Self-Management Support for Aboriginal people

1. Self-Management Support for Aboriginal people Kate Warren & Fiona Coulthard

2. Overview • Background • Self-Management & Self-Management Support • Principles of Self-Management • Aboriginal Health & Self-Management • LIFE Program • Closing

3. Background • Part of a National Demonstration Project • Sharing Health Care SA Project 2001 - 2004 • Test self-management tools (interventions) • Flinders Model • Stanford Model • Enhanced Primary Care package (EPC) • Health Promotion & Education • Best practice chronic disease management • 3 SA sites: Port Augusta (PWHS), Port Lincoln & Whyalla • Ongoing data collection to test effectiveness of interventions during project

4. Results Generally: • Increased self efficacy, increased quality of life, less unplanned hospital admissions and casualty visits, less unplanned GP visits, increased planned GP and allied health visits Pika Wiya Health Service: • Increase self efficacy, better coordination of chronic care through increased uptake of EPC items eg Aged Health Assessments & Care Plans • Other spin offs: • Community acceptance of & participation in CCSM activities • Staff empowerment & self-efficacy via training in CCSM • Increased use of information technology – recognition of problem areas and development of strategies to improve data systems

5. The Centre for Advancement in Health (1996) proposed the following definition: “Involves [the person with the chronic disease] engaging in activities that protect and promote health, monitoring and managing of symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes.” (p.1)

6. Kate Lorig (1993) states that self-management is also about enabling: “Participants to make informed choices, to adapt new perspectives and generic skills that can be applied to new problems as they arise, to practice new health behaviours, and to maintain or regain emotional stability”.

7. What is Self-management? Self-management is the active participation by people in their own health care. Self-management incorporates health promotion and risk reduction, informed decision making, following care plans, medication management, and working with health care providers to attain the best possible care and to effectively negotiate the often complex health system. National Chronic Disease Strategy, 2006

8. What is Self-Management Support? • The care and encouragement provided to people with chronic conditions to help them understand their central role in managing their illness, make informed decisions about care and engage in healthy behaviours Institute for Healthcare Improvement

9. Self-Management Support • Essential elements include: • Medical, behavioural and socio-economic models of promoting health • Ideally can be accessed across all levels: • Practice • Health System • Community • Success dependent on: • Relationships! • Underpins the quality of collaboration, negotiation and client centredness not just between the client and health care worker but also between health care workers who must work more as a team than individual practitioners • Communication – better electronic data sharing • Support for health workers to provide self-management support from all levels of management • Changes to funding models • Support systems

10. Six Principles of Self-Management • 1. Know your condition • Have active Involvement in decision making with the GP or health workers • Follow the Care plan that is agreed upon with the GP and other health professionals

11. Six Principles of Self-Management 4. Monitor symptoms associated with the condition(s) and Respond to manage and cope with the symptoms. 5. Manage the physical, emotional and social Impact of the condition(s) on your life. 6. Live a healthy Lifestyle

12. Principles of Self management • Knowledge • Involvement • Care planning • Monitor & Respond • Impact • Lifestyle

13. Why are our people dying? • Risk factors high • Healthy lifestyle messages not getting through • High rate of chronic disease • Focus on treatment instead of prevention • Lack of understanding • Social determinants of health more of a priority • Mainstream services inadequate/under accessed

14. Aboriginal Health Statistics • Difficult to obtain accurate data • ATSI status not recorded • Not asked • Not reported • Data only obtained from • Hospitalisations • Age at death • Cause of death • Lots of gaps • Not all states & territories collect ATSI specific information • Moving population

17. L.I.F.E Program Living Improvements For Everyone PWHS health staff Health Promotion L.I.F.E Course HEALTHIER ABORIGINAL COMMUNITY LIVING LONGER SHC Team Outside Providers Self-Management message strong throughout Holistic carecoordination

18. L.I.F.E Program Living Improvements For Everyone PWHS health staff Health Promotion L.I.F.E Course HEALTHIER ABORIGINAL COMMUNITY LIVING LONGER SHC Team Outside Providers Community Involvement! Holistic carecoordination

