Chronic Disease Management Living Well with a Chronic Condition

Transcription

1 Chronic Disease Management Living Well with a Chronic Condition 1 Goal of Living Well To enable as many people as possible with a chronic condition to better manage their conditions on their own and live the healthiest lives they can. 2 Program Components Supervised Exercise Classes Disease-Specific Education Self-Management Workshop (Row Your Own Boat) Nutrition & Social Work Counselling 3 1

2 Program Disciplines Kinesiologists Respiratory Therapists Physiotherapists Occupational Therapists Community Fitness Leaders Registered Dietitians Social Workers Administrative Support 4 Underlying Principles Chronic care model Integrated self-management Be patient-centered and community-based Provide one stop shopping close to the participant Many needs common across chronic conditions Be sustainable Create group atmosphere for continued support 5 Living Well Program Program Entry MD Referral CDM Nurse Other Health Professional Supervised Exercise Self - Referral 403-9HEALTH Dietitian SW Counselling Education Lifestyles Diseasespecific Self- Management Row Your Own Boat 6 2

3 Who Can Participate in Living Well? Entry Requirements People with a chronic condition People who are able to function in a group 7 Community Centered City Recreation Centres, Community Centres, YMCAs 8 Program Sites 9 3

4 Community Centered Crowfoot YMCA Cardel Place VRRI Village Square Richmond Rd TC Renfrew Pool & Leisure Centre Marlborough CC Mount Royal CECA RGH Beltline Fitness Jewish Centre Shawnessy YMCA 10 Exercise Purpose To teach individuals how to self-manage and monitor their chronic condition within an exercise environment 1 st Step: Attend Orientation & Intake Session (urban) 2 nd Step: Living Well Assessment - Kinesiologist, physical therapist, respiratory therapist, or occupational therapist Medical History Outcome measurements: 6 minute walk test, BMI, quality of life, etc. 11 Exercise Format -8 weeks - Group sessions sessions/week minutes per session - Inter-professional team 12 4

5 Easy Going Significant limitations to exercise <10 min of physical activity without stopping Focus: mobility balance strength Supervised by PT, OT Fitness leader Exercise Program Get Going Moderate limitations to exercise >10 min of physical activity without stopping Focus: endurance muscular strength flexibility Supervised by : RT, PT, &/or Kin Fitness leader Keep Going Few limitations to exercise, no symptoms Focus: endurance muscular strength/endur ance flexibility Supervised by Kin PT, RT, OT on consult Fitness leader On the Go Safe to exercise unsupervised Unable to attend site Focus: endurance muscular strength flexibility balance Supervised by Kin PT, RT, OT on consult 13 Exercise Class Routine Pre- Assessment Warm- Up Aerobic- Training Cardio- Cool down Resistance Training Balance Training Flexibility Training Post-exercise Assessment 14 Exercise Follow Up Maintenance Classes Supervised exercise class to promote participant exercise adherence Minimum 2x/week Offered by partner site; membership purchased Follow-Up Assessments Follow-up visits with LW staff Post-program, 6 mos, 1 yrs Repeat of intake assessment Communication with family MD 15 5

6 Education Purpose Educate patients on their condition Create support in group sessions Triage lower risk clients from specialty clinics Instructors Taught by professional staff (specialty clinics or Living Well staff) Education sessions ideally aligned with exercise program Topics Pre-diabetes, diabetes, hypertension, dyslipidemia, COPD, chronic pain, falls risk, food & mood, arthritis, osteoporosis, brain health, breast health, lifestyles Education Topics Arthritis 101 Blood Pressure Cardiovascular Risk Follow-up Celiac Disease - Going Gluten Free Cholesterol and Trigs COPD Breathing Matters Dementia: Developing a Positive Perspective Diabetes Essentials Insulin Pump Introduction Insulin Pump - Advanced Pre-Diabetes Reducing Your Risk Explaining Pain Food and Diabetes Food and Mood Life After Gestational Diabetes Lifestyles Living with Stroke Navigating the Web for Health Information Osteoporosis and Bone Health Pain Self-Management Tasting 101 Slips, Trips & Falls Smart Moves Smoke Free My Path to a Smoke Free Future Stroke 101 Vitamins, Minerals and Herbs Your Marvellous Brain 18 6

