action
planning
Organisational/Systems Skills
14. Working in multidisciplinary teams / Interprofessional learning and practice
15. Information, assessment and communication
management systems
16. Organisational change techniques
17. Evidence based knowledge
18. Conducting practice based research/ quality
improvement framework
19. Awareness of community resources
Current Models of SelfManagement Support
Disease Specific
Arthritis Self-Management ,
Diabetes, Cardiac Rehab, teaches
patients knowledge of disease,
disease self-management
Generic
Stanford 6 week course – teaches
patients skills in self-management
Coaching
Health/ Telephone coaching,
teaches health professionals a
range of engagement and
motivational techniques where the
client has identified goals
Motivational interviewing
Teaches health professionals
stages of change, explores
ambivalence, focus on a targeted
behaviour to change
Current Models of SelfManagement Support
• 5As: Assess, Advise, Agree, Assist, Arrange:
usually targeted at risk factors
• Flinders program: taught to health
professionals to use with individual patients
• Most are complementary
• Most teach patients goal setting and problem
solving as the core patient skills
Goal setting
• A goal is the object or aim of an action Ryan (’70)
• Motivation through conscious goal setting Locke
(1996)
• Higher self-efficacy enhances goal commitment
Social cognitive theory (Bandura, 1997)
•
•
Locke E, Motivation through conscious goal setting, Applied and Preventive Psychology 1996
Locke, Latham, Building a practically useful theory of goal setting, American Psychologist 2002
Goal attainment
1. The more difficult the goal the greater the
attainment
2. The more specific the goal the greater the
attainment
3. Both difficult and specific (progress is possible)
4. Difficult goals require commitment
5. Highest commitment when the goal is
important and achievable
Goal attainment
1. Self-efficacy
2. Feedback
3. Goals affect the direction, effort and
persistence
4. Goals require plans
5. Goals mediate the effects of personality
Increasing commitment - external
1.
2.
3.
4.
5.
6.
Leadership
Rationale
Authority
Rewards
Modelling
Feedback
Increasing commitment - internal
•
•
•
•
•
•
•
Values
Importance of the outcomes
Specific goals to achieve the outcomes
Training eg self-management skills
Cognitive effort
Success in sub-goals
Self-efficacy
5 functions of the Flinders Program
of chronic care management
•
•
•
•
•
Generic chronic condition management
Case management and coordination
Self-management support
Systemic and organisational change
Clinician change
Background - SA HealthPlus
• SA HealthPlus Coordinated Care Trial
1997 – 1999
• Patients with chronic and complex illnesses
• 8 projects in 4 regions of South Australia
• 4,500 patients randomised into Intervention (3000)
and Control (1500) groups in the 8 projects
Battersby et al, BMJ, March 2005
BACKGROUND -Year 1 review
•
Problems and Goals worked well for most patients
•
However the system designed to allocate coordination time
according to level of severity (H/M/L) wasn’t being used
•
WHY?
•
Because some people who had severe complicated conditions,
but were good self-managers, and did not need coordinated care
•
Service coordination was provided based on whether a
person was a good self-manager or not
•
Self management was not defined or operationalised
Learning
• Self-management capacity is affected by
–
–
–
–
the illness
personal attributes
attributes of health providers
cultural and social factors
• Self-management skills need to be assessed before the
right intervention is offered
• Not all consumers need self-management support and
those who do will respond to a wide range of learning
methods, some group, some individual
(Battersby et al, Milbank Quarterly, Dec 2006)
Care Plans
Should be derived from a self-management
assessment including
•
•
•
•
Knowledge
Behaviours
Attitudes
Impacts of the
condition
• Lifestyle risk Factors
• Barriers to selfmanagement
• Strengths.
Care Plans
Should contain
• Client defined
problems
• Clients defined goals
• Medical management
• A prioritised action
plan
• Community education
or resources
• Community services
• Planned review and
follow-up
Care Plans
Should
• Facilitate the persons engagement in their own
healthcare and treatment
• Enhance the client / provider relationship
• Enhance the clients self-efficacy for selfmanagement and health outcomes
• Enhance the clients ability to maintain changes /
improvements.
Care Planning
Should enhance clients skills in
•
•
•
•
•
Problem definition
Goal setting
Goal attainment skills
Action Planning
Problem solving
• Pain management
• Psychosocial
management
The Flinders Program™ of Care Planning
for Self-Management Support
The Flinders Program™ is:
• Bio psycho-social
• Motivational
• Outcomes based
• Patient-centred
• Integrates medical and self-management
• Communication tool
Seven Principles of Self-Management
1.
