ABHI PCIP Chronic Disease Self Management

1. ABHI PCIPChronic Disease Self Management ‘A leading Division providing General Practice with quality innovative services that improve health outcomes for individuals and the community’

2. Objective Presentation focused on: • Improve access to and utilisation of tools and strategies that will assist in better managing patients with chronic disease.

3. Strategies • CDSM Quality Improvement: • Engage practices in a chronic disease self management quality improvement program • Collaborative’s approach • Assessment and training in CDSM skills: • Assess practice nurse chronic disease self management skills and provide training to meet needs

4. CDSM Quality Improvement:Assessment tool • Assessment of Primary Care Resources & Supports for Self Management (PCRS) • Developed by Robert Wood Johnson Foundation in 2006 based on the Wagner Chronic Care Model • To help primary care settings focus on actions that can be taken to support self management by patients

5. CDSM Quality Improvement:PRCS Assessment Tool • Patient support: • Individualised assessment of patient self management educational needs • Self management education • Goal setting • Problem solving skills • Emotional health • Patient involvement in decision making • Social support • Links to community resources

6. CDSM Quality Improvement:Process • Practice team (GP, Practice Nurse & other staff) complete assessment tool. • Results compiled and reported back to practice. • Practice establish CDSM team. • Identify areas for change. • Use Plan Do Study Act (PDSA) approach to implement change. • Repeat assessment at completion of program.

7. CDSM Quality Improvement:Practice engagement • Original aim to engage 24 practices! • Something about change…. • God grant me the serenity to accept the things I cannot change; the courage to change the things I can; and the wisdom to know the difference!

8. CDSM Quality Improvement:Practice engagement outcomes • 19 Practices visited • 11 practices showed some interest but did not complete the assessment • 4 Practices not interested • 5 Practices completed the assessment tool

9. CDSM Quality Improvement:Practice engagement outcomes • Of the 4 Practices who completed the assessment: • 1 indicated that they were already achieving high quality across all 8 areas • 1 completed the assessment, received the report and then had to pull out as it wasn’t right for them at the time • 3 completed the assessment and 2 have committed to exploring the results

10. CDSM Quality Improvement:Practice results Practice 1 Goal setting Practice 2 ……is not done  …occurs but goals are established primarily by member(s) of the health care team rather than developed collaboratively with patients.  …is done collaboratively with all patients/families and their provider(s) or member of healthcare team; goals are specific, documented and available to anyone on the team; goals are reviewed and modified periodically. …is an integral part of care for patients with chronic disease; goals are systematically reassessed and discussed with the patient; progress is documented in the patient's chart.

11. Assessment and training in CDSM skills:CDSM training model • Health Coaching Australia courses conducted: Leeton, October 2008 Wagga Wagga, May 2009 • Total trained: 37  21 Practice nurses  4 Private Allied Health  9 Area Health employees (physio, diabetes eductor, respiratory, dietitian)  1 Primary Health Care Nurse  2 Program staff

12. Assessment and training in CDSM skills:Assessment of CDSM skills • Assessment tool developed by the Whitehorse Division of General Practice.

13. Assessment and training in CDSM skills:Evaluation results

14. Health Coaching Australia evaluation: 100% of participants rating it as Above Average (37%) or Excellent (63%) 100% of the participants indicated they would recommend the course to their colleagues 97% indicated that the content relevance and usefulness to current work was Above Average (43%) or Excellent (54%) Assessment and training in CDSM skills:Evaluation of training

15. Assessment and training in CDSM skills:Evaluation of training “I work as a practice nurse/Diabetes educator. I was very frustrated in my role not knowing how to approach my patients in a way that was productive and effective. I was getting very overwhelmed with processes that seemed to be going nowhere and producing little results. I am very excited about these skills and am more confident about my ability to motivate and empower my patients.”

16. Assessment and training in CDSM skills:Outcomes of training • “We are just starting up the Ambulatory Rehab Service out of Wagga Base so I am trying to fit the Health Coaching concepts in right from the day dot. Hopefully it will be reflected in everything from our forms from the referring GPs through to our initial goal setting for the client and across the multidisciplinary approach.” Occupational Therapist, GSAHS

17. Evaluation & sustainability • CDSM Assessment incorporated into Collaboratives program • Culture of change established around CDSM • Lead practices established to provide support to other practices once engaged in CDSM • Exposure to CDSM and Health Coaching model across all Division staff & Program areas, majority of general practices and the Area Health Service.

18. Key to success? • A small number of practices who are at the cutting edge of primary health care who are ready to take on the challenge.

19. Thank You! Narelle Mills RDGP&PH (02) 6923 3130 n.mills@rdgp.com.au