CDSM Support Strategies

Click on individual ô Headings to display information for that topic, or click here to Open or Close all headings.

ô Introduction

This section provides an overview of some of the tools and strategies used to support self-management.

Figure 1. Schematic representation of the inter-relationship between the tools and strategies that support CDSM

 ``` Click image for a larger version

 For a PDF Version of this Section Click on the links below:

Back to Top ñ
 

ô Prevention

"Chronic diseases are the leading cause of disability in the community...a significant proportion of the chronic disease burden can be prevented. "
 National Chronic Disease Strategy

Primary prevention strategies aim to eliminate or reduce the causes or determinants of illness, thereby reducing the number of new cases.

There are many factors that influence health and wellness, including:

  • socio-economic determinants; e.g., income or education level

  • psychosocial factors; e.g., social connectedness, self-esteem, sense of control

  • behavioural determinants; e.g., diet, exercise, tobacco use

  • environmental determinants; e.g., access to recreational activities and facilities

  • genetic factors; e.g., pre-disposition to a disease

  • biomedical risk factors; e.g., high blood pressure, high cholesterol

  • access to affordable health services

At a glance

Primary prevention strategies aim to reduce the number of new cases of a disease.

Because a wide range of factors influence an individual’s health, preventative strategies involve social and political process, directed not only at individual behaviours, but also at changing social, environmental and economic conditions.

For the broader prevention of chronic disease, strategies to alleviate any of these determinants should be part of public health policy frameworks rather than the responsibility of individual health units. While health care providers may advocate for greater social equity or environmental reforms, health sector strategies to prevent chronic disease are generally concerned with:

  • monitoring or screening for biomedical or psychosocial risk factors (See Case Study (CS) 1, 3)

  • providing education about nutrition, exercises and lifestyle (CS 1, 2, 5, 11

  • conducting activities that improve social connectedness, self esteem and an individual’s sense of control (CS 5, 7, 9)

  • creating or advocating for social and physical environments that support good health (CS 2, 4, 9)

  •  advocating for, or improving the accessibility of health services ( CS 10, 13)

Many of these services are also relevant for those who already have a chronic condition.

Click here for Printed Guide PDF Version of this Prevention Section

References (click)

Back to Top ñ
 

ô Early detection

"Self-management principles aim to optimise people’s capacity to self-manage throughout the continuum of chronic disease prevention and care. "
 National Chronic Disease Strategy

The detection of chronic conditions or pre-existing risk factors is the first step in the prevention or management of a condition. Detection can be via opportunistic or planned screenings, or via Medicare Funded EPC health assessments that are designed to identify a range of physical, mental and social health issues. Health assessments incorporate the requirement of negotiating management goals with the client.

Health Assessments
Enhanced Primary Care funded health assessments are available for:

  • all Aboriginal or Torres Strait Islander people of any age

  • non-Indigenous clients, aged 45-49 years and at risk of developing a chronic disease

  • non-Indigenous clients, 75 years and over

  • residents of Registered Aged Care Facilities

  • refugees and other humanitarian entrants to Australia

At a glance

Screenings and health assessments provide an opportunity to identify the presence of chronic conditions or risk factors that might lead to later impairment of a patient’s health. Early detection provides an opportunity to educate and to encourage self-management and preventative behaviours.

A range of EPC items exists to support health assessments.
 

EPC health assessments are funded by the Commonwealth to encourage the early detection, diagnosis and management of common conditions that cause considerable morbidity and early mortality. For example, the Adult Aboriginal and Torres Strait Islander Health Check aims to improve the early detection of the following:

  • cervical cancer
  • circulatory conditions
  • inappropriate substance use
  • infections of the ears, skin and gastrointestinal system
  • renal disease
  • respiratory conditions
  • type two diabetes

 While the exact requirements of different health assessments vary, they all aim to assess the physical, psychological and social aspects of a client’s health. They may include: 

  • physical examination and measurements; e.g., BP, pulse, vision, hearing
  • assessment of medical history, medication, immunisation, continence
  • assessment of physical functioning; e.g., daily living, falls
  • assessment of psychological functioning; e.g., mood, cognition
  • assessment of social functioning; e.g., carer arrangements, drug & alcohol use
  • arranging necessary interventions, education and referrals
  • documenting simple strategies to improve or maintain the client’s health status

Details of EPC health assessment items are available in the Medical Benefits Schedule book and also online at http://www9.health.gov.au/mbs . The requirements are also available at http://www.health.gov.au/epc  together with sample proformas, checklists and answers to commonly asked questions.

