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Module 5 - Self-management
Terms in this set (36)
Why try to implement self-management in health-care?
Chronic conditions are expected to overwhelm the medical and personal resources of countries like Canada
Due to aging population and rising health care costs
Clinicians are present for only a fraction of a patient's life
In past most healthcare and teaching was provided by healthcare professionals
Self-management is a promising approach for improving health outcomes and reducing costs
What is an example of self-management?
Now there is the acknowledgement that many of the clinical functions (ex. A diabetic monitoring their HbA1C levels, somebody monitoring their blood pressure or their weight) as well as teaching activities can be effectively carried out by patients themselves
What is the definition of self-management? Is it universal?
No universally accepted definition
Many different terms used
Self-management can mean:
To comply or adhere to medical treatments
For example, adhering to a medical doctor's recommendations to stop smoking to help with your heart condition or to take medication for arthritis as prescribed
To have a personal belief that one is capable of following treatment regimens
For example, if you don't believe you can monitor your blood sugar than you are less likely to do so (self-efficacy - to believe and follow treatment)
To have the functional abilities to carry out activities of daily living independently
Ex. walking, feeding, toileting, cooking and dressing
To self-determine how to meet one's unique needs
Ex. a patient might have different health or activities of daily life priorities in comparison to what a health care provider might
What else does the definition imply aside from managing behaviour?
The definition envisions self-management as behaviours but includes the notion of confidence and embraces clinical management and role and emotional management by the individual
The definition provides clarity and focuses on the person with CC and further introduces the concept of self-management support which specifies what health providers can do to aid in self-management
What is the definition addressed in this course for self-management?
"the tasks that individuals must undertake to live well with one or more chronic conditions. These tasks include having (sic: gaining) the confidence to deal with medical management, role (sic: social) management, and emotional management of their conditions."
What three tasks does the definition address that people with chronic conditions must accomplish?
Firstly, they need to manage the clinical aspects of the condition (ex. Someone overweight with diabetes needs to take their medication, change their diet, self-monitor their blood sugar levels),
Secondly, they also need to manage the way in which they accomplish their daily activities of daily life including work, personal care and recreation
Thirdly, they need to cope with the emotional aspect of having the disease such as fear, frustration and possibly sadness
What is the definition of self-management support?
"the systematic provision of education and supportive interventions by health care staff to increase patients' skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support"
In other words, what is self-management support?
Patients require support in order to obtain the educational skills and confidence required to effectively manage their condition
Health care providers utilize a variety of techniques and strategies to offer this support
How do we differentiate between self-management and self-management support?
To differentiate between self-management and self-management support, think of self-management as encompassing problem-solving skills, and patients collaborative involvement in establishing goals to manage their disease
Self-management support on the other hand, support consists of the means in which the individual practitioners and the broader health care system support patients in trying to exercise self-management
What is traditional patient education?
Traditional patient education
Education is disease specific; teaches information and technical skills
Theory: Disease specific knowledge leads to behavior change
Example: diabetes educator lecturing to a group of diabetics about the disease process and teaching them how to self-inject insulin or monitoring blood glucose levels
What is education delivered in self-management support?
The patient learns problem-solving skills that can be applied broadly
Theory: Greater patient confidence and capacity to make health changes yields better outcomes
Goal: Increased self-efficacy and improved clinical outcomes
Between traditional education and self-management, which is better to use?
BOTH are needed to achieve high levels of quality of life and independence
Consider education as practice in self-management support as complementing rather than substituting for traditional patient education.
What should education for patients with chronic illness include?
Strategies that increase patient confidence
Adequate peer role models and support networks
Explain each of these components
Disease-specific education is self explantory
Managing skills - these are the skills that help patients deal independently with the problems that might develop (ex. Developing skills like problem-solving and goal setting, learning to find and use health and social services)
Strategies that increase patient confidence, also known as self-efficacy, in terms of this, we are looking at their ability to deal with the problems of their condition on a daily basis
The fourth component helps with the initiation and the maintenance of the desired behavioural change
Why would use these guidelines in combination or independently?
Someone with a severe condition and may be in a complex social situation may need all of these strategies,
Whereas someone with a less severe condition with a supportive environment in place may need one or two of these strategies to be put in place
What is self-efficacy?
