Dr Fiona Jones
Principal Lecturer, Rehabilitation
Now embedded in Health Policy ( DH 2008)
 Stroke- not only an acute condition- or a
‘one-off’ ( O’Neil 2008)
 Lack of specialist support long term (NSSA
2008)
 Goal setting principles align with selfmanagement theory, but there is
inconsistency (Jones, 2006; Playford, 2009)
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Involves....
Problem solving
Goal setting
Self-discovery
Utilising resources
Knowledge about condition
Shared decision making
Collaboration
Behaviour change
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By 2010, 15 million people will have personalised
care plans, named lead professionals will ensure
that plans and services are tailored to needs (Darzi,
2008; NHS Next Stage Review, July 2008)
There will be a patients prospectus to provide
advice for those people with LTC’s that want to
take control of their health (NHS Next Stage
Review, 2008)
Rehabilitation and ongoing support should be
designed around individual needs and goals
Healthcare for London : Guidance for
Commissioners (2010)
Inpatient
rehabilitation
Early supported
discharge
Too medical?
Too much
going on
Risks to high?
Patient not
ready
Community
rehabilitation
Support structures
after rehabilitation
Team Goal
setting method
in place
Support not
available
Limited time
Limited
understanding
of rehabilitation
Goals ..who is in
control?
When we don't agree with
goals
 Use clinical reasoning to
justify
 Framing goals around
early rather than long
term
 Collaboratively framing
goal with other team
members
 Goals are non-negotiable
 Never written down
Playford et al., 2009
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In-depth reflective case
reports from professionals
Experiences of using a selfmanagement programme
Different stages of stroke
pathway
A new stroke self-management programme:
preliminary analysis of training for practitioners
International Journal of Stroke: 4: Supplement 2:
December 2009
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Timing when to use
‘Difficult to use in
Intermediate care as timing is
so short
Lost impetus when
transferred to day centre as
the no-one took over
supervision with workbook’
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Unrealistic goals?
‘I worried the goal was
too difficult and he
had set himself high
expectations
But he did manage itI could have trusted
him more!’
◦ People with cognitive, perceptual and
communication deficits
◦ Takes time which is limited in the acute
setting
◦ Difficult when patients have limited
motivation
◦ Too early in recovery – patients often still
adjusting to what's happened to
them/finding out what they have lost/kept
◦ Some difficulties in using the programme
alongside traditional rehab
◦ Not easy when the whole team has not been
trained
◦ Time pressures to “push through” patients
◦ Patient goals too ambitious
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Just giving it a go and getting some practice
Knowing the content of the programme
reasonably well
Helped to involve family in rehab
Using it flexibly e.g. with family, different
sections
Letting the patient set their own goals in own
words
Patient chooses an important goal to
themselves
Knowing other clinicians on stroke pathway are
trained
Incorporating self-management into daily
practice
Belief in the concept and commitment
Confidence in the use of the workbook
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Yes ...but more limited in acute stage
Yes.... if we do not try it then we will never know
Helps with communication but dependent on existing relationships between
services
Therapists need to get together and discuss how the transition of care/self
management concept is taken forwards.
Puts client in charge of own pathway leads to continuity of care
Aids continuity of care
The same goals are aimed for by all clinicians and teams involved
The patient could feel less vulnerable and more in control
Helpful for transitional stages
Help patient to focus on what they want to achieve at difficult stages of their
journey
Helps seamless transfer of goals
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Hardeman and Mitchie (2009) ‘in the absence
of training healthcare professionals do not
usually posses the knowledge and skills to
deliver self-management interventions
‘(p102).
Early supported
discharge
acute
community
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Supporting individuals to:
◦ Make informed choices
◦ To assess their own needs and
develop confidence to self-care
◦ Access appropriate information
to manage needs
◦ Develop skills to self-care
◦ Use technology to support selfcare
◦ Access support networks, and
participate in the planning and
development of services
◦ Risk management and risk
taking to maximise
independence and choice
Skills for Health & Skills
for Care, 2008
Services need:
 Benchmarks of good
practice
 Framework for staff
development
 Develop new ways of
working
 People focused services
 Emphasis on role of people
in their own care
 Address personalisation
agenda
Boost confidence to ‘let go’
Reflective practice
Research in partnership
Patient’s and carer’s experiences
Responsive CPD. Exemplars of best practice
13/04/2015
14
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Measuring change : PROMs, Goal Attainment
Scale, COPM
The goal setting dilemma
Self-management will mean risk
Professional intransigence
Translational research, multi-methods
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‘Our plans to transform care for patients with
long-term conditions will involve people
being offered personalised care planning and
support for self-care.’ NHS 2010–2015: from
good to great preventative,peoplecentred,productive. ( DH, 2009)
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Self-management principles embedded into
pathway
Shared benchmarks of good practice
Research programme in self-management
◦ Effectiveness, feasibility, acceptability, equity,
efficiency
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Training and research in collaboration with
service users
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‘I read the book to begin with, and then I had
another small stroke, I started looking at the
workbook properly after that, I didn’t realise
how fed up I was, looking in it regularly made
me realise I can make some small steps to
make progress in my life, and that those
small steps could add up to giant steps’
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f.jones@sgul.kingston.ac.uk
www.bridges-stroke.org.uk