Chronic Disease Self-Management

Concept and application Eve LOONG, Manager Self Management Training & Development Centre eve.loong@rehabsociety.org.hk April 26, 2012

Content

1. SM services /approach in CRN2. Who will benefit ?3. How we can facilitate the patients to benefits

from CDSM ?4. Way ahead

SM - Self Management

CDSM- Chronic Disease Self Management

Community-based Rehabilitation

CRN

Psycho-therapeuticGroup

Rehabilitation Course / Self-Management Course

Patients’ Self-help Organization

Changingclients’

perception & self-

valuation

knowledge & skills, build-

up confidence

and behaviors

Information sharing, Communit

y education

&Advocacy Vision, Mission and Value of CRN

Mutual-aid Supportive Network

Mutual-aid Self-helpGroup

Information sharing,

Emotional support

Peer support and participation

Sharing of coping

method, Emotional support

Se

lf Man

ag

eme

nt

Psycho-socialIntervention

Self-mgt Education

Mu

tua

l-aid &

Se

lf-he

lp

Conceptual Framework of CRN Service Model

Exercise• Can you site some examples of our

programs matching the boxed in green, yellow and orange?

Background for Chronic Disease Self- Management

Cure Care Self-Manage

Paradigm Shift

Medical Model Social Model

Why are we doing so poorly?

The IOM Quality Chasm report says:

• “The current care systems cannot do the job.”

• “Trying harder will not work.”• “Changing care systems will.”

IOM : Institute of Medicine, U.S.

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Chronic care model

• Chronic Care model is one of the model for improving chronic care

• One of the elements is Self Management which should be a collaboration of the medical organizations and community services

• It aims to get “productive interactions” between medical practitioners and patients

What distinguishes good chronic illness care from usual care?

Informed,Activated

Patient

ProductiveInteractions

PreparedPractice

Team

What characterizes an “informed, activated patient”?

Informed,Activated

Patient

They have goals and a plan to improve their health, and the motivation, information, skills, and confidence

necessary to manage their illness well.

What characterizes an “informed, activated patient”?

Informed,Activated

Patient

They have goals and a plan to improve their health, and the motivation, information, skills, and confidence

necessary to manage their illness well.

The Kaiser Permanente Triangle

第三層非常複雜

個案管理

第二層高危

疾病 /護理管理

第一层 :

70-80% 慢性病人口可以自我管理 /

自我照顧促进健康

Ratio of Shared Professional Care to Self Care across the Chronic Illness Population base

專業共同照顧

Shared Professional

Self Care 自我照顧

促進健康

自我照顧

自我照顧

Self-Management

Definition Involves [the person with the chronic disease] engaging in activities that protect and promote health, monitoring and managing of symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes

Gruman and Von Korff (1996)

自我管理的定義 學習如何可以積極及正面去面對長期健康

問題 目標是令參加者採納積極和配合的態度與

醫護人員合作

Kate Lorig, Stanford Patient Education Center, 1993

Tasks of being a good Self-Manager

• Understand yourself• Alert of symptoms• Take up an active role to make up a

rehab. plan with health care professionals (HCP)

• Adhere to the agreed rehab. Plan • Manage the impact in physical,

emotional and social aspect• Living a healthy life

Objective of Self Management

• Decrease the cost for professional and nursing care

• Enhance the quality of life of patients

• Empowerment : different levels

Self-Management Strategies Based on patient perceived problems Builds confidence (self-efficacy) to perform

3 tasks Disease management Role Management Emotional Management

Focus on improved health status and appropriate health care utilization

Symptom Cycle

Vicious Cycle

Disease

Tense musclesFatigue

Depression

Difficult emotions

Stress/Anxiety

Symptom Cycle

• It points out the most common symptoms experienced by patients with chronic conditions.

• The Cycle demonstrates that the one symptoms get worse, it get the other one even worse or vice versa

• The tools in the Self Management toolbox is on the other hand the skills and techniqes for lessen the effect of they symptoms which everyone can learn to better self-manage

• 良好的呼吸方法 問题解决方法• 漸進式肌肉鬆弛法 溝通技巧• 药物 重建生活起居流程• 處理疲勞 自信心• 行動計劃 健康信息• 運動 處理痛楚• 醫護人员合作 健康飲食 • 了解情绪 利用思想處理症状

慢病自我管理工具箱

節錄自：身心力行課程組長手冊

Self-management Support

• The systematic provision of education and supportive interventions by health related professionals

• Increase patients’ skills and confidence in managing their health problems

–including regular assessment of progress and problems, goal setting, and problem solving support

We provide self-management Support via

Improving/Enhancing : • client knowledge of illness• knowledge of treatment and interventions• involvement in decision making• ability to take action if symptoms worsen• ability to arrange and attend appointments• ability to manage the impact of their illness• support client to live a healthier life style

Evidence : 6-Month Improvements in Health Outcomes

Self-Rated Health

Disability

Social and Role

activities limitations

Energy/Fatigue

Distress with Health

State

WAY AHEAD• The development of

community rehab. service for CRN

Patient Empowerment Program (PEP)

• We start the service of NTE in 3/2010 and KW in 9/2010, KE in 4/2011,HKW 8/2011

• Target : patients with hypertension and DM Type II

• Referral from GOPC and family medicine

• Provide self-management education through talks, groups, individual work with follow ups.

The Flinders Model Explained

• A generic set of tools and processes • Enables clinicians and clients to undertake a structured process • Includes assessment of self-management behaviors, collaborative i

dentification of problems and goal setting• Development of individualized care plans

Assessment of Self-management

Patient identified problems & Goals Statements

Care Plan, Agreed Issues, Agreed Aims, Agreed Interventions, Review Processes

Disease Management

Self-Management

+

Flinders Human Behavior & Health Research Unit, Flinders University

Global Initiatives• The Expert Patient Program (UK)• The Sharing Health Care Initiative (Australia)• CDM Initiatives (BC, Canada)

– BC NurseLine CDM Initiative: Telehealth Self-Management Support

– Physician Self-Management Pilot Project• Health in Action (Hong Kong)• Flinders Program (South Australia)• CDSMP Pilot Projects in NCNCD, China

Training in China

Find more if you want

• http://patienteducation.stanford.edu/ ( Website of Patient Edu. Research Centre Stanford University)

http://www.expertpatients.co.uk

(Expert Patient Program, UK )

Quiz1. Which one of the followings is not the

characteristics of a good Self-Manager?

A. Alert of the symptoms

B. Have a healthy living style

C. Monitor the impact of disease in physical, emotional and social aspects

D. Try alternative medicine

E. Understand yourself

2. The symptom cycle includes the following except :

A. Fatigue

B. Pain

C. Depression

D. Frustration

E. Insomnia

3. The Self Management toolbox includes the followings except :

4. Self-Management education or program is proven to be effective in improving patients

a. Self-rated health status

b. Quality of life

c.

Approaches of CRN service :

1. Invite expert for teaching

2. Emphasize the group work process

3. Division of labor ntf