การสนับสนุนการดูแลตนเอง
Self-Management Support
ประณีตศิลป์ เชาวน์ลักษณ์สกุล
ขอบเขตเนื้ อหา
ความหมาย
ความแตกต่าง (What
is a difference?)
– Self management (SM) VS SM Support
– Traditional Health Education VS SM
Education
What are the existing SMS?
How are the SMS effect DM outcomes?
What are the predictors of SM?
What are the barriers of SMS?
Definitions
Self care VS self-management
VS self -management Support
Self care
หมายถึง
กิจกรรมทีแ
่ ตละบุ
คคล ครอบครัว
่
และชุมชน
ปฏิบต
ั เิ พือ
่ สรางเสริ
มสุขภาพ
้
ป้องกันโรค
ควบคุมการกาเริบของโรค หรือ
รักษาสุขภาพ
means activities that individuals, families, and
communities undertake with the intention of
enhancing health, preventing disease, limiting
illness, and restoring health’’ (Clark, 2008).
Definitions
Self management VS Self Management Support
“Self-management”
“Day-to-day tasks that an individual must
understand to control or reduce the
impact of disease on physical health
status. At home management tasks and
strategies are undertaken with the
collaboration and guidance of the
individual’s physician and other health
care providers” (Clark et al, 1991).
Definitions
“A treatment that combines biological,
psychological, and social intervention
techniques, with a goal of maximal
functioning of regulatory processes”
(Nakagawa-Kogan et al., 1988).
Definitions
“the individual’s ability to manage the
symptoms, treatment, physical and
psychosocial consequences and lifestyle
changes inherent in living with a long
term disorder’’ (Barlow, 2001;
Department of Health England, 2005).
Definitions
Increasing the individual’s consumer’s capacity
to engage in “activities to promote (their own)
health” and empowering them to monitor and
respond appropriately to the signs and
symptoms related to their disease and as thus
minimize the negative impact on their level of
“functioning, emotions, and interpersonal
relationships (Ermel, Crombie, Ham, & Bendigo
Health Care Group).”
Definitions
“Self-management support”
“activities in the clinic that prepare and
empower patients to have a central role in
their health care, including goal setting,
action planning, problem solving, and followup” (Wagner, et al., 2001).
“the process of making multi-level changes
in health care systems and the community
to facilitate patient self-management
(Glasgow RE. et al, 2003, Rothman AA &
Wagner EH., 2003 cited in Coleman &
Newton, 2005).
Definitions
“Inter-disciplinary group education,
based on the principles of adult
learning, individualised treatment and
case management theory”
(Alderson et al., 1999).
Definitions
“Self-management support”
1. กิจกรรมหรือโปรแกรมทีจ
่ ด
ั ขึน
้ ในคลินิกเพือ
่ เตรียม
หรือเสริมกาลังให้ผู้ป่วยมีบทบาทสาคัญในการดูแล
สุขภาพของตน อาทิ
การตัง้ เป้าหมาย
แผนปฏิบต
ั ก
ิ าร
การแกไขปั
ญหา
และการ
้
ติดตาม (Wagner, et al., 2001).
2. กระบวนการของระบบบริการสุขภาพและชุมชนที่
จะกระตุนให
้
้ผู้ป่วยดูแลตนเอง
(Glasgow RE. et al, 2003, Rothman AA & Wagner EH.,
2003 cited in Coleman & Newton, 2005).
Definitions
3. การสอนสุขศึ กษากลุมระหว
างสาขาวิ
ชาชีพ
่
่
บนหลักการเรียนรูแบบผู
ใหญ
เฉพาะ
้
้
่
รายบุคคล และการจัดการรายกรณี
(Alderson et al., 1999).
A concept analysis of SM
Reaction of diagnosed
Reactions to being diagnosed
with a long-term condition are
unpredictable.
Self efficacy
Resource use
Collaboration
Education
Problem solving
and decisionmaking
Goal setting and
monitoring
(Embrey, 2006)
• Empowerment
• Development of
competencies that
allow people to gain
control
• Improved health
outcomes
• Increased selfconfidence
What is a difference?
Diabetes Education
(Didactic Education)
SMS Education
• What is taught ?
• How are problems formulated?
• Relation of education to the disease
•What is the relationship between patient and health professionals?
• What is the theory underlying the education?
• Who is the educator?
• What is the goal?
Table 2. Comparison of Traditional Patient
Education and Self-management Education
Issue
Traditional Patient SelfEducation
management
Education
สอนอะไร?
ข้อมูล โรค และการ
แก้ไขปั ญหา
ทักษะในการจัดการ
กับปั ญหา
What is
taught?
Information and
technical skills
about the disease
Solution to their
problems
Skills on how to act
on problems
Basic problemsolving skills (Lorig,
2003)
(Lorig, 2003)
(Bodenheimer, Lorig, Holman, & Grumbach, 2002)
Table 2. Comparison of Traditional Patient
Education and Self-management Education
Issue
ปั ญหามา
จากไหน ?