7 Program Cost Exercise - $80 Self-management - no cost Education no cost Subsidy programs available 19 Nutrition Counseling & Education Primary care practices Clients not appropriate for group setting Chronic diseases not included in education series General out-patient nutrition services 20 Social Work Services Assistance accessing services Provide emotional support Agency liaison Patient advocacy 21 7

8 Multicultural Programs Purpose To provide the Living Well Program in a culturally sensitive manner to multicultural populations Staff Multidisciplinary and multilingual health professionals from a variety of ethnic communities Sites Delivered in cultural or community sites (Temples/Mosques) 22 Demographics Percent of Patients 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 47.5% 38.4% 31.1% 23.2% 51% married or common law 60% female Average Age = 57 n = % 7.9% 5.9% 1.7% Diabetes Hypertension Dyslipidemia Chronic Pain Obesity COPD Asthma CHF Condition 23 Outcomes: Diabetes 70% 60% Percent at target 50% 40% 30% 20% Baseline 12 mos 10% 0% HbA1c <7% n=876 HDL:TC <4% n=749 Tg <1.7% n=752 Outcome 24 8

9 Outcomes: Dyslipidemia & Hypertension 80% 70% 60% Percent at Target 50% 40% 30% 20% 10% Baseline 12 mos 0% HDL:TC <4% (Dyslipidemia) n= 465 Tg <1.7% (Dyslipidemia) n=468 SBP <140 (<130 DM) (Hypertension) n=64 Outcome 25 Absolute Change HbA1c (Diabetes) Mean Leve All (N=730) High Risk (N=121) Population baseline 12-months *High Risk (9.0% or higher at baseline) All High Risk p < Utilization Outcomes Visits per 1000 patients ED Visits/1000 pts n=2550 P< % IP Admissions/1000 pts n= % ED Visits/1000 pts (High Risk 2/yr) n=281 75% IP Admissions/1000 pts (High Risk 2/yr) n=113 Baseline 12 mos 27 9

10 Exercise: 6-Month Outcomes Variable Weight (kg) BMI 6MWT (m) BP (mmhg) Sit-to-Stand Baseline / mo Change -4.8* -2.1* +24.8* -4.5/-2.1* +1.7* * p< Calgary COPD & Asthma Program Asthma, COPD, chronic cough and smoking cessation education & spirometry Specialty clinics, primary care, community health centres, in-patients Certified Respiratory Educators 29 Next Steps Add new education topics Incorporate CDM Key Performance Indicators Implement process improvements to increase access Roll out Chronic Cough to primary care 30 10

11 Questions Living Well with a Chronic Condition 31 11

12 Self - Management Row Your Own Boat Presented by: Doris Listoe, Coordinator I identify no real or potential conflicts of interest to disclose 2 Definition of self-management Self-management relates to the tasks that an individual must undertake to live well with one or more chronic conditions. 3 Asthma/COPD Day, March 26,

13 Self - Management Self-management Tasks 1. To take care of your illness 2. To carry out your normal activities 3. To manage your emotional changes 4 Core self-management skills 1. Problem solving 2. Decision making 3. Knowing how to find and utilize resources 4. Forming partnerships with health care providers 5. Taking action 5 Row Your Own Boat Program 6 weeks, 2 ½ hours / week Small group format Peer led by volunteers and/or staff: Leaders have chronic condition or are caregivers Trained as per Stanford program Follow a carefully scripted course 6 Asthma/COPD Day, March 26,

14 Self - Management Row Your Own Boat Program Regular workshop offered for adults 18 years and over in English, Punjabi and Cantonese Adolescent in Transition workshop offered for transitioning youth (ages 15 25) and separate workshop for parents / caregivers 7 Be Your Own Boss* CSDMP was adapted by CDSMP Trainers and youth in the Edmonton area. Workshop adapted specifically for adolescents and young adults living with long term illnesses Separate workshop adapted for parents of adolescents with long term illnesses (*called Row Your Own Boat in Calgary area) 8 Objectives of program: Help participants gain self-confidence in their ability to control their symptoms Help participants learn the skills to manage their health problems 9 Asthma/COPD Day, March 26,

