Self Management in Rheumatology

1. Self Management in Rheumatology

2. Origins of Self Management • Psychosocial studies – psychological, environment • Effects on Physical, Mental health, ability to function • Sense of Coherence • Hardiness • Comes from feeling we can cope with, understand and have personal meaning from our life approach or in this case management of our health • 1 – Manageability – I have/can find in those around me the resources to cope • 2 – Meaningfulness – This means something to me and is worth my effort/ commitment (MI) • 3 – Comprehensibility – I understand what is going on

3. Benefits of Living Life in This Way • According to Arthritis Foundation • Improved confidence • Improved perception of health • Reduced perception of pain • Reduced limitation on daily activity • Reduced worry about health

4. Areas of Self Management Used in Rheumatology • Work • Education • Shared Decision Making • Social Contact • Skills Building e.g. Sleep Management • Link Workers

5. Work • “The right type of work is good for our physical and mental health” • (Work, health and disability green paper: improving lives. 30th Nov 2017)

6. Definition of Disability • Equality Act 2010 • “A physical or mental impairment that has substantial and longterm negative effect on your ability to do normal daily activities” (ie >12 mths) • Rheumatoid Arthritis /MSD’s not yet a special class • (HIV, Cancer, MS are immediately classified as disability)

7. Mental Health and Musculoskeletal Disorders • - Ill health among the working age population costs economy £100 Billion p.a. • - Sickness absence costs employers £9 Billion p.a. • Over half (54%) of all disabled people out of work have mental health and /or musculoskeletal disorders as main health issue

8. Employment 2017

9. LTC Effect on Maslow’s Hierarchy 5. Self Actualise Creative, Problem Solve, Freedom of choice 4. Esteem LTC ‘s Self esteem, confidence, respect of others 3. Love/ Belonging Friendship, Family, Intimate Relationship 2. Safety Employment, resources, health, property 1. Physiological Breath, food, water, sex, sleep

10. Case Study 1. Ms J • 45 year old woman with rheumatoid arthritis and fibromyalgia. Presented with low mood, over use of analgesics and suicidal ideation • Victim of domestic abuse. Left husband but was unable to work sufficient hours to support herself and children due to RA. • Ended up in homeless accommodation. Children were taken from her and put to live with father • Psychological input provided to address low mood, plus schema origins of life patterns • Joint work with DWP, Employer - P/T bank work as nurse + benefits • Rheum Dept. liaised with employer to support implementation of the legal requirements of Reasonable Adjustment and support increased understanding of her condition • Offered on demand intermittent support from psychology by email & face to face to reduce inappropriate use of meds, address depression and maintain work between flares

11. Case Study 1. Outcomes of Ms J • Utilised her key motivation to access her children. Once she felt heard and understood she began to attend and keep in contact with progress reports • She was able to maintain a lower level of work plus benefits • She continues to struggle financially but was able to rent her own council house which gave access to her sons • Inappropriate analgesic use was reduced, mood improved • Key elements – Motivational Interviewing and help to Work

12. 1. Case Study 2 Mr N • Mr N is 63 year old man with Rheumatoid Arthritis referred as a result of depressive symptoms • F/T employment as a handyman and manager • Had begun to feel less able to carry out practical tasks at work, did not like saying no to employer, problems with sexual function, not discussing problems with wife, death of his father, reported feeling less masculine in both work life and home life. Felt he was not the man he liked to be – self perception undermined

13. 2. Case study 2 Outcome of Mr N • Work was discussed in psychology session along with other elements which were contributing to clinical level depression. Mood improved to non clinical level of depression, sexual function improved, felt managing at work, reported improved self perception. • Info from psychology sessions were fed back to his medical consultant to facilitate a more person centred consultation with Mr N’s key motivators front and centre of the discussion. Mr N reported feeling team was in touch with his particular needs. • Rheum Dept liaised with work HR dept. Helped facilitate changes in work responsibilities – able implement more management and a step back from the heavier lifting duties. • Importantly the it was introduced into discussion that this was a disease where future changes in health might necessitate renegotiation of these reasonable adjustments. The door was therefore left open for Mr N to talk further with HR if required in the future. This proved to be necessary after he sustained a fall and had to take further time off. • As a result of this intervention Mr N felt able to stay on at work when he had been considering immediate retirement. His involvement with work, the financial implications and his self perception all improved despite his LTC.

14. Mental Health In Rheumatology • Psychology survey of waiting room patient (N=41) over several days in waiting room • * 73% Pain • *50% Fatigue • *41% Depression • *29% Anxiety • *23% Stress

15. What Helps LTC’s Complicated By Mental Health Issues • Re-entry to workforce after time off aids recovery and shortens treatment (OECD,2015) • Workplaces which are accommodating and non-discriminatory have greatest positive impact (WHO,2008) • High demand Low Control and imbalance of effortrewardare worst for health(WHO, 2008) • Positive employment decreases risk of depression & improves general mental health (Cohen et al, 2010) • Incorporate the return to work in healthcare planning increases likelihood of work as outcome e.g. Cardiac rehab programmes in which Dep & Anx are addressed and tailored to the specific work setting – increased returnt o work rates (de Jong et al, 2014)

16. Avoiding Reaching Stage of Unemployment • Start the work discussion in the clinic • Find out how important it is and in what way to each individual patient • Disabled people with LTC are much less likely to enter work • Aiding self management therefore needs to happen before they loose their job • (see: What Colour Is Your Parachute, Richard Bolles, 2017, ISBN: 978-0-399-57820-5)

17. IF CHANGE ONLY ONE THING • Early intervention to support those with LTC to stay at work