19. Health Promotion Empower people through • Prevention & early intervention: Adult Health Checks, Child Health Checks (EPC), Immunisations, Ante-natal & baby care etc • Building Self Efficacy – self confidence, self reliance • Knowledge: • Services available and what’s works best at what time • Healthy lifestyle choices – education to link lifestyle risk factors with disease • Disease Specific Information • Art For Heart/Kidney Foundation/Cancer Council etc • Chronic Disease/Diabetes Camps • Community Activities: • Crocfest • Health Expos • Community Days • Media – Umeewarra Radio, Transcontinental • Fundraising & Awareness Raising Activities All these activities involved, empowered and educated the community

21. “If you don’t have diabetes now, then eat proper food so you don’t get it.”

22. L.I.F.E Program Living Improvements For Everyone PWHS health staff Health Promotion L.I.F.E Course HEALTHIER ABORIGINAL COMMUNITY LIVING LONGER SHC Team Outside providers Focus on TEAMWORK Holistic carecoordination

23. Holistic Care Coordination • Chronic disease Triage • All clients screened at presentation • Thorough assessment of health needs including EPC items, immunisations, blood & other tests • Flinders Model of Chronic Condition Self-management • Enhanced Primary Care (EPC) items • Care planning (GP & Health worker, TCA) • Aged Health Assessments • Diabetes Cycle of Care • Asthma plans etc • Best practice chronic disease care plan templates • Supportive IT system (Medical Director, CME, etc) • Internal and external referral system • Automated recall and review system

24. Flinders Model of Chronic Condition Self-Management Flinders Human Behaviour & Health Research Unit (FHBHRU) • Generic set of tools: • Partners in Health (self assessment) • Cue & Response (interview by HCP) • Problems & Goals • Self-management Plan This process assesses the clients self-management skills and behaviours and ensures that social & emotional aspects of the clients life are identified and included in the medical management plan EPC care plan and team care arrangement

25. Impact of Flinders Tools • Traditional assessment methods focus on medical and physical • Structured approach builds rapport and mutual trust and respect • Identifies the social, economic, spiritual, emotional and cultural issues which may be barriers to self-management • Client agrees what is to be addressed, when and how. Their priorities are important! • Not all things can be tackled at once! • Health workers need to look after themselves as well! They are role models!

26. Training involves • 2 day workshop • Flinders Resource Manual • Open mind and willingness to participate • Volunteers on 2nd day • Certificate of competence issued when 3 completed plans evaluated by trainer within 3 months of completion of training • Tertiary qualification also available via Flinders online course

27. Enhanced Primary Care (EPC) • Care planning • Health worker involvement as advocate imperative! • GP Management Plan – anyone who has a chronic condition • Team Care Arrangement – multidisciplinary needs • Access to Private allied health services • Via care planning process • Aged Health Assessment • Over 55 if ATSI • Home Medicines Review • Anyone with multiple medications – initiated by GP but anyone can refer or recommend • Case Conferencing • Used in conjunction with care planning for multidisciplinary meetings to plan or review care. • Adult Health Check for ATSI – 2 yrly • Any person of ATSI 15 – 54 years of age • Child Health Checks • Maternal & infant Checks

28. Care Plan Case Study Ms A, 55 year old lady with multiple chronic conditions, obese, hypertension, high cholesterol Care plan completed: • Multiple medications… • BSL 18.3 (random) – recurrent thrush & bleeding gums • Attended most sessions and 2 camps. Formed friendship with other ladies in the group. Tried ten pin bowling for the first time in her life Outcomes: • Medication review • Blood tests & screening • Referrals & appointments • Follow up

29. Care Plan Review… Care plan review - all clinical measures improved: • BP↓, • weight↓, • cholesterol↓, • HbA1c↓ (from 8 to 6.5) She is also more confident in dealing with day to day problems.

