Introduction to
Co-Creating Health
Preparatory Workshop
Welcome and Introductions
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Tutors
All in group
Name and area of work
House keeping;
-Manage self
-All teach, all learn
-Toilets
-Fire alarm & exits
-Refreshments
-Mobile phones
Aims Preparatory Workshop
During this workshop you will have the opportunity to;
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Understand the contextual background regarding the challenges for today’s
healthcare economy with regard to Long Term Conditions (LTCs)
Explore your knowledge, beliefs and understanding of Self Management (SM)
and Self Management Support (SMS)
Raise your awareness of the evidence base to support this approach
Consider what you already do that works well to support SM
Find out how to signpost people living with a long term condition to the
parallel skills training programme for patients
Understand the support tools available to help you change processes
Start to develop your team’s action plan for SMS
Pre-training questionnaire
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Please complete the pre training questionnaire (or other chosen version) and
return to the facilitator.
This questionnaire will be repeated at the end of the last workshop and will
enable you to assess your development and will contribute to the programme
evaluation
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Thank you
The Challenge – Long term Conditions (LTC’s)
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15.4 million people in UK living with at least one LTC
People with LTCs are far higher users of health and social care
Accounts for; approx 69% primary and acute care budget in England
Includes; 50% General Practitioner consultations, 65% of out-patient
appointments and 70% of inpatient bed days
Aging population and rising numbers
At current rate of growth, expenditure on LTCs would increase by 94% by 2022
(with minimal real potential increase in NHS budget)
Increasing pressure to improve quality and cost
Our healthcare system is not currently configured to cope with the increased
demand
Meeting the Challenge
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No decision about me without me
Equity and excellence: Liberating the NHS: The 2010 NHS white paper
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82% people living with a LTC want more support to self care
Half those identified with LTC unaware of treatment options & no care plan
GP Patient Survey 2008/9 - 61% surveyed felt discussion of care plan would
result in better care
The Co-Creating Health Programme; improve quality of healthcare services,
increase personalisation and reduce costs
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http://www.dh.gov.uk
Reflective exercise
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Exploring your philosophy – What do you think?
Work in groups of two or three
Discuss statements on the handout/next slide
Score how much you agree with them on a scale of 0-10
(0=strongly disagree, 10=strongly agree)
Each group start with a different statement
Move onto the other statements
Come back as a large group
Discuss and debrief
Statements
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The person with a long term condition is in charge of their own life and
managing their condition(s)
The person with a long term condition is the main decision-maker in terms of
how they live with and manage their condition(s)
The person with a long term condition is more likely to act upon the decisions
they make themselves rather than those made for them by a professional
The person with a long term condition and the health care professional are
equals and experts
The Year of Care Consultation Skills and Philosophy Toolkit © Year of Care v7 08/07/10
http://www.diabetes.nhs.uk/year_of_care
Why Self-Management Support?
Life with a long term condition: the person’s perspective
Interactions with the service: planned or unplanned
NB : People may also be accessing a wide variety of other support e.g. from within their
communities
What is Self-Management?
What is SM? (Interactive discussion)
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Self-management, by definition, is led, owned and done by people themselves
The NHS cannot do self management to people, however it can create an
environment where people feel supported and have increased confidence to
self-manage
This is not just about a change in service provision, but a cultural change,
allowing people with long term conditions to be partners in their care,
supporting them to decide what is important to them, what support they need,
when they need it and how it should be available
What is Self-Management Support?
What is SMS? (Interactive discussion)
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“Self-management support is what health services do in order to aid and
encourage people living with long term-conditions to make daily decisions that
improve health-related behaviours and clinical outcomes. It can be viewed in
two ways: as a portfolio of techniques and tools; and as a fundamental
transformation of the patient-caregiver relationship into a collaborative
partnership”
Tom Bodenheimer CHF 2005
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Personal Care Planning (is a process that) empowers individuals, promotes
independence and helps people to be more involved in decisions about their
care. It centres on listening to individuals, finding out what matters to them and
finding out what support they need.
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They are verbs not nouns!
People who optimally self manage are;
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Optimistic
Determined
Contextually informed (health information that ‘makes sense to me’)
Confident
Problem solvers, decision makers
People who inhabit rich social networks
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Chicken and egg – however;
All of these are amenable to change – often with simple interventions
Active support works best
There is a continuum.
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There are many ways to support self
management.
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Some approaches are passive and
focus on improving technical knowledge.
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Other ways are more active and focus
on changing confidence and behaviours.
Research shows that more active support focused on
confidence and behaviour works best to improve outcomes.
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Self management works
Research shows that supporting self management
can improve:
•self confidence / self efficacy
•self management behaviours
•quality of life
•clinical outcomes
•patterns of healthcare use
A review of almost 600 studies found that when
people are supported to look after themselves, they
feel better, enjoy life more and have fewer
emergency visits to GPs and hospitals.
