Implementing EHR Modifications to Support Self-Care to Patients with Chronic Conditions
Implementing Self Management Support.
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Transcript of Implementing Self Management Support.
www.livinghealthychamplain.ca
Implementing Self Management Support
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
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 could be
Self-Management Support
Do we have to wait until a patient has a chronic condition?
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
What are we trying to do?
Implementation Stage 1
Trained health care professional
Patient ready to make a plan
Behaviour change
Implementation Stage 2
Trained health care professional
Patient ready to make a plan
Behaviour change
Record goals
Follow up with patient
Implementation Stage 3
SocialWorker
HealthCoach
Dietitian
Physician
Physician
Foot nurse
Diabetes Educator
Stanford Workshop at practice
Endocrinologist
Optometrist
Other specialists
Implementation- Health Care Organization
Individuals undertaking tasks to live well withtheir chronic health conditions and includeshaving to deal with medical management,
role management and emotionalmanagement of these conditions
FamilyPhysicians
Ministryof Health Health
AuthoritiesFederal Government Employers
Media
Researchers
Non-Governmental Organizations
Health CareProfessionals
ProfessionalAssociations
Universities
CommunityGroups
Provincial Programs
From Self-Management Support: A Health Care Intervention, BC Ministry of Health
Implementation- Community
Patient
Safe recreational space
Affordable community resourcesAdequate housing
Affordable fresh food
Combatting food deserts
Employment
Supportive Care Team
Family
Survey Time
>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 tointegrate SMS into routine care”
14-16: “ I think I’m in the wrong workshop”
Where are we at?
Planning Next Steps
Where do you realistically want to be next spring, in terms of implementing SMS?
Action Planning
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
Practical tips about change
Institutional change……lays the groundwork for other changes
All aspects of the Chronic Care Model are necessary to improve Chronic Illness Care
Lessons from the Field: California Health Foundation
Think about team composition and workflow
Clinical and administrative champions are needed at each site
Doctors’ participation is essential
System Design and Patient Flow
On-site training, hands on experience and regular booster sessions
Providers and patients need to build confidence
Training
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
Measurement
Celebrate Success
Support is available
Kate Nash: Training Facilitator
613-562-6262 x 1622
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 LearnedCalifornia Healthcare Foundation, April 2008
Strategies to Support Self-Management in Chronic Conditions: Collaboration with ClientsRNAO, September 2010
Resources and References
Thank you
