PCP Integrated Chronic Disease Management - Case study template
Details of PCP contact
Name of PCP Bendigo Loddon Primary Care Partnership
Contact Person
Position/Title
Phone No.
Email Address
Leanne Oberin
PCP Team Leader
03 5448 1624 blpcp@bchs.com.au
Identified Partners
Partner Organisation
Bendigo Health Care Group
Roles and responsibilities with regard to the project
Facilitated Learning Circle
Contact person details
(name, position)
Angela Crombie, Acting
Operations Manager, CHERC
Inglewood and Districts Health
Service
Participated in Learning Circle and work within the PDSA model
Jenny Boromeo, Diabetes
Educator/Cardiac Rehabilitation
Nurse, SFF Facilitator/Life
Bendigo Health Care Group
Bendigo Community Health
Services
Northern District Community
Health Services
Health Coaching Australia
Participated in Learning Circle and work within the PDSA model
Rhonda Bell, HARP Care
Coordinator
Pauline Nolan, Health
Promotion Worker
Chris Withington-Brown,
Registered Practice Nurse
David Scicluna, District
Nurse
Donna McCallum, District
Nursing
Terri-Anne Chapman,
District Nursing
Jodie White, Clinical
Educator
Liz Whelan, District Nurse
Participated in Learning Circle and work within the PDSA model
Dallas Coghill, Care
Coordinator, Chronic Disease
Participated in Learning Circle and worked within the PDSA model
Angela Roney, Diabetes
Educator/Community Health
Nurse
Deliver the final review and update workshop to Learning
Circle participants
Vanessa Cook
Case Study Title Learning Circle for Chronic Disease Management
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Summary/Abstract (200 words)
The Learning Circle for chronic disease self management was convened and supported by the
Bendigo Loddon PCP in partnership with the Collaborative Health Education Research Centre
(CHERC) at Bendigo Health Care Group and Health Coaching Australia (HCA). Partners in this project also included Inglewood and Districts Health Service, Northern Districts Community
Health Service, Bendigo Community Health Services Ltd, and Bendigo Health District Nursing,
HARP and Community Health. This project was initiated as a result of evidence demonstrating the value of self management for people living with a chronic disease and the support from
Bendigo Health for District Nurses to implement health coaching into their daily practice. The project aligned to two objectives in the PCP Strategic Plan.
The methodology developed for the project was based on the Plan, Do, Study Act (PDSA) model of Continuous Quality Improvement (CQI), and consisted of the facilitation of three meetings of the Learning Circle clinician participants held over a twelve month period. The participants used the HARP developed Triage Tool for identifying risks in people living with a chronic disease and the principles of client-centred and consumer-focused care was a key element in the methodology.
The project has demonstrated that with follow up, encouragement and peer support, clinicians and others are able to carefully embed the theory and skills learnt in training programs into their clinical practice. This Learning Circle project also demonstrates the importance of not only delivering a training or education program, but following this up with participants and providing the opportunity for facilitated discussions, peer support, and brainstorming to identify and problem solve the barriers to using these skills in the workplace.
The results of this project have demonstrated the importance of using case studies to assist clinicians to understand and clarify how the theory and skills learnt in training programs can be used in clinical practice and should therefore be embedded into daily work.
The skills of the facilitators of the Learning Circle is a key element in the success of the technique, as is the importance of providing a safe and trusting environment for clinicians to speak openly and without caution. Using a respected partner agency to facilitate is also an advantage as is the ability to bring in a high profile trainer for part of the process.
Participants in this type of learning application need to be sure that management support and backfill for the meeting times is provided. Otherwise clinicians feel they have wasted their time in attending those parts of the Learning Circle they could get to, but are unable to put the pieces together due to not being able to attend each meeting.
This technique of embedding skills development and training into practice is transferrable to other groups and training projects and will be used by Bendigo Loddon PCP for other workforce capacity building in the future.
Background
Name of Project Learning Circle for Chronic Disease Management
Target client group The target group which will benefit indirectly from this project will be consumers of District Nursing Services in the Bendigo
Loddon catchment who are living with a chronic disease.
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DHS ICDM expectations
2009-12
Background
The program logic that relates to this project are:
D evelop and review local agreements, implementation plans, and supporting resources to improve chronic disease care by: a) enhancing the capacity of the local workforce to: o provide coordinated, best practice clinical care and support for self management, and o plan, implement and measure service system improvements, including evaluation of impacts and outcomes for consumers.
This project was selected as an activity for two reasons.
Firstly, evidence demonstrates that people living with chronic disease are more able to cope and become less reliant on the health system if they are able to take an active role in managing their own health. Secondly, in this area, health coaching for those people living with chronic disease had previously been left to chronic disease case managers, and nurse consultants and general nursing staff had not had the opportunity to undertake health coaching training. The District
Nursing Manager at Bendigo Health Care Group approached the PCP to discuss whether there may be a partnership opportunity to build the capacity of his district nursing workforce to enable district nursing consumers with a chronic disease to receive support that enhances their capacity to self manage their health and care. Other partner agencies were contacted to identify the numbers of staff interested in participating and it was then decided to implement the Health
Coaching Australia training course, then require participants to practice their training in their workplace before joining the
Learning Circle to implement a Plan, Do, Study, Act (PDSA) approach to measuring their ability to actively turn the theory into practice in the workplace.