15 Self - Management Topics include: Goal setting Problem solving Using your mind to manage symptoms Medication management Healthy eating Exercise guidelines Communication Working with your healthcare professional Self-Management Toolbox 12 Asthma/COPD Day, March 26,

16 Self - Management Core Assumptions People with different chronic diseases have similar self-management problems and disease-related tasks People can learn to take responsibility for the day-to-day management of their disease(s) 13 Core Assumptions Trained lay persons with chronic conditions can effectively deliver a structured patient education program Confident, knowledgeable persons practicing self-management will experience improved health status and use fewer health care resources 14 Row Your Own Boat Program* Utilization-Focused Evaluation Quantitative CDSMP Survey baseline, 6 month, & 1 yr Qualitative Participant Feedback Post-workshop surveys & letters Ongoing Communication with Leaders & Participants *Regular English Program 15 Asthma/COPD Day, March 26,

17 Self - Management Demographics Age Gender Percentage Age of Participants Gender Male 24% 0 45 or younger Fe m ale 76% Age n = 193 n = Demographics Chronic Condition Mood Disorders Pain Asthma COPD Hypertension Heart Disease Diabetes Arthritis n = 195 Percentage 17 Survey Results Baseline to 6 month surveys Less limitations to daily activities More self-confidence for managing chronic conditions Less health distress Less physical disabilities Better coping with symptoms 18 Asthma/COPD Day, March 26,

18 Self - Management Survey Results Effects maintained to 1 year Better coping with symptoms Less limitations to daily activities More self-confidence for managing chronic conditions 19 What participants valued most: Making an Action Plan / Problem solving Discussion with other participants Learning skills to better manage condition Learning how to work with your healthcare professional 20 Participants most important things learned : Making an Action Plan / Problem solving Discussion with other participants Learning I was not alone I can make a difference for myself Learning skills to better manage condition Be positive 21 Asthma/COPD Day, March 26,

19 Self - Management RYOB Contact information Regular workshop: Call 9-HEALTH Youth or parent workshop call: Marielle LeClair (Currently collecting names on a wait list) 22 Main references: What is Self-Management? Flinders Human Behaviour & Health Research Unit Lorig, K., Holman, H. Self-Management Education: History, Definition, Outcomes, and Mechanisms. Annals of Behavioral Medicine 2003, 26(1):1-7 McGowan, Patrick, PhD, Self-Management: A Background Paper. New Perspectives: International Conference on Patient Self- Management 23 Websites (includes extensive bibliography re. self-management) 24 Asthma/COPD Day, March 26,

20 Self - Management Questions / Comments? Questions 25 Asthma/COPD Day, March 26,

21 Chronic Disease Management Living Well with a Chronic Condition 1 Goal of Living Well To enable as many people as possible with a chronic condition to better manage their conditions on their own and live the healthiest lives they can. 2 Program Components Supervised Exercise Classes Disease-Specific Education Self-Management Workshop (Row Your Own Boat) Nutrition & Social Work Counselling 3 1

22 Program Disciplines Kinesiologists Respiratory Therapists Physiotherapists Occupational Therapists Community Fitness Leaders Registered Dietitians Social Workers Administrative Support 4 Underlying Principles Chronic care model Integrated self-management Be patient-centered and community-based Provide one stop shopping close to the participant Many needs common across chronic conditions Be sustainable Create group atmosphere for continued support 5 Living Well Program Program Entry MD Referral CDM Nurse Other Health Professional Supervised Exercise Self - Referral 403-9HEALTH Dietitian SW Counselling Education Lifestyles Diseasespecific Self- Management Row Your Own Boat 6 2

23 Who Can Participate in Living Well? Entry Requirements People with a chronic condition People who are able to function in a group 7 Community Centered City Recreation Centres, Community Centres, YMCAs 8 Program Sites 9 3