Further information
A list of EPC items, including all Health Assessments items, can be found in the “Incorporating CDSM into General Practice” implementation guide in this resource.  As EPC items change over time, it is recommended that details and checklists associated with the use of the Chronic Disease Management items be checked periodically at http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease or http://www.health.gov.au/epc .

Training
Training in health assessments, including the use of practice staff and clinical software to facilitate the process may be available from your local Division of General Practice.

Click here for Printed Guide PDF Version of this Early Detection Section

References (click)

Back to Top ñ
 

ô Patient Centred Care-planning

"Increasing the effectiveness of self-management involves an ability to identify and respond to client needs using appropriate planning tools at the start, on-going coaching and follow up. "
 Sharing Health Care Initiative, National Evaluation.

Patient-centred care plans, developed collaboratively by the client and their health care provider, are the central tool that allows for and promotes self-management of chronic conditions.

A completed care plan outlines the client’s health care and goals for a one to two year period. The plan:

  • recognises the expressed needs and goals of the client
  • includes a program of health monitoring and interventions based on best practice guidelines
  • can schedule health promoting activities and education of a disease-specific or general nature

As a client-held document, it also provides a portable record of a client’s medical history, medications, immunisations, allergies, health providers, and current health plan

‘It allows you to feel you are part of your health care when you have a list reminding you to have blood test etc..……you feel you are more part of it and in control’

 Client comment - Sharing Health Care SA, Qualitative Impact Evaluation

The provision of a range of EPC items to support care planning recognises the importance of the process. The most commonly used items cover the preparation (Item 721) and periodic review (Item 725) of a GP Management Plan for patients with chronic or terminal conditions. If such clients have more complex needs, requiring multidisciplinary care, then a Team Care Arrangement can also be prepared (Item 723) and periodically reviewed (Item 727).

GPs have a critical role in the care planning process. Experience suggests that a verbal explanation and an invitation by GPs during consultations is the most effective strategy for recruiting clients into the care planning process. Other health care providers can contribute to the preparation of a care plan, but the plan must be authorised by a GP.

At a glance

Care plans are central to self-management. Care planning is a process whereby health care providers and clients  collaboratively produce a document that outlines the client’s goals and agreed care schedule for a one to two year period. As a client-held document it promotes self-management. It also provides a portable record of a client’s medical history, medications, immunisations, allergies, and health providers. There are a number of EPC items available to support this activity

The Flinders Tools can also be used to produce patient-centred care plans. They are designed to allow a client’s issues and goals to be identified, acknowledged and incorporated into the care plan.

The Flinders Model of Chronic Condition Self-Management

"It is not my point of view as a nurse, it is their point of view as a client and everything they say I write down in their words, so it is actually documented what they are saying.  So,  it is not how I feel about their health, it is how they’re feeling about their health, so I think they feel listened to, so that empowers them straight away because someone is taking notice of what they say, and then I guess, time goes on and self-management comes.’
Port Lincoln Aboriginal Health Service nurse

The Flinders Model provides a generic, structured approach to enable individuals and their health care providers to work together to better manage chronic conditions. Developed and supported by the Flinders Human Behaviour and Health Research Unit (FHBHRU), the model grew out of the SA HealthPlus coordinated care trials. The FHBHRU was originally the Coordinated Care Training Unit (CCTU).

 The model provides structured tools, referred to in the guide as the Flinders Tools, to support self-management of chronic conditions by:

  • improving the partnership between the client and their health care provider
  • allowing for a collaborative identification of problems and goals to form the basis of a patient-centred care plan that becomes a significant self-management tool
    motivating clients to make sustained behavioural changes
  • allowing self-management progress to be monitored and reviewed
  • the model includes the use of tools, referred to in this document as the Flinders Tools, to improve the quality of care planning.
  • the Partners in Health Scale allows self assessment of the effectiveness of the client’s current self-management behaviour.
  • the Cue and Response Interview © allows further exploration of self-management skills, identifies barriers to health improvement, allows checking of assumptions that either the health care provider or client may have, provides a structure for motivational interviewing, and prompts for behavioural change.
  • the Problem and Goals Assessment enable the client’s perspective of their main problem or problems, which may be non-medical, to be recognised and recorded. The identification of and agreement on goals can therefore follow.