Project Management and Governance of the project was undertaken by the EO of the PCP and the Acting Operations
Manager of the Bendigo Health Collaborative Health Education and Research Centre at Bendigo Health with reports to the PCP
Board.
This project was strongly aligned to the PCP Strategic Plan and the catchment wide priorities as can be seen from the following two objectives in the PCP Bendigo Loddon Strategic
Plan:
Objective 1.2.5: Facilitate Health Coaching Course to
District and Community Nurses in the Greater Bendigo and
Loddon areas; and
Objective 4.7.5: Establish a Learning Circle to embed the skills developed through the Health Coaching Course into practice using PDSA techniques.
Refer www.blpcp.com.au
.
The objective set for this specific project reflected the Strategic
Plan Objective 4.7.5 as stated above.
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Objectives The objective set for the project was to develop and maintain a twelve month Learning Circle to embed Health Coaching Skills into everyday practice.
Project participants
Participants in this project varied over the course of the twelve months. The project commenced with nursing staff from:
Inglewood and Districts Health Service
Bendigo Health
Northern Districts Community Health Service
Bendigo Community Health Services Ltd
By the last evaluation and review conducted as part of the Health Coaching Australia facilitated one day workshop, the partner agencies represented were:
Inglewood and Districts Health Service
Bendigo Health
Northern Districts Community Health Service
These clinicians ranged from District Nurses, Nurse Care Coordinators, Diabetes Educators, and District Nurses.
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Methodology and approach
Three Learning Circle meetings were convened by CHERC over the twelve month period. The first meeting was to share practice issues related to self management for chronic disease, identifying the barriers and enablers for the conversion of skills to practice, developing strategies to embed theory to practice and increase support and learning, and lastly to develop a triage process for assessing client's ability to self manage. The methodology then provided for the participants to implement these strategies in their workplace.
The second meeting of the Learning Circle convened with a facilitator drawing out the participants ’ experiences, and the ways they were able to implement those strategies. The barriers and enablers were then discussed and each participant reviewed her/his individual implementation plan in consultation with the Circle. Updated implementation plans were then prepared in accordance with the findings and utilising the information gained during the discussion and brainstorming held at the Learning Circle.
The final meeting of the Learning Circle was arranged as a full day workshop conducted by
Health Coaching Australia. This meeting was a one day review and update workshop for the
Learning Circle participants and was to build on the original Health Coaching training by assisting the clinicians to adapt the model to their particular role and clinical practice. The workshop enabled the clinicians to review and practice the most critical processes to apply, particularly when clients are low in readiness to make changes and use self management techniques.
The HARP Triage Tool for chronic disease risk management was shared amongst participants and this is attached. CQI strategies of PDSA were used throughout the project and in effect the project was built around these CQI processes.
The principles of consumers and carers actively participating in their own care and the delivery of that care provided the foundation of this project and consumer-focused care was a key element of the project.
Communication and engagement strategies used included respect for the knowledge that the clinicians brought to the Learning Circle, the principles of adult learning were used, and communication was via email and telephone. Face to face learning and sharing was also an important part of the communication process.
Engagement with GPs and consumers were an important part of the strategies employed by the clinician participants and were involved and consulted when each participant implemented their own individual strategies to embed self management and health coaching theory into practice.
Results
Service improvement and innovation
This initiative has supported clinicians to embed the theory and skills of health coaching for self management of chronic disease into their practice, improve health outcomes for clients of health services and, in particular, build the capacity of the health workforce to educate and encourage self management by clients with a chronic disease.
In addition, the service improvement process has enabled the building of partnerships between the participants who work in both small rural health services in sole positions to large regional health services as members of big teams.
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Outcomes The outcomes achieved through this project have demonstrated that with follow up, encouragement and peer support, clinicians are able to carefully embed the theory learnt in training projects into their practice in the field. It demonstrates the importance of not just delivering a training program, such as the Health
Coaching Australia two day course, but following this training up with participants and providing opportunities for peer support, discussion and the facilitation of brainstorming to identify and problem solve the barriers that may exist in the workplace for the implementation of such strategies.
In measuring the outcomes achieved in the Learning Circle project, 66.6% of the participants stated that they thought the results were "excellent" and 33.3% thought that the results were "above average".
The use of case studies presented by participants as learning tools and items for discussion were identified as being "very useful" by 66.6% of participants and "moderately useful" by
33.3% of the participants.
Whilst 66.6% of the participants state that the use of written responses to a range of 16 questions about the Health Coaching
Australia model was "very useful", 33.3% of the participants reported that they "did not do" these question responses.