Traditional
Patient
Education
Self-management
Education
การรักษาโรค ผูป้ ่ วยบอกปั ญหาที่เขา
ไม่ดีพอ
พบอาจจะไม่เกีย่ วกับโรค
How are
Problems
problems
reflect
formulated? inadequate
control of the
disease
The patient identifies
problems he/she
experiences that may
or may not be related to
the disease
(Bodenheimer, Lorig, Holman, & Grumbach, 2002)
Table 2. Comparison of Traditional Patient
Education and Self-management Education
Issue
Traditional
Self-management
Patient Education Education
ความสัมพันธ์ เกีย่ วกับโรค
การให้สุขศึกษา Education is
กับโรค
disease-specific
Relation of
education
to the
disease
and teaches
information and
technical skills
related to the
disease
สอนทักษะการแก้ไขปั ญหาที่
เกิดตามมากับอาการเรื้ อรัง
Education provides
problem-solving skills
that are relevant to the
consequences
of chronic conditions in
general
(Bodenheimer, Lorig, Holman, & Grumbach, 2002)
Table 2. Comparison of Traditional Patient
Education and Self-management Education
Issue
Traditional
Patient
Education
Self-management
Education
่
ป้ ่ วย ความ
ความรู้หรือทฤษฏี ความรูเ้ ฉพาะโรค การ ความเชื่อมันของผู
่
่
ปฏิบตั ิทีท่ าให้อาการดีขึ้น เชื่อมันในความสามารถของตนที
ที่เกี่ยวข้ อง ?
What is the
theory
underlying
the
education?
Disease-specific
knowledge
creates behavior
change, which in turn
produces better
clinical outcomes
จะทาให้ชีวิตดีขึ้น
Greater patient
confidence in his/her
capacity to make lifeimproving changes
(self-efficacy) yields
better clinical outcomes
(Bodenheimer, Lorig, Holman, & Grumbach, 2002)
Table 2. Comparison of Traditional Patient
Education and Self-management Education
Issue
เป้าหมายคือ
อะไร ?
What is the
goal?
Traditional Patient SelfEducation
management
Education
ให้ทาตาม...
Compliance with the
behavior changes
taught to the patient
to improve clinical
outcomes
เพิม่ ความมันใจว่
่ าตน
จะดูแลตนเองได้
Increased selfefficacy to
improve clinical
outcomes
(Bodenheimer, Lorig, Holman, & Grumbach, 2002)
Table 2. Comparison of Traditional Patient
Education and Self-management Education
Issue
Who is the
educator?
Traditional
Patient
Education
A health
professional
Self-management
Education
A health professional,
peer leader, or other
patients, often in group
settings
(Bodenheimer, Lorig, Holman, & Grumbach, 2002)
Table 1. Comparison of Traditional and
Collaborative Care in Chronic Illness
Issue
What is the
relationship
between patient
and health
professionals?
Traditional Care Collaborative-C
Professionals
are the experts
who tell patients
what to do.
Patients are
passive.
Shared expertise
with active
patients.
Professionals
are experts
about the
disease
and patients are
experts about
their lives.
Table 1. Comparison of Traditional and
Collaborative Care in Chronic Illness
Issue
Who is the
principal
caregiver
and problem
solver?
Who is
responsible for
outcomes?
Traditional Care Collaborative-C
The professional. The patient and
professional are
the principal
caregivers; they
share
responsibility for
solving problems
and for
outcomes.
Table 1. Comparison of Traditional and
Collaborative Care in Chronic Illness
Issue
Traditional Care
What is
Compliance with
the goal? instructions.
Noncompliance is a
personal deficit of
the patient.
Collaborative-C
The patient sets goals
and the professional
helps the patient
make informed
choices. Lack of goal
achievement is a
problem to be solved
by modifying
strategies.
Table 1. Comparison of Traditional and
Collaborative Care in Chronic Illness
Issue
How is behavior
changed?
Traditional Care Collaborative-C
External
Internal
motivation.
motivation.
Patients gain
understanding
and
confidence to
accomplish
new behaviors.
(Bodenheimer, Lorig, Holman, & Grumbach, 2002)
Table 1. Comparison of Traditional and
Collaborative Care in Chronic Illness
Issue
How are
problems
identified?
Traditional Care
By the
professional,
e.g, changing
unhealthy
behaviors.
Collaborative-C
By the patient,
e.g, pain or
inability to
function; and by
the professional.
(Bodenheimer, Lorig, Holman, & Grumbach, 2002)
Table 1. Comparison of Traditional and
Collaborative Care in Chronic Illness
Issue
How are
problems
solved?
Traditional Care
Professionals
solve problems
for patients.
Collaborative-C
Professionals
teach
problem-solving
skills and
help patients in
solving
problems.