Depending on the effectiveness of the client’s current self-management behaviour ,the Flinders Care Plan © targets one or more of the following six principles of chronic condition self-management:

1. Have knowledge of their condition
2. Follow a care plan that they constructed with their health professional
3. Actively share in decision making with health professionals
4. Monitor and manage the signs and symptoms of their condition
5. Manage the impact of the condition on their physical, emotional and social life
6. Adopt lifestyles that promote health
© FHBHRU Finders University June 2006

Evidence Base
  SA HealthPlus coordinated care trials demonstrated improved client wellbeing. Evidence suggested that the key components of that success were:

  • the Problems and Goals approach
  • the care plan
  • the coordination of services by GPs, clients and service coordinators

The key determinant of successfully coordinating care was the effectiveness of the client’s self-management behaviours. It was found that some participants were already effective self-managers, and others only required a small amount of training. The largest improvements in self-management, however, were for clients who initially:

  • lacked knowledge of their condition
  • lacked motivation to change behaviours
  • were depressed
  • had lifestyle risk factors
  • had poorly controlled conditions

"The Partners in Health scale was developed to assess a client’s existing self-management skills and abilities, and therefore allow better targeting of self-management training." Battersby (2005)

Further Information
A list of EPC items, including all Care Plan items, can be found in the “Incorporating CDSM into General Practice” implementation guide in this resource.  As EPC items change over time, it is strongly recommended that the details and checklists associated with the use of the Chronic Disease Management items be checked periodically at http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease or http://www.health.gov.au/epc .

 Details of all care planning and other EPC items are available in the Medical Benefits Schedule book, or online at http://www9.health.gov.au/mbs.

 Further details of the Flinders Model, its rationale, and evidence base are available at http://som/flinders.edu.au/FUSA/CCTU .

Training
Training in care planning, including the role of non-GP staff and clinical software to facilitate the process, may be available from your local Division of General Practice.

The Flinders Human Behaviour and Health Research Unit provides training courses on their chronic care model. Details of these are available at http://som/flinders.edu.au/FUSA/CCTU .  The Spencer Gulf Rural Health School (SGRHS), based in Whyalla, also offers training in the Flinders Model. For more information contact Kate.warren@unisa.edu.au or SGRHS at http://sgrhs.unisa.edu.au

Flinders University offer a Graduate Certificate in Health (Chronic Condition Self-management) and a Graduate Diploma in Chronic Condition Management. Details of these are available at www.flinders.edu.au or by emailing Sharon.Lawn@fmc.sa.gov.au. Students come from a range of backgrounds, including Nursing, Social Work, Occupational Therapy, Physiotherapy and Dietetics. 

"As I commenced study I had not reflected on how much mental health dictates to clients and expects ‘compliance’ for their benefit, and from an acute perspective. I have experienced so many positive outcomes from the Flinders Model that it will be almost impossible to work in any other way with clients."  Graduate of CCSM certificate course

Click here for Printed Guide PDF Version of this Patient-centred Care Planning Section

References (click)

Back to Top ñ
 

ô Self-management education for clients

"Self-management support structures that were found to be most effective were those that develop self-efficacy in relation to specific behaviours such as diet and diabetes"
 A Systematic Review of CDM, Research Centre for Primary Health Care and Equity

Self-management training is a recognised element of successful self-management support structures. While the training may provide instruction on physical management, it can also address behavioural, attitudinal, social and communication issues. Courses are considered disease-specific or generic depending on how closely they focus on the specifics of a particular chronic disease.

The Stanford Course
Kate Lorig and her colleagues developed the Chronic Disease Self-Management Program (CDSMP) at Stanford University in the United States. Research has shown the course, commonly referred to as the Stanford Course, is effective in improving the confidence, knowledge and health status of participants.

The Stanford Course was designed as a generic course because it was based on the beliefs that:

  • clients with different chronic diseases all face similar self-management issues

  • they can all learn to actively and effectively manage their illnesses on a daily basis

Topics covered include:

  • Self-management and becoming an active self-manager

  • Exercises for strength, flexibility and endurance

  • Communicating with friends, family and health professionals

  • Safe use of medication

  • Nutrition

  • Dealing with frustration, fatigue, pain and isolation

  • Relaxation techniques

  • Using the mind to manage symptoms

The course uses a peer-education strategy. Two leaders run the six-week course. At least one of the leaders has a chronic disease and is not a health care provider. Each weekly session lasts about two hours, allowing time to develop relationships, share experiences, support each other and develop individual skills in a group environment.

At a glance

Self-management training for clients is a recognised element of successful self-management interventions. While the training may provide instruction on disease-specific management, it can also address behavioural, attitudinal, social and communication issues. Self-efficacy, the belief in one's ability to carry out behaviour necessary to reach a desired goal, is an important pre-requisite for behavioural change.

The Chronic Disease Self-Management Program, developed by Stanford University, has been shown to improve the confidence, knowledge and health status of participants.