The activities in the Learning Circles that the participants found most useful and relevant to them were the use of brainstorming and the work and discussions undertaken in small groups.
Participants also reported that they would like to see more case studies used for learning experiences and 100% of participants reported that they would recommend this form of learning to their colleagues.
Status and sustainability This initiative is now completed and participants are now using health coaching theory as part of their practice in the workplace.
By embedding theory and skills learnt into participants ’ practice, the outcomes of the project will be sustained.
Participants of the Learning Circle have demonstrated their ability to learn new skills, carefully embed these skills into their work practice and continue to use these skills in an ongoing capacity.
The Learning Circle technique will now be able to be applied in other forms of workforce capacity building undertaken by PCP with its partner agencies whether that be more ICDM, or Service
Coordination or IHP.
The findings of this project will be disseminated to our partners via the Bendigo Loddon PCP website www.blpcp.com.au and by presentations by participants to other PCP groups in our catchment, eg Diabetes in Loddon Action Group and others.
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Conclusions
The key success factors that enabled this project to work, was the sense of partnership and cooperation that supported the clinician participants through the problem solving processes and development of strategies to overcome the barriers to self management.
The skills of the facilitator from one of the partner agencies, Bendigo Health CHERC
Operations Manager, and the expertise of the HCA Trainer encouraged the Learning Circle participants to be open and honest about their experiences in using the health coaching skills in their daily practice. The safe environment, where participants did not have to be cautious in their disclosures, was a key success factor in this project.
Some of the challenges for the project included the lack of health literacy among the client group that the clinician participants were working with, the negative experiences some clients had previously experienced in prior medical interventions, and resistance by some clients with chronic disease to self management.
The limitation of the project was basically time. Time for the clinicians to spend attending the
Learning Circle when no back fill was provided in some workplaces, and time needed to spend with clients to implement Health Coaching strategies for self management when the roster did not provide for any more than the physical tasks required to provide the service. One clinician was unable to complete the Learning Circle due to his management requiring him to see a client rather than attending the final Learning Circle and Review Workshop conducted by HCA.
The outcomes of this Learning Circle project will be sustained via two activities: the first through the clinicians who attended the full project and were able to embed their skills into their clinical practice and, secondly, though the Partnership understanding that the most effective way to build the capacity of the health workforce is to initially provide the training and then follow up with formal encouragement and peer support to embed these skills into daily practice. This technique will be used in other workforce capacity building activities in the future.
References (optional)
PCP IHP Process and Impact Evaluation Reporting
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NAME: _______________________________
UR: __________________
SERVICE CRITERIA:
Resides in catchment are for Bendigo Health HARP (within 1 hours drive from centre of Bendigo).
Can be allocated to a HARP cohort. ( Chronic Respiratory Disease, Chronic Cardiac disease, Chronic Kidney disease, Diabetes, Complex Psychosocial Issues,
Complex Aged Care Needs)
Has attended the ED at least twice and /or spent at least 5 days in the acute hospital in the past 12 months.
There are issues identified by the referrer which indicate that the patient is at risk of further deterioration and admission to ED or hospital.
Patient /carer aware of referral.
RISK OF RE-PRESENTATION:
Risk indicator High (2 pts) Medium (1 pt) Low (0 pts)
1. knowledge
2. self management
Poor understanding of condition and treatment.
Poor compliance with medications and diet.
Limited knowledge about condition & treatment but no barriers to learning about it.
Limited understanding or compliance with meds, fluid restriction or diet.
Knowledgeable about their condition and treatment.
Compliant with diet and medication.
3. carer requirements
Elderly with sig. carer responsibilities.
OR
No suitable carer identified.
4. social contact Inadequate social supports.
5. lifestyle Requires many lifestyle changes.
Elderly with codependant spouse/family member.
Limited social supports.
Some changes that need to be incorporated into their lifestyle.
May be symptomatic at times.
Has supportive and active carer available.
Receiving adequate social supports.
No major lifestyle changes needed.
Not symptomatic. 6.symptoms Will remain symptomatic with impact on functioning/ Currently acutely unwell
7. medications Uses >10 medications.
Uses 4-10 regular medications.
Uses less <4 regular medications.
8. GP contact Has frequent contact and/or poor relationship with GP
(2-4 x per mth)
Total Score:
Monthly contact with
GP
6-8 weekly contact with GP with no other issues.
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RISK ASSESSMENT OUTCOME:
Admit to HARP.
□
Admit to HARP.
□
Refer to appropriate services if needed. □
Take to next case conference.
□
Discuss with team leader/ manager if urgent allocation required. □
Liaise with GP and other relevant service providers. □
Refer to other services for immediate care if required.
□
Place on waiting list for relevant cohort.
□
Inform pt and services about waiting list.
□
Refer to appropriate services if required.
□
Inform pt and services about re-referral to
HARP when required. □
Discharge on Data Base and isoft. □
Completed by:
Name:____________________________ Signature____________________
Date: / /
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