Caring for high-risk, polychronic patients accounts for over 18% of U.S. GDP and 50% of all UK GP visits. Yet it's estimated that 70% to 80% of this population can be supported to self-manage their conditions.
Think you can't customise care to each of your patients? Think again.
Patient Activation—which refers to people's motivation, confidence, and skills to manage their own health—is key to sustainable self-management, but it's incredibly difficult to foster for a few key reasons. Notably, our systems are incentivised in a way that pushes care away from individual patient needs, making patient behaviour difficult to change. Further, providers are often too pressed for time to educate patients effectively and promote good chronic disease self-management.
In an ideal world—where our systems are built to help patients become stewards of their own care—systems would build pathways that reflect clinical and non-clinical needs with patients at the centre. We would also have a more personal understanding of patient need, allowing us to tailor a care pathway that helps address each patient's root-cause barriers to self-management.
Obviously this is no simple task, but we have seen systems begin to make headway here. Advisory Board speaker Bec Richmond will be facilitating a discussion on sustainable self-management at the upcoming Health Service Journal (HSJ) event in Manchester, UK. Ahead of the event, we looked at the three biggest self-management questions we are hearing from our members and offered our take on each one.
1. What's the biggest barrier to successful self-management?
The disconnect between health and social care is one of the biggest barriers to 'success' in self-management. A lack of effective communication and decentralised social and clinical care pathways often mean patients don't feel empowered or knowledgeable enough to engage in their own health care and instead move about passively.
One social action organisation, York Centre for Voluntary Service, found it could alleviate the communication gap through its "Ways to Wellbeing" programme, which uses a centralised coordinator to connect patients who need support with community services and then develops individualised programmes accordingly. The programme resulted in a 75% increase in self-confidence among 80% of users. This, in-turn, led to better self-management habits, which freed up capacity for GPs to support other high-risk patients. Overall, the programme reduced the number of user GP appointments by 20%.
2. What criteria should we consider when identifying candidates for self-management programmes?
While some self-management programmes overlook certain candidates, assuming the patients will never 'get with the programme', other programmes include too many patients and become overwhelmed by the sheer number of patients. This begs the question: Who should be included in a self-management programme?
Evidence suggests that almost all chronic patients are good candidates and do want to manage their own condition(s)—but there is a caveat. To make best use of your resources, it's vital to identify how ready patients are to manage their own conditions. Luckily, there is a tool that does just this: the Patient Activation Measure (PAM). PAM allows providers to evaluate patient activation levels on a four-point scale, and then formulate individualized pathways based on clinical needs and activation levels for each patient.
This was exemplified by VA San Diego in the United States, which used PAM to measure activation levels for its heart failure patients, allowing the organisation to personalise each in-person visit and phone appointment to improve a patient's overall self-management skills. Our research shows PAM to be consistently useful in tracking activation levels, preparing patients for self-management, and providing insight necessary to enable services to intervene earlier.
Click this link to see our brand-new research report on PAM.
3. Who should design and deliver self-management programmes?
For self-management programmes to work, it is vital to involve multiple sources of support. This doesn't just include clinicians and carers, but also charities, community-based organisations, and non-traditional support such as peer groups. This inclusive structure reflects the fact that most barriers to self-management are non-clinical in nature, and not related to the diseases themselves.
Along those lines, in terms of actually managing a patient journey, the general rule of thumb is that the worker capable of addressing a patient's 'most at-risk needs' should be in charge of the pathway. That might mean a COPD patient at-risk of readmission is paired with a nurse manager, whereas a patient over-utilising the system due to homelessness is paired with a housing or social worker. Systems that improve self-management at scale spread out this responsibility across these clinical and non-clinical providers.
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