The course has been modified by Spencer Gulf Rural Health School and Pika Wiya Aboriginal Health Service for use in Aboriginal communities and is known as the LIFE course.

"Sharing is a big help, Making plans and trying to stick to them is very rewarding." "The course has also shown me that I am not the only one with a chronic condition and that you can live with it and have a full life."

"I get good ideas on exercising and eating healthy…. Ideas on relaxing and being able to talk about problems and concerns."
 Participants, Stanford CDSMP, In Our Hands Health Information & Resource Centre, Whyalla

All course leaders must be accredited by Stanford University, and their organisation must be licensed. The SA Department of Health holds a licence to allow their personnel or personnel of any organisations funded or partially funded by the State Government, to conduct courses. Other organisations should apply to Stanford University for a license.

The Spencer Gulf Rural Health School (SGRHS) and the Arthritis Foundation of SA offer leader training and accreditation under the Stanford Model.

Spencer Gulf Rural Health School (SGRHS) and Pika Wiya Aboriginal Health Service have adapted the course for use within Aboriginal communities. The modified course, known as the Living Improvements for Everyone (LIFE) course, is covered in more detail in Case Study 7.

 Evidence base
A systematic review of randomised control trials on CDSM education programs made the following conclusions: Self-management programs for non-disease specific (generic) chronic conditions:

Are effective for people with a range of chronic conditions for improving self-efficacy to manage their condition, symptom experience, quality of life, and for increasing physical activity: and Reduce hospitalisation and bed days and lessen emergency department use. Peer-led self-management programs: Improve self-efficacy, quality of life, physical activity and health service use;" Appear to be as successful as health professional led programs, though at lower cost Shaw et al (2006 p.46)

Further information
Further information on the Stanford course is available online at http://patienteducation.stanford.edu/programs. 

Further information on the LIFE course is available in this resource guide (Case Study 7), from Spencer Gulf Rural Health School at www.sgrhs.unisa.edu.au, from the In Our Hands Health Information & Resource Centre at www.inourhands.com.au, or by emailing Kate Warren kate.warren@unisa.edu.au.

Training
Contact the Arthritis Foundation of SA http://www.arthritissa.org.au or email info@arthritissa.org.au
Contact Kate Warren at kate.warren@unisa.edu.au.

Click here for Printed Guide PDF Version of this Self-management Education Section

References (click)

Back to Top ñ
 

ô Community participation in health

"Participation is the keystone of the new public health."
Baum – The New Public Health

In this context, community participation is the process of involving the community in decisions about health service planning, the development of policy, and the setting of priorities. Participation means more than just consultation and implies that the power for decision making, problem solving, service planning and service delivery is shared with the community.

 Benefits for the health service include:

  •   a higher profile for the health service in the community

  •   staff gain insights into the way people perceive the care they are receiving

  •   higher quality and more relevant service provision and projects are possible

  •   greater credibility when lobbying for additional funding

 Benefits for the community members include:

  •   an increased sense of control over factors affecting their health

  •   improved health outcomes

At a glance

Community participation in decision making can have benefits for health services and the community.

There are a variety of strategies to encourage participation.

While achieving full participation is problematic, genuine attempts to involve the community and consumers in decisions are likely to result in more relevant and higher quality service provision

Strategies to encourage participation include satisfaction surveys, meetings, focus groups, a structured complaints mechanism, community representation on boards, direct consumer feedback at the time of service, and participatory action research.

True community participation is difficult to achieve. Issues surrounding the extent of participation and power sharing, and questions of who should participate, compound the difficulty of involving the community as equal partners.

 Case Study 5 in this guide reports on a participatory action research project involving Elders from the Port Lincoln Aboriginal community.

 Further information
Johnson, S. & McAdam, H. 2001 Building consumers in: A resource manual in consumer participation for the not for profit sector, Arthritis Victoria, [Online], Available:http://www.participateinhealth.org.au/ClearingHouse/Docs/cappsbuildingconsumersinmanualweb.doc [22 April 2007]

Click here for Printed Guide PDF Version of this Community Participation Section

References (click)

Back to Top ñ
 

ô Community development in health

Self-management must be responsive to the unique needs of different individuals, communities and population groups.
 National Chronic Disease Strategy

Community development is aimed at empowering individuals and groups. The methods used are also designed to improve participants’ sense of control over their lives and ultimately to improve the health status of those involved. Like community participation, community development relies on trust and respect between the health care providers and the community members involved.

Two specific examples of small group development are reported in Case Study 2. Case Study 9 outlines the development of a community volunteer organisation that is providing self-management support.