The belief in one's capabilities to organize and execute the course of action required to produce a given attainment
More briefly, it can be described as the confidence in one's ability to achieve a behaviour
A strong sense of self-efficacy has been shown to have a positive influence on achieving health promoting behaviors in people with CDs
Self-efficacy has been positively associated with better health outcomes in a range of conditions relevant to rehabilitation
Aside from self-efficacy, what else is needed for an individual's behaviour to change?
Raising self-efficacy is important, but so is changing an individual's circumstances in which they live
According to the chronic disease framework, healthy living is difficult in neighbourhoods without things such as sidewalks, or without stores selling nutritious foods, or without individuals who cannot afford to buy nutritious foods
In order to change behaviours population-wide, personal skills-building needs to be part of the broader health promotion strategy addressing all of the social determinants of health
What are self-management support strategies?
Registered Nurses Association of Ontario (2010) produced best practice guidelines focusing on strategies to support self-management
Encouraged the use of the "5 A's" of behavioural change
A set of behavioural strategies to encourage patients with chronic disease to engage in self-management
What is the goal of the 5 A's?
This was first proposed by Glass et al., in 2002, and the 5A's are: Assess, Advise, Agree, Assist and Arrange
These patients with chronic diseases are trying to engage in self-management, these activities are not exactly linear with each step following the other sequentially
The goal of the 5 A's is to develop a personalized, collaborative action plan between the patient and their health care provider
And this includes specific behavioral goals, and a specific plan for overcoming barriers and then reaching those goals
What is assess?
During the assessment step, it is important that the health care practitioner takes the time to establish trust and rapport with the patient.
It is important to ensure that patient's have the opportunity to address priority concerns
The health care provider may collaboratively set a visit agenda to make sure that concerns are addressed during the visit, they may gather health behavior info, and they should assess the patient's readiness to make a change and tailoring the discussion according to the degree of change
In the RNAO self management guidelines, registered nurses are encouraged to screen for depression on the initial assessment and at regular intervals after that, and then to advocate for follow-up treatment when identified
Major depression is a major health concern commonly seen in those with chronic diseases
What is advise?
health care provider should provide specific information about health risks and benefits of change to a person with a chronic disease, this is where all the information already presented on patient education is most applicable
The RNAO recommends that health care practitioners combine behavioral strategies, psychosocial strategies, traditional patient education, and self management education approaches in order to deliver effective self-management support
It is also effective to utilize the closing the loop technique, when giving health information to a patient
This technique is a communication technique where the patient is asked to repeat in their own words the information that was just given to them
It is a useful way of testing the patient's level of understanding of the info given and to identify areas that need to be clarified
Lastly, it is recommended that the health care provider supports clients to effectively self-monitor their condition (ex. Advice in this area would include self-monitoring techniques for blood pressure or glucose monitoring) but also methods to keep track of their health condition such as a diary or a log
What is agree?
Agree: The health care provider collaborates with the patient to establish goals for self-management, they develop an action plan that enables the achievement of goals and to monitor progress towards the goals
Although all of the activities (5 A's) contribute to the creation of a personal action plan, it is in the third step that the initiation of developing an action plan that is put into place
An action plan is an agreement between the health care provider and the patient to help the patient work towards behavioral change
The purpose of an action plan is to increase self-efficacy or the confidence that the patient can change something
***Both the setting of goals and the development of an action plan should be done collaboratively, and it is important that the steps that are involved in the agree activity are done with the patient's interest in mind and that their willingness to change a specific behavior is taken into account
Without doing this there is less of a chance that the behavior will actually be changed
A standard question asked by the health care provider "Is there anything you would like to do this week to improve your health?"
What is assist?
the health care provider is encouraged to identify the patient's personal barriers to change, to teach and assist the patient about problem solving techniques, and provide the client with access to community self-management programs
Motivational interviewing is an example of a strategy to facilitate behavior change by exploring the patient's ambivalence to change
The effect is to reduce defensiveness and encourage engagement, thereby increasing the motivation to make behavioral change - this is a patient-centered approach that does not try to coerce the patient to change
Motivational interviewing is an advanced skill that requires training and practice , but it has been shown to be very effective in treating chronic conditions
The assist stage includes problem-solving, and the ability to problem solve is a core self-management skill, it is important that HCPs help patients with CCs acquire the skills that are necessary for effective problem solving
The process usually includes defining the problem, generating possible solutions, implementing the solution, and then evaluating the results
Lastly, another component of this activity is to provide social and environmental support, HCPs can inform patients about community self-management programs that are available
They can tell their patients about existing community resources such as self-help groups and support groups
What is arrange?
