Implementing Self Management
Support
www.livinghealthychamplain.ca
What is encompassed by the term
Self-Management Support?
Self-Management Support could be:
 Stanford Workshops
 Group Medical Appointments
 Health Coaching
 Motivational Interviewing
 Peer Support
 Community Health Workers
 Panel Management
Self-Management Support could be
 Patient Education
 Group Education
 Care Plans
 Telephone Coaching
 On-line Forums
 Shared Medical Records
Self-Management Support could be
 Support Groups
 Training patients to be participants in their medical care
 Community Resources
 Family-based programs
 School based programs
 Community Associations and Neighbourhood Plans
Self-Management Support
Do we have to
wait until a
patient has a
chronic
condition?
What are we trying to do?
What are we trying to do?
Improve patient outcomes
Improve patient quality of life
Provide a service that meets the needs of clients
Improve our work satisfaction
Keep long term health spending within
reasonable limits
Implementation Stage 1
Patient ready to make a plan
Trained health care
professional
Behaviour change
Implementation Stage 2
Patient ready to make a plan
Record
goals
Trained health care
professional
Behaviour change
Follow
up with
patient
Implementation Stage 3
Endocrinologist
Social
Worker
Stanford
Workshop
at practice
Other
specialists
Health
Coach
Diabetes
Educator
Dietitian
Physician
Optometrist
Foot nurse
Physician
Implementation- Health Care Organization
Ministry
of Health
Family
Physicians
Health
Authorities
Federal
Government
Employers
Provincial
Programs
Community
Groups
Individuals undertaking tasks to live well with
their chronic health conditions and includes
having to deal with medical management,
role management and emotional
management of these conditions
Media
Researchers
Universities
Professional
Associations
Health Care
Professionals
Non-Governmental
Organizations
From Self-Management Support: A Health Care Intervention, BC Ministry of Health
Implementation- Community
Supportive Care Team
Employment
Combatting food deserts
Patient
Safe recreational space
Affordable fresh food
Family
Adequate housing
Affordable community resources
Survey Time
Where are we at?
>3 : “ I feel like the lone voice crying in the wilderness”
4-7: “We’re doing OK but I’m not sure about the rest of them”
8-10: “ Everyone in the organization thinks SMS is a good idea, but in
practical terms, we can’t always put it into operation”
11-13: “ Our organization is doing everything it can to
integrate SMS into routine care”
14-16: “ I think I’m in the wrong workshop”
Planning Next Steps
Where do you
realistically want
to be next
spring, in terms
of implementing
SMS?
Action Planning
Practical tips about change
 You can’t be too specific
 You can’t start too small
 Timing is important
 Adaptability is key
 Change needs to become as easy to do as not to do
 Evaluation builds confidence
Lessons from the Field:
California Health Foundation
 Institutional change……lays the groundwork
for other changes
 All aspects of the Chronic Care Model are
necessary to improve Chronic Illness Care
System Design and Patient Flow
 Think about team composition and workflow
 Clinical and administrative champions are
needed at each site
 Doctors’ participation is essential
Training
 On-site training, hands on experience and
regular booster sessions
 Providers and patients need to build
confidence
Measurement
 Measurement and reporting are critical for the
organization, the providers and the patients
 Organizations need to think about appropriate
measures
 Feedback to providers is critical, to close the loop
 Keep action plans short term 6-8 weeks
Celebrate Success
Support is available
Kate Nash: Training Facilitator
lhcconnect@bruyere.org
613-562-6262 x 1622
Resources and References
Self-Management Support: A study and Implementation Guide,
Fraser Health Authority 2008
Self-Management Support: A Healthcare Intervention,
BC Ministry of Health, June 10th 2011
Promoting Effective Self-Management Approaches to Improve Chronic Disease
Care: Lessons Learned
California Healthcare Foundation, April 2008
Strategies to Support Self-Management in Chronic Conditions: Collaboration with
Clients
RNAO, September 2010
Thank you