Care Planning and Goal setting in Diabetes management

How can we provide self-management support to people with chronic conditions?

Professor Malcolm BattersbyFlinders University

Flinders Human Behaviour and Health Research Unit

Overview• What is self-management?• Health professional capabilities in self-

management support • Goal setting• Care planning• Flinders Program• Diabetes care planning

Why is self-management support important? - Adherence

•Drug treatments are effective•Compliance with medications poor

- diabetes = 60%,- asthma and hypertension 40%

•Behaviour change is poor with 30% adherence to advice for lifestyle changes•Relapse over 12 months requiring care

- 30 -50% diabetes - 50 -70% asthma and hypertension

•Worse for lower socio economic groups

Asthma, Diabetes, Hypertension McLellan et al JAMA 243; 1689, (2000).

Capabilities of health professionals for supporting chronic condition self-

managementFunded by the Australian Department of Health and Ageing

Based on being able to deliver the 6 elements of the Chronic Care Model (Wagner et al)

http://som.flinders.edu.au/FUSA/CCTU/pdf/What's%20New/Capabilities%20Self-Management%20Resource.pdf

Flinders University, University of South Australia, AGPN, Australian Psychological Society

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health SystemResources and Policies

Community Health Care Organization

Chronic Care Model

Self-management (CCSM)• Having knowledge of the condition and/or its

management• Adopting a self-management care plan agreed and

negotiated in partnership with health professionals, significant others and/or carers and other supporters

• Actively sharing in decision-making with health professionals, significant others and/or carers and other supporters

• Monitoring and managing signs and symptoms of the condition

Self-management• Managing the impact of the condition on

physical, emotional, occupational and social functioning

• Adopting lifestyles that address risk factors and promote health by focusing on prevention and early intervention

• Having access to, and confidence in the ability to use support services

Self-management support

• Self-management support is what health professionals, carers and the health system do to assist the person – to manage their disease or condition, – in order to promote health and prevent illness, – detect, treat and manage early signs of disease, – and minimise the disabling impact of existing

conditions and complications’

Capabilities of health professionals for self-management support

• General person centred skills• Behaviour change skills• Organisational/system skills

General person centred skills1. Health promotion approaches2. Assessment of health risk factors3. Communication skills 4. Assessment of self management capacity

(understanding strengths and barriers)5. Collaborative care planning6. Use of peer support 7. Cultural awareness 8. Psychosocial assessment and support skills

Behaviour change skills9. Have knowledge of models of health

behaviour change 10. Motivational Interviewing11. Collaborative problem definition12. Goal setting and goal achievement 13. Structured problem solving and action

planning

Organisational/Systems Skills14. Working in multidisciplinary teams / Inter-

professional learning and practice 15. Information, assessment and communication

management systems 16. Organisational change techniques17. Evidence based knowledge18. Conducting practice based research/ quality

improvement framework19. Awareness of community resources

Current Models of Self-Management Support

Teaches health professionals stages of change, explores ambivalence, focus on a targeted behaviour to change

Motivational interviewing

Health/ Telephone coaching, teaches health professionals a range of engagement and motivational techniques where the client has identified goals

Coaching

Stanford 6 week course – teaches patients skills in self-management

Generic

Arthritis Self-Management , Diabetes, Cardiac Rehab, teaches patients knowledge of disease, disease self-management

Disease Specific

Current Models of Self-Management Support

• 5As: Assess, Advise, Agree, Assist, Arrange: usually targeted at risk factors

• Flinders program: taught to health professionals to use with individual patients

• Most are complementary• Most teach patients goal setting and problem

solving as the core patient skills

Goal setting• A goal is the object or aim of an action Ryan (’70)

• Motivation through conscious goal setting Locke (1996)

• Higher self-efficacy enhances goal commitment Social cognitive theory (Bandura, 1997)

• Locke E, Motivation through conscious goal setting, Applied and Preventive Psychology 1996• Locke, Latham, Building a practically useful theory of goal setting, American Psychologist 2002

Goal attainment1. The more difficult the goal the greater the

attainment2. The more specific the goal the greater the

attainment3. Both difficult and specific (progress is possible)4. Difficult goals require commitment5. Highest commitment when the goal is

important and achievable

Goal attainment1. Self-efficacy2. Feedback3. Goals affect the direction, effort and

persistence4. Goals require plans5. Goals mediate the effects of personality

Increasing commitment - external

1. Leadership 2. Rationale3. Authority4. Rewards5. Modelling 6. Feedback

Increasing commitment - internal• Values• Importance of the outcomes• Specific goals to achieve the outcomes• Training eg self-management skills• Cognitive effort• Success in sub-goals• Self-efficacy

5 functions of the Flinders Program of chronic care management

• Generic chronic condition management• Case management and coordination• Self-management support• Systemic and organisational change• Clinician change

Background - SA HealthPlus• SA HealthPlus Coordinated Care Trial

1997 – 1999• Patients with chronic and complex illnesses

• 8 projects in 4 regions of South Australia

• 4,500 patients randomised into Intervention (3000) and Control (1500) groups in the 8 projects

Battersby et al, BMJ, March 2005

BACKGROUND -Year 1 review• Problems and Goals worked well for most patients

• However the system designed to allocate coordination time according to level of severity (H/M/L) wasn’t being used

• WHY?

