Self Care - An interesting article

Dr. Janine Bycroft (MBChB, Dip Obs, Dip Paeds, MPH (Hons), FRNZCGP)
Contact: jby@ihug.co.nz

Over the next 25 years, The World Health Organisation (WHO) predicts a serious global epidemic of obesity, diabetes and related chronic conditions. The incidence of many other serious chronic conditions is increasing and the associated disease burden and health costs will be crippling for virtually all countries. The care of chronic conditions is now of major global public health significance and there is an urgent need for cost-effective and evidence-based prevention and treatment strategies.For chronic conditions, patient controlled self-care behaviours (positive or negative) have a greater impact on long-term health outcomes than medical care.

Approaches to chronic conditions that emphasis self-care/self-management* need to be prioritised.*(Self-care and self-management are used interchangeably in this discussion, reflecting the lack of a standardised term).

BACKGROUND

Chronic conditions have been described as the health challenge of the 21st century, and currently account for approximately 80% of all deaths, and 70-78% of all healthcare expenditure in New Zealand. (National Health Committee, 2005) The global obesity epidemic, ageing populations and pervasive adoption of unhealthy lifestyles (in particular unhealthy nutrition, physical inactivity and continued smoking) are just some of the contributing factors to the changing burden of disease.The WHO Report 2002 highlighted the importance of these risk factors and emphasised that the “risk factors of today are the diseases of tomorrow.”(World Health Organization, 2002b) A strong message from the report is that much greater effort is needed globally and nationally to adopt evidence-based system changes to reduce risk factors within at risk populations, address health disparities and improve chronic care delivery. Millions of people are suffering unnecessarily, with recent estimates suggesting 80% of cardiovascular disease, diabetes and strokes and 40% of cancers are preventable (WHO, 2005).Chronic conditions like mental health problems, cancers, obesity, diabetes, arthritis, serious allergies and asthma continue to increase, and estimates suggest up to 70% of all general practice consultations are now secondary to a chronic condition. The current health system was designed for acute, episodic care (also referred to as the Radar Syndrome) where quality of life and “cure” is highly dependent on professional care. This contrasts with the complex medical, emotional and social aspects of long-term health conditions that require ongoing care. Quality of life and long-term health outcomes are more strongly influenced by non-medical factors such as:

• Patients’ self management and decision making
• Support services
• Coordination of care Some programmes such as Care Plus and Chronic Care Management encourage longer consultations, teamwork and patient-centred care but further changes are needed. The healthcare costs and increasing service demands secondary to chronic conditions are huge. Unless dramatic changes are made, the burden of disease, health disparities and costs resulting from chronic conditions are predicted to overwhelm virtually all existing health systems (World Health Organisation, 2002).Increased self-care support is one evidence-based approach that has become pivotal within the UK National Health Service, in Australia, Canada and leading organisations within the USA. Internationally, investment in increased self-care support has been shown to reduce:

• Visits to GPs by up to 40%
• Visits to outpatient clinics by up to 17%
• Visits to A&E clinics by up to 50%
• Drug expenditure & improve medication adherence

(Self Care – A Real Choice. Department of Health, UK. January 2005)

There is now good evidence that increased self-care support reduces health disparities, improves adherence to treatment regimes, decision-making, communication, coordination, reduces hospitalisations, improves health outcomes and quality of life.

Multilevel system changes are required to help individuals and their families to self care/manage more successfully. These changes will include self-care training and programmes (practice and community based), community networking and process changes.

WHAT IS SELF-CARE?

Self-care involves an individual with a chronic condition working in mutual agreement with their carers and health professionals so that they can:

• Know their condition and various treatment options;
• Negotiate a plan of care, i.e. a Care Plan, and review/monitor the plan;
• Engage in activities that protect and promote health;
• Monitor and manage the symptoms and signs of the condition;
• Manage the impact of the condition on physical functioning and emotions and interpersonal relationships.

(Flinders Human Behaviour and Health Research Unit)

The aim of self-care is to equip individuals and their families with the necessary tools and skills so they can have more control and confidence in managing the daily challenges of living with a chronic condition. A key goal is to improve their health, reduce disease progression and maximise the wellbeing of themselves and their families. This leads to improved quality of life, self-determination, increased resilience, patient centred care, and reduces demand on overloaded services.