There is a lot of evidence from systematic
reviews and randomised trials and much of the
research is good quality.
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Diabetes
had at least one check up
in the last 12 months
and
discussed ideas about the
best way to manage their
diabetes
agreed a plan to manage
their condition over the
next 12 months
discussed their goals in
caring for their diabetes
From ‘Managing Diabetes’ Healthcare Commission: 2007
Self management of warfarin and INR.
Cochrane review Heneghan et al April 2010
1.
2.
3.
Clinician management of warfarin and INR
Self monitoring of INR and clinician advice re: warfarin dose
Self management of INR and warfarin
Compared to groups 1 and 2, group 3 have
• same risk of bleeding
• 50% fewer thrombotic episodes
• 36% lower mortality
Patient contacts by care setting
Data is provided for 19 patients for whom a care planning approach has been implemented. Data
includes patients with data is available for 12months prior to care planning and for 12 subsequent
months.
Costs:
The unit costs of health and social care are derived by the Personal
GP appointment
£35
Social Services Resource Unit (PSSRU) annually. These costs are
Outpatient attendance
£126
applied to the activity levels for each type of contacts to estimate the A&E attendances
£110
Acute admissions
£1,317
financial impact of care planning.
Over a 12-month period, care planning for the 19 patients in this study has reduced the total
number of health care contacts from 529 to 246. The associated change in costs is a reduction
from £47,346 to £17,860.
Patient contact activity
Patient contact costs (£)
400
350
300
250
200
150
100
50
practice visits out patient visits
A&E
attendences
Acute
admissions
20,000
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
practice visits
out patient visits
A&E
attendences
Acute
admissions
Co-creating Health:
What are we trying to achieve?
Our aim is to support people with long term conditions to develop
the knowledge, skills and confidence to manage their own health
and healthcare (to become activated).
Co-creating Health supports people with long term conditions on
their journey of activation
Compared with people at low levels of activation, people at high
levels of activation tend to live a higher quality of life, have better
clinical outcomes and make more informed decisions about
accessing medical services.
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Levels of activation
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The CCH Integrated Model
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Health behaviour modeling
Biological
Biological
Emotions / Thoughts
Social / Behavioural
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An Integrated Approach
Service
Improvement
Programme
Focus
Patient
Practitioner
Development
Programme
Role change
From passive patient
to self-management
Activation and
partnership: confidence
and skills
Clinician/work
force
Self-management
Programme
Who
From expert who
cares to enabler who
supports selfmanagement
Building clinicians’
skills and addressing
attitudes
Service/processes
Programme
From cliniciancentred 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
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The Three Enablers
Becoming an active partner
Agenda setting
– Identifying issues and problems
– Preparing in advance
– Agreeing a joint agenda
– Exploring ambivalence, decisional
balance
Making change
Goal setting & action planning
– Small and achievable goals
– Builds confidence and momentum
Maintaining change
Goal follow-up
– Proactive – instigated by the system
– Soon – mutually agreed and ideally
within 14 days
– Encouragement and reinforcement
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Practitioner Development Programme
Three x 3 hour skills development workshops
Time interval between for practice
Adult learning methods
Co-facilitation lay and clinical tutor equal partnership
Pre course reading
Interactive exercises
Large and small group discussion
Based on three enablers – agenda setting, goal setting and follow up
Experiential role play with simulated patient
Goal setting and action planning between sessions
Clinical communication skills, motivational interviewing, CBT approach
Mapped to KSF & Appraisal/revalidation
Evaluation
Ongoing support & continued development
Continuous improvement measurement tools
PDP skills list
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Reflection/Empathy
Explore agenda - something else
- priority & expectation
- clarify boundaries
Explore beliefs self management
Explore importance
Explore confidence
Support autonomy & choice
Explore ambivalence
Invite goals
Ask before advise
Problem solving
Action planning
Follow up
Self management programme for Patients
(SMP)
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Skills development programme
Co-facilitation lay and clinical tutor equal partnership
Combination of education, interactive learning and role play
Based on three enablers – agenda setting, goal setting and follow up
Each session follows up goals set for the week and sets new goals for the
following week
Seven 3 hour workshops at weekly intervals
Follow up support, but aims to build effective peer support.
Skills descriptor list
SMP Skills list
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Goal setting and action planning
Problem solving
Follow up
Pacing and balancing life
Communication – with family, friends and effectively with clinicians
Agenda Setting
Making choices, deals and decisions.