This is where the plan for follow-up is specified, the way in which follow-up is arranged and needs to be the most appropriate approach (ex. Face-to-face, or a phone call)
Follow-up provides ongoing assistance and support to the patient that has the CC, it provides opportunity for adjustment of the treatment plan or of the action plan as needed, and includes referral to a more intensive or specialized treatment where this might be warranted
What is the personal action plan for the 5A's?
List specific goals in behavioural terms.
List barriers and strategies to address them.
Specific follow-up plan.
Share plan with practice team and client's social support.
What is rehabilitation?
Rehabilitation is the health strategy applied by health professionals in the health sector and across other sectors that aims to enable people with health conditions experiencing or likely to experience disability to achieve and maintain optimal functioning in interaction with the environment.
What is the goal of rehabilitation
the primary goal of rehabilitation is to enable people to achieve optimal function and mitigate the effect of the disability
Rehabilitation from a public health perspective can be classified as one of four health strategies
One health strategy is curative while the other is preventative, and the key outcomes for both of these is survival
goal is not to cure but to maximize functioning and the quality of life of someone that is living on their own
What does the definition of rehabilitation mean by health professionals?
the most well known health professionals are trained at rehabilitation schools
These are professionals that by definition are involved in rehabilitation in most of its carnations
There is also a specialty in medicine called physical and rehabilitation medicine, these people are referred to as physiatrists
Nurses can also specialize
What does it mean by health sector and other sectors?
Health sector can be referred to as the reference or the root or the anchor sector where rehabilitation takes place, but rehabilitation is multisectoral strategy, in many situations (such as rehabilitation of children with special needs), services and care are primarily provided by the educational sector rather than the health sector
Another example is vocational rehabilitation, this is often provided and/or paid by the labor or social sector
What does it mean by aims to enable people?
The aim of rehabilitation is to enable people with health conditions experiencing or likely to experience disability to achieve their maximum or optimal functioning but also to maintain it and to interact with their environment
You are not just trying to enable a change within the person but also through adapting and modifying the environment that the person lives in such as making changes to their housing situation, an assistive device, it may involve their family or their peers or their employers
Rehabilitation strives to reverse what is being called the disabling process, and may be therefore be called the enabling process
What does it mean by experience disability?
The definition says experiencing disability as opposed to with disability, which can apply an attribute of the person
Saying experiencing suggests that its not just the capacity of the person that rehab addresses but also the environmental issues
Lastly, what does it mean by achieving and maintaining optimal functioning?
The last comment is in respect to remediation versus compensation
When someone seeks out a rehabilitation the therapist, the rehabilitation will first attempt to remediate the person's disability (ex. Person with arthritis would be to strengthen that part of the body, but if the weakness doesn't improve then the therapist may need to compensate for the problem such as a gate aid)
What type of rehabilitation is available?
Rehabilitation clinics for people with addiction problems
Psychologists, social workers, psychiatrists, nurses etc.
Pediatric rehabilitation centres (e.g. children with cerebral palsy and autism spectrum disorder)
Rehabilitation programs for people with specific physical disorders (stroke, cerebral palsy, traumatic brain injury, respiratory problems)
What is the FIM instrument?
Functional independent measure instrument
It is used to evaluate the severity of a disability of people that have conditions like a stroke
The functional ability of a person with a stroke will change over time and the FIM is used to track those changes
The FIM comprises of 18 items and they are categorized into self care, sphincter control, transfers, locomotion, communication and social cognition
Each one of these items can be evaluated using a 7-point scale
A rating of 1 means total assistance and a rating of 7 means totally independent in the item that you are rating
Once you evaluate each item, you add up the scores, the range of scores is between 18 and 126
The lowest score of 18 this would be someone that is extremely dependent of someone with all of their needs
The highest score of 126 is somebody that is completely independent in their abilities in each one of these items
When can it be used?
This can be used in three different time periods, for instance, it can be scored in admission, at discharge and at follow-up
It is important to use this to see how someone has changed over time as they are becoming rehabilitative
Who uses the FIM?
Each one of these categories is measured by a separate rehabilitation professional
For example, self-care is evaluated by an occupational therapist, and sphincter control (bowel and bladder management) is evaluated by a nurse, transfers such as bed, chair, wheel chair, toilet tub tranfers are done by a physiotherapist, communication items are done by a speech pathologist etc
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