Small group development, one strategy of community development, is described below to illustrate the general principles involved:

At a glance

Community development aims to empower individuals, groups or communities with the skills and knowledge to develop and implement solutions to problems identified by the community.

Community developed self-management strategies should be valued.

  • A community group identifies a problem and may start to form a plan of action.
     

  • This group can be provided with professional help to increase its effectiveness.
     

  • Community Health, for example, may be asked to provide that assistance. They could allocate human and other resources to the project. These resources would be used to develop the skills and abilities of at least some members of the community group, enabling them to develop and implement a solution to the original problem.
     

  • Over time, as the community members are empowered, the amount of assistance provided by Community Health would be gradually reduced until the group became self-sufficient and self-sustaining.
     

  • The original problem may be solved but, more importantly, the community now has a group of individuals with the skills and knowledge to determine and implement solutions to other problems that may be identified by the community.
     

  • Community development and empowerment has occurred.

Often, funding for community development activities is short-term, allowing little more than the trust and dialogue required between the professionals and the community group to be established. Community health services, as pre-existing, known, and trusted services in country towns, are well placed to effectively facilitate community development projects.

Because it is not possible to know exactly how projects will evolve, managing community development requires flexibility. As developmental projects, they are well suited to action research methods and a mix of quantitative and qualitative evaluation approaches.

It is argued that projects, identified by the community and facilitated using a community development approach, are likely to be more efficient, more effective, more sustainable, and generate more self-reliance than projects that are imposed onto a community. The final report of the Sharing Health Care Initiative, for example, concluded that the key to implementing self-management in Indigenous communities would be innovative approaches driven by the community. Local initiatives should be encouraged, but need to include appropriate evaluation strategies to determine their on-going effectiveness.

Click here for Printed Guide PDF Version of this Community Development Section

References (click)

Back to Top ñ
 

ô References
Prevention

  1. Sindall, C. & Stratton, J. 2006, The prevention terminology, Public Health Bulletin, ed. 3, pp. 9-11.

  2. Whitby, B. & Herriot, M. 2006, The prevention of chronic disease – the policy context, Public Health Bulletin, ed. 3, pp. 2-6.

Early detection
  1. Eyre Peninsula of General Practice 2005, Health Assessments made easy, Port Lincoln.
  2. Port Lincoln Aboriginal Health Service 2006, Health Team Programs, Procedures and Roles, Port Lincoln.
  3. SA Divisions of General Practice Inc. 2005, Desktop Guide to MBS item numbers, Adelaide.

Patient-centred care planning
  1. Battersby, M., Ask, A., Reece, M., Markwick, M., & Collins, J. 2003, The Partners in Health scale: The development and psychometric properties of generic assessment scale for chronic condition self-management, Australian Journal of Primary Health, vol 9, pp. 41-52.

  2. Battersby, M. 2005, Health reform through coordinated care: SA HealthPlus, British Medical Journal, vol. 330, pp. 662-665.

  3. Eyre Peninsula of General Practice 2005, Care planning made easy, Port Lincoln.

  4. Port Lincoln Aboriginal Health Service 2006, Health Team Programs, Procedures and Roles, Port Lincoln.

  5. SA Divisions of General Practice Inc 2005, Desktop Guide to MBS item numbers, Adelaide.

  6. ‘The Flinders Model of Chronic Condition Self Management Information Paper’, 2006, [Online, Jan 8 2007].

  7. ‘What is self management?’, [Online, Jan 8 2007].

Self-management education for clients
  1. 'Chronic disease self-management program', [Online],  [Jan 9 2007].
  2. Lorig, K., Sobel, D., Gonzalez, V.& Minor, M. 2006, Living a Healthy Life with Chronic Conditions, 3rd edn, Bull Publishing Company, Boulder.
  3. Shaw, J., Hagger, V., Graham, M. & Keleher, H. 2006, Systematic Review of Chronic Disease Self-Management Programs: a health promotion and determinants approach, Final report, International Diabetes Institute, Melbourne.
  4. 'What is self management?', [Online, Jan 8 2007].
  5. Zwar, N., Harris, M., Griffiths, R., Roland, M., Dennis, S., Powell-Davies, G. & Hasan, I. 2006, A systematic review of chronic disease management, Research Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, UNSW.

Community participation in health
  1. An introduction to consumer participation, National Resource Centre for Participation in Health, [Online, 22 April 2007].
  2. Baum, F. 2002, The new public health, 2nd edn, Oxford University Press, Melbourne.

Community development in health
  1. Baum, F. 2002, The new public health, 2nd edn, Oxford University Press, Melbourne.

Back to Top ñ