Finding Common Ground:
Supporting Change in Healthcare
and at Home
A new kind of relationship
• RuthJean Francois, Patient Advisor,
Cambridge Health Alliance
What is self-management?
“The individual’s ability to manage the
symptoms, treatment, physical and
social consequences and lifestyle
changes inherent in living with a
chronic condition.”
Barlow et al, Patient Educ Couns 2002;48:177
What is self-management support?
Making and refining the health care
system to facilitate patients and
families managing chronic health
problems self-management. This
includes at the level of patientprovider, patient-health care team,
patient-health care system and the
community.
Glasgow et al
What is Self-Management Support?
• Skills and Tools
• A change in CULTURE to a whole new
relationship
– Tom Bodenheimer
Setting the Stage: Patients
Differences Between Acute and
Chronic Conditions
Beginning
Cause
Duration
Diagnosis
Diagnostic
tests
Treatment
ACUTE
CHRONIC
Rapid
Usually one
Short
Commonly
accurate
Often
decisive
Cure
common
Gradual
Many
Indefinite
Often
uncertain
Often limited
value
Cure rare
Differences Between Acute and
Chronic Care Roles
Role of
Professional
ACUTE
Select and
conduct
therapy
Role of Patient Follow orders
Lorig 2000
CHRONIC
Teacher/coach
and partner
Partner/ Daily
manager
Symptom Cycle
Disease
Fatigue
Tense muscles
Vicious
Cycle
Depression
Stress/Anxiety
Anger/Frustration/Fear
A philosophical shift
Professional
patient
Professional
Patient
Patient
Professional
Patient
professional
Person professional
Person-Person
Adapted from Tom Janisse
Learning Community Journey
Pilot Collaborative
on Self-Management Support
Karen’s Story in NHP
• Quality Allies and New Health
Partnerships – A bigger sea to swim in
• Finding our place as patient and family
faculty
• More than “giving feedback”, bringing
patient and family members in from the
beginning
Participation at all levels
•
Patient and family participation on the
National Advisory Committee.
•
Patient and family participation on the
faculty team.
•
Patient and family participation on the
learning community teams.
Changing Practice, Changing Lives
1. Through collaborative self-management
support, enhancing partnerships with patients
and families.
2. Engaging patients and families in quality
improvement and the redesign of ambulatory
processes, practices, programs, and facilities.
The Patient
The Medical Assistant
The Provider
Leaves with scripts,
referrals, and
instructions
Other Activated Patients
The Patient
The Medical Assistant
Integrated plan
Medical
&
SMG
The Provider
Typical experience with their PCP
First key service…
1) Planning and preparation- MA planned
visits with goal setting
2)The Provider- taught how to negotiate
a medical plan and integrate with a
patient-oriented self-management goal
(SMG)
B ACKGROUND
B ARRIERS
S UCCESSES
W ILLINGNESS…
A CTION PLAN
R EMEMBER
NON-DIRECTIVE COUNSELLING
And our Group Visits…
Patients helping
Patients…
3) The MINI-group visit
4) The Open-Office Group
visit
Stressors, depressed mood,
barriers, difficulty coping
ALWAYS covered
Coping strategies develop
Both involve goal setting
• Participation on QI
teams and traveling
with the team.
Clinic Patient and Family Advisory Council
Helping to develop informational and educational materials.
Teaching classes such as the Healthier Living Series.
Developing Bulletin Boards
Designing charting and documentation forms
Improving Electronic Medical Records
Patient and Family
Advisors serve on
the Patient Safety
and Medicine
Reconciliation
Committees.
Patient and Family
Advisors teach
residents and
medical and nursing
students and
participate in staff
orientation.
Developing peer support and buddy programs,
especially for newly diagnosed patients.
Family HealthCare Center, Fargo, ND
Creating a Patient Advisory
Council, developing patient
portals on the Center’s
website, and planning,
implementation, and
evaluating group visits.
Humboldt Del Norte IPA, Eureka, CA
Participating on
the QI team,
teaching
classes in the
Healthier Living
Series, and
training peer
support group
facilitators.
Participating in the design of Web
sites.
www.NewHealthPartnerships.org
What’s it like being involved: Dennis Malloy,
patient with COPD, Chair of Lambeth Breathe Easy Group
‘You’ve given
us the
lollipop and
we’re not giving
it back’
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