Know your condition
2. Have active Involvement in decision making with
the GP or health workers
3. Follow the Care plan that is agreed upon with the
GP and other health professionals
Seven Principles of Self-Management
4. Monitor symptoms associated with the
condition(s) and Respond to, manage and
cope with the symptoms.
5. Manage the physical, emotional and
social Impact of the condition(s) on your life.
6. Live a healthy Lifestyle
7. Have access to Services
Principles of Self-Management
K
I
C
MR
I
L
S
Knowledge
Involvement
Care plan
Monitor and Respond
Impact
Lifestyle
Services
The Flinders Program
Assess
Self-Management
SelfManagement
Healthcare
Management
+
Problems and
Goals
Community /
Family Support
Action Plan
Agreed Issues
Agreed Interventions
Shared Responsibilities
Review Process
Psychosocial
Support
Assessment of SelfManagement Capacities
Partners in Health Scale (PIH)
• 12 questions
• self assessed and scored on 9 point scale
Cue and Response Interview (C&R)
• 12 questions with cues
• explores the strengths and barriers
• HP assessed and scored on 9 point scale
Leads to collaboratively identified issues
CUE & RESPONSE INTERVIEW V10 JUNE 2010
Problems & Goals Assessment
• Identifies what the client sees as the
biggest problem
and
• Identifies the goal(s) the client wants to
achieve
Problem Statements
3 parts to a problem statement
• The Problem
• What happens to the client because
of the problem?
• How this makes the client feel?
Problem Measurement
Problem Statement
“Because I’m so tired from looking after my
grandkids, I don’t do the exercise I should and I feel
like a failure.”
Rating Scale
How much of a problem is this for me?
0
Not at
all
1
2
3
4
5
Very little Somewhat
6
A fair bit
7
8
a lot
Goal Statements
• Goals are linked to the problem statement
• Achieving goals may result in improved
problem rating because of changes to
- The problem
- What happens because of the problem
- How the problem makes the client feel
Goal Statements
Repeated and S.M.A.R.T.
Specific
Measurable
Action based
Realistic
Time-framed (how long / how often)
Care Plans for
Chronic Condition Management
•
•
•
•
•
•
Identifies medical needs /management aims
Evidence based guidelines
Planned Appointments
Planned tests
Medication list
May be individualised but may be templates
Care Plans for Self-Management
Contains:
• Identified issues from the C&R Interview &
P&Gs
• Agreed goals / management aims
• Agreed interventions
• Sign off
• Review dates
Supports:
• Self efficacy
• Empowerment
The Flinders Program
• Certificate of Competence
¾Part of a Quality Assurance Process
¾Submit a minimum of 3 care plans
¾Results in a licence to use the Flinders Program of
Self Management Support.
Achievement of Goal 1
Figure 2.15.
Extent of Achievement of Goal 1 by project, end of
trial.
EP Diabetes n= 347
S somatisation n= 76
S COPD n=140
S. Aged n= 525
EP Chronic and complex n=831
W COPD n= 212
W Diabetes n= 154
Central cardiac n= 194
0%
20%
Positive %
40%
60%
No change %
80%
Negative %
100%
Eyre Peninsula Aboriginal Diabetes Project
• Self-management program that is
– culturally sensitive and flexible,
– promotes self management principles through goal
setting, care planning
– lifestyle changes
– access to preventative services
• 60 participants - 12 months follow up
• Sustainability through the care planning item
numbers
Eyre Peninsular Diabetes
• Improved scores on PIH self management
at 12 months
• Problem improved 6.22 – 5.28 (p <0.01)
• Goal improved 7.26 – 5.42 (p <0.001)
• Improved HbA1c 8.74 -8.09 (p< 0.01 )
• BP 139/84 -136/83
• No change in SF-12 (difficulty with
questions)
Education and Training
•
•
•
•
Flinders Program on-line
Communication and motivation workshop
Revised (shorter) version of FP
Flinders Graduate Certificate and Diploma in
chronic condition management
• Master of Primary Health Care (chronic condition
management)
[email protected]
Thank You
Contact: Prof Malcolm Battersby
Flinders Human Behaviour and Health Research Unit,
Flinders University
Phone: 8404 2608
Fax: 8404 2101
Email: [email protected]
[email protected]
http://som.flinders.edu.au/FUSA/CCTU/Home.html