CDSM Case Studies

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ô Introduction

The case studies in this guide present a wide variety of approaches to supporting self-management. The strategies are applicable to various points across the chronic disease continuum from prevention to early detection, through to the management of the disease and its complications.

They are presented to  allow the reader to ‘pick and choose’ the elements of the strategies or models that are best suited to their context, their health care philosophy, and their clients’ needs.  

Click below to review the case studies.  

Notes:

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Figure 2.   A diagrammatic representation of the range of self-management support strategies presented in the case studies. The model represented here is explained in Section Five (CDSM Models).
 

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ô Case study origins

The amount of detail provided about each of the case studies in this guide has been limited to allow the presentation of a wider range of models. The detailed policies, processes, procedures, forms and templates used by a particular case study can be requested from the people listed in the ‘Further Information’ section of each the case studies.

At the time of publication, May 2007, all the models, apart from Case Study 6 which covers the Care Plan Support Centre in Whyalla and Case Study 4 which covers a 2002 research project, were still operating. Retention of trained staff is a constant issue on Eyre Peninsula and staff movements, as expected, can affect the on-going operation of any of the self-management support strategies presented. 

Some of the case studies presented owe their origins and staff training to a range of research activities conducted on Eyre Peninsula over the last decade.

  • SA HealthPlus, a coordinated care trial, tested resource substitution, pooling and service coordination as strategies for reducing service duplication and improving patient health and wellbeing. This project highlighted the importance of patient self-management.
     

  • The South Australian Sharing Health Care Initiative Project was one of eight national demonstration projects. It aimed to test several different self-management models including the Flinders and Stanford models of self-management. The project built on the findings of SA HealthPlus, and aimed at building a business model around the Enhance Primary Care MBS item numbers (mainly care planning), along with various self-management interventions to build client self-efficacy and compliance. The project also aimed to build successful partnerships between private and state funded health care providers, community-based services, health consumers, their families and carers.
     

  • A participatory action research project conducted at Port Lincoln Aboriginal Health Service explored the ‘lay knowledge’ of the Elders Ambassador Group to elicit strategies for successfully supporting self-management.
     

  • The Chronic Disease Demonstration Projects were run at Port Lincoln and Ceduna-Koonibba Aboriginal Health Services.
     

  • The ‘Shape up for Life’ research project is investigating the application of self-management education to the prevention of chronic disease.
     

  • The Self Management and Rating Tool (SMaRT) research and development activity is developing online support for people with depression.

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ô Case studies

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Case Study 1 A private rural General Practice supporting self-management involves the Cummins Medical Practice, which bases its self-management support on early detection, negotiated patient-centred care planning, and internally provided disease-specific education. They integrate their service provision with the local State health service and other service providers to provide support for self-management.
Case Study 2 Community-based health promotion supporting self-management looks at the local State health service, the Lower Eyre Region Health Services and, in particular, the educational and community development activities offered by their Community Health Service to support self-management.
Case Study 3 An Aboriginal Health Service supporting self-management looks at the screening and health assessment program, the production of patient-centred care plans using the Flinders Tools, and the provision of both generic self-management education and disease-specific education. With health, social & emotional wellbeing, family preservation and drug & alcohol teams the service is well placed to provide holistic care.
Case Study 4 Community participation in designing self-management support reports on a 2002 participatory action research project in which the Elders Ambassador Group developed a series of recommendations about self-management support strategies.
Case Study 5 A collaborative project to provide preventative education reports on a collaborative project between PLAHS, the Port Lincoln Health Service, Lincoln Garden Community House and local schools. Together they run an innovative chronic disease prevention program for primary school students based around shared meals.
Case Study 6 The Care Plan Support Centre model looks at the model in which GPs, from a range of practices, refer clients to a shared Care Plan Support Centre where nurses assist with the production of care plans using the Flinders Tools.
Case Study 7 Modifying self-management training for Aboriginal communities reports on a collaboration between Spencer Gulf Rural Health School (SGRHS) and Pika Wiya to modify the Stanford Chronic Disease Self-Management Program for use within Aboriginal communities. The modified course, known as the Living Improvements for Everyone (LIFE) course, is peer led and provides generic self-management training.
Case Study 8 Building health care provider capacity to support self-management examines the Flinders Model and Stanford Course training provided to enable health care providers to better support self-management.
Case Study 9 Volunteers supporting self-management reports on a volunteer centre that offers generic self-management training, exercise classes, and provides a range of information to support self-management.
Case Study 10 Acknowledging the importance of the HCP/client relationship in recognition of the importance of the health care provider/client relationship in improving self-management, the Flinders and Far North Division of General Practice trialled the employment of an Aboriginal Health Worker to assist with the self-management support offered to Aboriginal clients that attend private GP practices in Port Augusta.
Case Study 11 Investigating self-management education as a preventative strategy this study is an account of a Spencer Gulf Rural Health School research project, 'Shape up for Life', which is combining exercise and nutrition education with the methodology and content of the Stanford self-management course to determine the suitability of the approach to chronic disease prevention programs.
Case Study 12 Investigating the Internet as a self-management support tool the Spencer Gulf Rural Health School is developing and testing an online self-management and rating tool for people with depression.
Case Study 13 Reorienting health services to support self-management this case study reports on advocating for resource substitution and additional funds in an attempt to implement the findings of the SA HealthPlus trial.