Relaxation & mindfulness
Managing setbacks
Handling and challenging difficult emotions
Planning to stay well
Self Management Programme outcomes
Produces statistically significant changes in:
• positive engagement with life
• constructive attitude/approach towards condition
• more positive emotional well being
• using self-management skills and techniques
Person living with a
long-term condition
“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? ’ “
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Self management programme signpost
process and information leaflet
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Describe your local signposting process with examples of relevant
documentation
The lay co-facilitator can share their experience of the SMP together with any
key messages
Describe local data for total numbers, completed and outcomes
Update this information regularly
Does CCH improve diabetes control?
Results from The Whittington Hospital, 2010
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Patient Activation
and Self Efficacy
Outcome Measure Score
80
Pre SMP
70
6 Months Post SMP
60
50
40
30
20
10
0
PAM
PSEQ
Results Pre and Post SMP from NBT and CHFT, August 2010
Examples of improvement
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A Cochrane review of 36 trials found that self monitoring and agenda setting reduced
hospitalisations, A&E visits, unscheduled visits to the doctor and days off work or
school for people with asthma (Gibson et al 2004).
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A US trial found that personalised goal setting for older women with heart conditions
reduced days in hospital and overall healthcare costs (Wheeler et al 2003).
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A trial found that telephone support may improve self care behaviour, glycaemic
control, and symptoms among vulnerable people with diabetes (Piette et al 2000).
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US researchers found that motivational interviewing helped improve self efficacy,
patient activation, lifestyle change and perceived health status (Linden et al 2010).
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A large meta analysis found that individual education and group sessions improved
symptoms for people with high blood pressure (Boulware et al 2001).
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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Understanding
the problem.
Knowing what
you’re trying to do
- clear and
desirable aims
and objectives
Measuring
processes and
outcomes
What have others
done?
Langley G, Nolan K, Nolan T, Norman
C, Provost L, (1996), The improvement
guide: a practical approach to
enhancing organisational performance,
Jossey Bass Publishers, San Francisco
Act
Plan
Study
Do
What hunches do
we have? What
can we learn as
we go along?
Outcome
Secondary Drivers
Organisational
Changes
Patient / Clinician
Engagement
Pre Visit
Changes
The 3 Enablers
During Visit
Changes
Patient Confident
in Self
Management
Ideas for
Change
Agenda Setting
Goal Setting
Goal Follow Up
Post Visit
Changes
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Appendix 2
Self Management Questionnaire
To help us to continually improve our services we would be grateful if you would kindly answer the following 6 questions.
HAVE YOU ATTENDED A SELF-MANAGEMENT PROGRAMME?
In your consultation today:
YES/ NO
(please circle)
(please circle)
YES/ N0
1. Did you Discuss what was most important to You in managing your own health?
2. Did you Get support to set a short-term goal for yourself?
YES/ N0
3. Did you Arrange to discuss your progress on your short-term goal?
YES/ N0
4. How supported did you feel in managing your health?
10 9 8 7 6 5 4 3 2 1 0
Totally
Not at all
supported
supported
“I am confident that I can manage my health condition”
10 9 8 7 6 5 4 3 2 1 0
Strongly
Strongly
agree
disagree
Evaluation & measuring success
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Practitioner longitudinal questionnaire
Workshop evaluation
Patient feedback questionnaire – The self management questionnaire,
CARE measure
Measurement tools for continuous service improvement (PDSA)
Referral rates to SMP
You may also wish to consider measuring;
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Qualitative data capture
Health economic data such as length of stay, reduced emergency
admissions, increased referral and completion rates for disease
specific programmes such as pulmonary rehabilitation and diabetes
programmes
Examples of Activating interventions
•Patient held record
•Negotiated agenda setting
•Patient access to record
•Information sharing
•Results sharing
•Supported goal setting
•Agenda setting sheets
•Supported problem solving
•Access to information
•Follow up on goals
•Self management programmes
•Peer support groups
•‘Buddy system’
Implementing activating intervention(s);
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Which activating intervention can you develop in your team or practice that
will impact activation and confidence for people living with a long term
condition(s)?
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Agree one which you will work on before the next session
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Nominate an improvement lead who will co-ordinate goal setting and action
planning for this
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All contribute and all support
Activating intervention- goal setting and
action planning
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Work in groups of three
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On a scale of 0-10 consider how important it is that you/your team support your
chosen activation intervention? (0=no importance 10=maximal importance
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Set a SMART goal and develop your action plan to progress implementation of
your chosen activating intervention between now and the next session.
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On a scale of 0-10 how confident are you that you/your team can do this?
(0=no confidence 10=maximal confidence)
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Explore what things would need to happen to increase this confidence?
Next steps
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Three skills development workshops – List dates and venues
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Start to use the ‘Self Management Questionnaire’ with people that you see who
are living with a long term condition.
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Agree action plan for activating intervention activity between now and next
workshop.
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Consider how you will embed signposting to Self Management Programme or
how you will find out what programmes are available locally.
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If there are no local programmes start considering how can you deliver Self
Management skills training for your local population?