• Because some people who had severe complicated conditions, but were good self-managers, and did not need coordinated care

• Service coordination was provided based on whether a person was a good self-manager or not

• Self management was not defined or operationalised

Learning• Self-management capacity is affected by

– the illness – personal attributes – attributes of health providers – cultural and social factors

• Self-management skills need to be assessed before the right intervention is offered

• Not all consumers need self-management support and those who do will respond to a wide range of learning methods, some group, some individual

(Battersby et al, Milbank Quarterly, Dec 2006)

Care PlansShould be derived from a self-management

assessment including

• Knowledge• Behaviours • Attitudes• Impacts of the

condition

• Lifestyle risk Factors• Barriers to self-

management• Strengths.

Care PlansShould contain

• Client defined problems

• Clients defined goals• Medical management• A prioritised action

plan

• Community education or resources

• Community services• Planned review and

follow-up

Care Plans Should

• Facilitate the persons engagement in their own healthcare and treatment

• Enhance the client / provider relationship• Enhance the clients self-efficacy for self-

management and health outcomes• Enhance the clients ability to maintain changes /

improvements.

Care Planning Should enhance clients skills in

• Problem definition• Goal setting• Goal attainment skills• Action Planning• Problem solving

• Pain management• Psychosocial

management

The Flinders Program™ of Care Planningfor Self-Management Support

The Flinders Program™ is:• Bio psycho-social• Motivational• Outcomes based• Patient-centred• Integrates medical and self-management• Communication tool

Seven Principles of Self-Management

1. Know your condition

2. Have active Involvement in decision making with the GP or health workers

3. Follow the Care plan that is agreed upon with the GP and other health professionals

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 Lifestyle7. Have access to Services

Seven Principles of Self-Management

Principles of Self-ManagementK KnowledgeI InvolvementC Care planMR Monitor and RespondI ImpactL LifestyleS Services

Action PlanAgreed Issues

Agreed Interventions Shared Responsibilities

Review Process

The Flinders Program

Problems and Goals

+AssessSelf-Management

PsychosocialSupport

Community / Family Support

Self-Management

HealthcareManagement

Assessment of Self-Management Capacities

Partners in Health Scale (PIH)• 12 questions• self assessed and scored on 9 point scale

Cue and Response Interview (C&R)• 12 questions with cues• explores the strengths and barriers• HP assessed and scored on 9 point scale

Leads to collaboratively identified issues

CUE & RESPONSE INTERVIEW V10 JUNE 2010

Problems & Goals Assessment

• Identifies what the client sees as the biggest problem

and

• Identifies the goal(s) the client wants to achieve

Problem Statements3 parts to a problem statement

• The Problem

• What happens to the client because of the problem?

• How this makes the client feel?

Problem MeasurementProblem Statement“Because I’m so tired from looking after my grandkids, I don’t do the exercise I should and I feel like a failure.”

Rating ScaleHow much of a problem is this for me?

0 1 2 3 4 5 6 7 8Not at Very little Somewhat A fair bit a lotall

Goal Statements

• Goals are linked to the problem statement• Achieving goals may result in improved

problem rating because of changes to - The problem- What happens because of the problem- How the problem makes the client feel

Goal StatementsRepeated and S.M.A.R.T.

Specific Measurable Action based Realistic Time-framed (how long / how often)

Care Plans for Chronic Condition Management

• Identifies medical needs /management aims• Evidence based guidelines• Planned Appointments • Planned tests• Medication list• May be individualised but may be templates

Care Plans for Self-ManagementContains:• Identified issues from the C&R Interview &

P&Gs• Agreed goals / management aims• Agreed interventions• Sign off• Review datesSupports:• Self efficacy• Empowerment

The Flinders Program

• Certificate of Competence

Part of a Quality Assurance Process

Submit a minimum of 3 care plans

Results in a licence to use the Flinders Program of Self Management Support.

Achievement of Goal 1Figure 2.15. Extent of Achievement of Goal 1 by project, end of

trial.

0% 20% 40% 60% 80% 100%

Central cardiac n= 194

W Diabetes n= 154

W COPD n= 212

EP Chronic and complex n=831

S. Aged n= 525

S COPD n=140

S somatisation n= 76

EP Diabetes n= 347

Positive % No change % Negative %

Eyre Peninsula Aboriginal Diabetes Project

• Self-management program that is – culturally sensitive and flexible, – promotes self management principles through goal

setting, care planning– lifestyle changes – access to preventative services

• 60 participants - 12 months follow up• Sustainability through the care planning item

numbers

Eyre Peninsular Diabetes • Improved scores on PIH self management

at 12 months• Problem improved 6.22 – 5.28 (p <0.01)• Goal improved 7.26 – 5.42 (p <0.001)• Improved HbA1c 8.74 -8.09 (p< 0.01 )• BP 139/84 -136/83 • No change in SF-12 (difficulty with

questions)

Education and Training• Flinders Program on-line• Communication and motivation workshop• Revised (shorter) version of FP• Flinders Graduate Certificate and Diploma in

chronic condition management• Master of Primary Health Care (chronic condition

management) Sharon.lawn@health.sa.gov.au

Thank You

Contact: Prof Malcolm BattersbyFlinders Human Behaviour and Health Research Unit,

Flinders UniversityPhone: 8404 2608

Fax: 8404 2101Email: malcolm.battersby@flinders.edu.au

Paula.harris@flinders.edu.au

http://som.flinders.edu.au/FUSA/CCTU/Home.html