30. L.I.F.E Program Living Improvements For Everyone PWHS health workers Health Promotion L.I.F.E Course HEALTHIER ABORIGINAL COMMUNITY LIVING LONGER Outside providers SHC Team Focus on Peer Education Holistic carecoordination

31. Stanford Model of Chronic Disease Self Management • Follows the principles of self management • Meet once per week for 6 weeks - 2 ½ hours • Focus on group interaction & dynamics • People with different chronic health problems attend together • Course is led by 2 trained leaders, at least one should be peer educator • Skills learnt and practiced every week are goal setting (action planning) and problem solving

32. Other topics include: • Techniques to deal with difficult emotions such as anger, fear & frustration • Appropriate exercise to improve and maintain strength, flexibility and endurance • Safe use of medicines • Communicating effectively with family, friends and health professionals • Nutrition • Cognitive symptom management

33. Training involves • 4 day intensive • Experience the course as a participant • Practise teaching sessions (assessed) • Bring a volunteer (1:1 ratio encouraged) • Leave your HP hat at home! • PROCESS VS CONTENT • Ideally split over 2 weeks (2 days per week) • Text book “Living a Health Life with Chronic Conditions” • Leaders manual

34. Stanford & Aboriginal Health Presented course (in original format) to a group of Aboriginal community members who all have chronic conditions Participants were invited to give feedback at every session Through our observations, evaluation activities and a focus group after the course, we found that changes were needed

35. Adaptation Process Course re-presented with a few minor changes… Findings: • Difficulties with language predominant • Some activities needed to presented in different order • Examples to reinforce concepts were made ‘real’ • Grief & Loss recognised as having a major impact on Aboriginal people’s health – new activity designed using the same process! • Less emphasis on people attending only one 6 week course

36. Outline of ‘Understanding Grief & Loss’ • Placed immediately after ‘Dealing with Difficult Emotions’ • After a brief definition of ‘Grief’ we brainstorm “What are some of the feelings that people go through when they are grieving?” • Stages of Grief & explanation • Brainstorm “What are some of the reasons for people to feel grief?” • Discussion around Coping with Grief • Brainstorm “What are some ways for people to cope with grief?” • Further discussion leading to possible ways to get help

37. How did it go? • Previous sessions on grief and loss difficult – some people loathe to discuss - “taboo subject” • This session, based on the process designed by Stanford, was a gentler way to get people to open up and no one objected • The process allowed people to talk generally without feeling like they were in the spotlight

38. Cover for the LIFE Course Manual reflecting the overall theme of the course people looking after themselves and each other

39. Session 1: reflecting the Keeping Active theme

40. Session 2: reflecting the themes of relaxation, spirituality, grief and positive thinking

41. Session 3: reflecting the themes of healthy eating and bush tucker including goanna’s, witchetty grubs, honey ants, quandongs, wild figs, bush tomatoes, bush bananas and bush berries

42. Session 4: Reflecting the themes of communication, communities and relationships

43. Session 5: Reflecting the themes of bush medicine, western medicine, doctors, health care workers, people and patients

44. Session 6: Reflecting the themes of family, families, camps, shelter, water and being bored

45. Master Training Implications • Leaders manual needed to be more user friendly • Aboriginal Leaders trained in the future need to be confident enough to lead courses in their own communities • Training competent and confident Leaders is an integral part of adapting the Leaders Manual

46. LIFE Leaders Training • An extra day • Rationale for change • New manual • Paintings • Different order of activities • Language • New activity modelled • More practice teaching (assessed) • Trainees encouraged to draw on local knowledge and adapt further as needed

47. Organisational Change Management • Health care worker culture change • Teamwork crucial • Communication – meaningful and timely!! • Commitment from key health care workers • Staff acceptance • Information systems • Staff training & Education (ongoing) • Marketing & promoting to staff & community • Management commitment and support • Administrative support • Meetings and more meetings…

48. Self management is an essential element across the care continuum:

49. Something to think about… “Mum, is it true that I am going to die 20 years before my friend Sarah?”

50. The L.I.F.E Program has the potential to turn that statistic around.