Most individuals with chronic conditions only see their health provider for a fraction of the year. The rest of the time individuals have to manage the many aspects of living with a chronic condition. These range from self-triage and care of minor ailments to knowing when something is serious and needs urgent attention. It also includes managing and minimising disease impact on physical, social, emotional, and psychological functioning.

Traditional patient education has been found to be relatively ineffective at changing behaviour. Self management education is much more effective as it teaches individuals and their families practical and generic skills that help them manage their health conditions. These skills also tend to improve individual’s emotional, social, and financial functioning, not only within their families but also their communities. Practically this results in improved health, wellbeing, work productivity and reduced family stress.

Self-management skills that can be learnt include:

• decision-making
• problem solving
• goal setting
• action planning
• improving communication with health professionals
• utilising resources within one’s community
• fatigue and pain management
• interpersonal skills
• adoption of healthier lifestyle behaviours such as healthier nutrition and increased physical activity

Learning such skills has positive benefits for many other aspects of our lives. People that have learned self management skills have returned to work, improved their communications skills and relationships and improved their social wellbeing.

Key features of a self management approach include:

• improving self-efficacy (confidence in one’s ability to perform a certain task)
• collaborative approach
• holistic view that health and wellbeing includes emotional, cultural, social, environmental, spiritual and physical dimensions
• empowerment
• mutual respect and trust
• increasing self responsibility, autonomy and self-determination
• starting with the patient’s priorities
• aligning interventions with a person’s stage of change
• inclusion of motivational interviewing and cognitive behaviour therapy techniques

WHY IS INCREASED SELF-CARE SUPPORT IMPORTANT?

• Over the last 20-40 years there has been a significant epidemiological shift with increasing burden of disease and death rates secondary to chronic diseases
• Chronic conditions now account for approximately 78% of all medical care spending
• Medical costs associated with chronic conditions are continuing to escalate and are predicted to overwhelm most health systems throughout the world unless major changes occur (WHO Report 2002, 2005)
• Supporting populations to become more effective self-managers reduces demands on overloaded services
• Chronic conditions are a major contributor to the growing disparity in life expectancy and disease burden between Maori/Pacific and non-Maori/non-Pacific
• Research confirms most consumers want more information and involvement with health care decisions – these are two key areas of increased self-management support.
• Self-management training teaches evidence-based behaviour change techniques needed to properly implement chronic care programmes such as Care Plus. (Most GPs and practice nurses currently have very little, if any, specific training in behaviour change management.)
• Increased self-management support has the potential to reduce health inequalities and be of most benefit to high needs groups if financial barriers are removed and self-management interventions designed for culturally diverse groups.
• The people that will benefit the most are those that are currently poor self managers and therefore most at risk of complications and hospitalisation

CONCLUSION

It has been said that patients are the health system’s largest untapped resource. Self-management approaches seek to tap this potential by supporting and encouraging patients and their families to be more in control of their health and to increase their confidence and skills to self-care more optimally.
SELF-CARE/SELF-MANAGEMENT PROGRAMMES IN NEW ZEALANDLiving a Healthy Life with Chronic Conditions:
A six-session course run by The Arthritis Foundation for anyone with a chronic condition such as diabetes, asthma, a heart condition and arthritis. It has been widely researched and is recognised in many countries as an effective way of learning to become a self-manager. Many of the course leaders are volunteers and a number of them have chronic conditions, which they have learnt to manage effectively through attending the course. For more information, contact the Arthritis Foundation: (04) 472 1427; www.arthritis.org.nz

Flinders Model – Chronic Conditions Self-management:
Training for health professionals in chronic condition management
http://som.flinders.edu.au/FUSA/CCTU/New%20Zealand.htm

Counties Manukau DHB Chronic Care Management Programme:
The first structured chronic care management programme to be developed and evaluated in New Zealand.
http://www.cmdhb.govt.nz/About_CMDHB/Planning/Chronic-Care-Management-Plan/CCMSept2001.pdf OVERSEAS RESOURCESExpert Patient
UK based long term condition management programmes and information. Includes link to ‘Stepping Stones to Success’ – a resource to help individuals and organisations develop and run lay-led self-mangement programmes.
www.expertpatients.co.uk.