(Bodenheimer, Lorig, Holman, & Grumbach, 2002)
DM Management Skills
Problem solving
– Problem definition, generation of possible solutions
including the solicitation of suggestions from friends
and health care professionals, solution implementation,
and evaluation the results
Decision making
Resource utilization
Forming of a patient/health care provider
partnership
Taking action
(Lorig, 2003)
DM Management Skills
“ไม่ ให้ แค่ ปลา แต่ สอนวิธีการหาปลา”
“วิเคราะห์ สั งเคราะห์ ตัดสิ นใจ > รู้ จา”
Classifications of SM
Knowledge or information
Life style behaviors (diet, physical activities)
Skill development (skill to improve glycemic
control e.g., self – monitoring of blood glucose)
Skills to prevent and identify complications
(foot care)
Coping skills (to improve psychosocial function
e.g., intervention that used empowerment
techniques or promoted relaxation or selfefficacy)
(Norris, Lau, Smith, Schmid, & Engelgau, 2002)
Long term,
continuous FU,
supporting
The Predictors of SMS
Meta-regression
– Duration of contact time between
educator and patient was the only
significant predictor of effect with
23.6 hours of contact time needed
for each 1% absolute decreased in
GHb
(Norris, Lau, Smith, Schmid, & Engelgau,
2002)
SMS
Processes
Patients
Providers
•Physician
Problem-based
solving
Goals setting & Plans
Glycemic control
Education& Empower
SM Behaviors
Topics-ADA
Types
• Group
•Nurses
• Individual
•Dietician
• Group discussion
•Pharmacist
Supports
•Physiotherapist
• FU-Phone/Visit
•Others
• Resources use
Evaluation &
Feedback
Nutrition
Exercise
Medication
Selfmonitoring
Problem
solving
Risk reduction
Psychosocial
adjustment
รูปแบบ self-management support
The Stanford and Flinders Programs
- are complimentary approaches to chronic
condition self-management (CCSM).
- developed by Kate Lorig and associates at
Stanford University – USA.
- It has been well researched for over 20
years.
http://www.risen.org.au/CDSM/CDSM_Program_Flinders.asp
รูปแบบ self-management support
The Stanford and Flinders Programs
- กิจกรรมสาคัญ ได้ แก่
- a group setting
- using peer leaders and standardised structured
sessions
- Individuals share experiences and learn generic
self-management skills and strategies that will help
them help themselves.
http://www.risen.org.au/CDSM/CDSM_Program_Flinders.asp
รูปแบบ self-management support
The Flinders Program
- was developed by Malcolm Battersby and
associates at the Flinders Human Behaviour and
Health Research Unit (FHB&HRU) in Australia.
- is a one-on-one model, with interventions
/actions agreed between clinician and patient and
tailored to the identified needs and priorities of the
individual.
http://www.risen.org.au/CDSM/CDSM_Program_Flinders.asp
รูปแบบ self-management support
The Flinders Program is underpinned by:- cognitive behavioural therapy (CBT)
principles.
- provides a structured, patient centered
framework for collaborative problem definition,
goal setting, care planning and review and
offers a generic approach to chronic condition
self-management that can be applied to a wide
range of health conditions.
http://www.risen.org.au/CDSM/CDSM_Program_Flinders.asp
A five-component heuristic model
(Glasgow, et al., 2002)
The Big Bad Sugar War (BBSWAR)
Figure 1. St. Peter Family Medicine Residency Program. Self-Management Goal Cycle with the Big Bad Sugar War
approach to setting goals. (Langford, Sawyer, Gioimo, Brownson, & O'Toole, 2007)
Background: find out about the patient, how
they view their disease, what is concerning
them, what support they have at home, how
well they are managing, and so forth.
Barriers: explore what has not worked well
in the past for the patient and what makes it
difficult to make lifestyle changes such as
healthy food choices and physical activity.
Successes: focus on what a patient has done
well, and celebrate their accomplishments no
matter how small they may seen.
(Langford, Sawyer, Gioimo, Brownson, & O'Toole, 2007)
Willingness to change: once you know the
patient’s background and have explored
barriers and celebrated successes, find a
behavior that he or she is willing to change.
Action plan: coach the patient to set a
specific and detailed goal that is important to
him or her. Write down the goal, and give the
patient a copy.
Reinforce and remember: conduct
telephone follow-up to provide encouragement
and motivation. Refine, redefine, or stretch
the goal at the next MA planned visit,
provider visit, or group visit. It is vital for
the health care team to remember patient
goals and incorporate them into conversations
at each visit.
(Langford, Sawyer, Gioimo, Brownson, & O'Toole, 2007)
Goal setting Supports
Planed visit = routine health checks and
laboratory tests prior to traditional
individual appointments
Mini-group medical visits = a provider
and medical assistant meet with 3
patients at one time
Open office group visits = 7-12
patients attend 2-hour sessions staffed
by a provider
(Langford, Sawyer, Gioimo, Brownson, & O'Toole, 2007)
Self-management support
Assessment, not only knowledge but
needs to know more about what
patients value and what they do.
Advice, needs to link to scientific
evidence, not provider biases
Agree, on shared goals
Assist, by identifying barriers and
problem-solving to deal with them
Arrange, a specific follow up plan