24 Community Centered Crowfoot YMCA Cardel Place VRRI Village Square Richmond Rd TC Renfrew Pool & Leisure Centre Marlborough CC Mount Royal CECA RGH Beltline Fitness Jewish Centre Shawnessy YMCA 10 Exercise Purpose To teach individuals how to self-manage and monitor their chronic condition within an exercise environment 1 st Step: Attend Orientation & Intake Session (urban) 2 nd Step: Living Well Assessment - Kinesiologist, physical therapist, respiratory therapist, or occupational therapist Medical History Outcome measurements: 6 minute walk test, BMI, quality of life, etc. 11 Exercise Format -8 weeks - Group sessions sessions/week minutes per session - Inter-professional team 12 4

25 Easy Going Significant limitations to exercise <10 min of physical activity without stopping Focus: mobility balance strength Supervised by PT, OT Fitness leader Exercise Program Get Going Moderate limitations to exercise >10 min of physical activity without stopping Focus: endurance muscular strength flexibility Supervised by : RT, PT, &/or Kin Fitness leader Keep Going Few limitations to exercise, no symptoms Focus: endurance muscular strength/endur ance flexibility Supervised by Kin PT, RT, OT on consult Fitness leader On the Go Safe to exercise unsupervised Unable to attend site Focus: endurance muscular strength flexibility balance Supervised by Kin PT, RT, OT on consult 13 Exercise Class Routine Pre- Assessment Warm- Up Aerobic- Training Cardio- Cool down Resistance Training Balance Training Flexibility Training Post-exercise Assessment 14 Exercise Follow Up Maintenance Classes Supervised exercise class to promote participant exercise adherence Minimum 2x/week Offered by partner site; membership purchased Follow-Up Assessments Follow-up visits with LW staff Post-program, 6 mos, 1 yrs Repeat of intake assessment Communication with family MD 15 5

26 Education Purpose Educate patients on their condition Create support in group sessions Triage lower risk clients from specialty clinics Instructors Taught by professional staff (specialty clinics or Living Well staff) Education sessions ideally aligned with exercise program Topics Pre-diabetes, diabetes, hypertension, dyslipidemia, COPD, chronic pain, falls risk, food & mood, arthritis, osteoporosis, brain health, breast health, lifestyles Education Topics Arthritis 101 Blood Pressure Cardiovascular Risk Follow-up Celiac Disease - Going Gluten Free Cholesterol and Trigs COPD Breathing Matters Dementia: Developing a Positive Perspective Diabetes Essentials Insulin Pump Introduction Insulin Pump - Advanced Pre-Diabetes Reducing Your Risk Explaining Pain Food and Diabetes Food and Mood Life After Gestational Diabetes Lifestyles Living with Stroke Navigating the Web for Health Information Osteoporosis and Bone Health Pain Self-Management Tasting 101 Slips, Trips & Falls Smart Moves Smoke Free My Path to a Smoke Free Future Stroke 101 Vitamins, Minerals and Herbs Your Marvellous Brain 18 6

27 Program Cost Exercise - $80 Self-management - no cost Education no cost Subsidy programs available 19 Nutrition Counseling & Education Primary care practices Clients not appropriate for group setting Chronic diseases not included in education series General out-patient nutrition services 20 Social Work Services Assistance accessing services Provide emotional support Agency liaison Patient advocacy 21 7

28 Multicultural Programs Purpose To provide the Living Well Program in a culturally sensitive manner to multicultural populations Staff Multidisciplinary and multilingual health professionals from a variety of ethnic communities Sites Delivered in cultural or community sites (Temples/Mosques) 22 Demographics Percent of Patients 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 47.5% 38.4% 31.1% 23.2% 51% married or common law 60% female Average Age = 57 n = % 7.9% 5.9% 1.7% Diabetes Hypertension Dyslipidemia Chronic Pain Obesity COPD Asthma CHF Condition 23 Outcomes: Diabetes 70% 60% Percent at target 50% 40% 30% 20% Baseline 12 mos 10% 0% HbA1c <7% n=876 HDL:TC <4% n=749 Tg <1.7% n=752 Outcome 24 8

29 Outcomes: Dyslipidemia & Hypertension 80% 70% 60% Percent at Target 50% 40% 30% 20% 10% Baseline 12 mos 0% HDL:TC <4% (Dyslipidemia) n= 465 Tg <1.7% (Dyslipidemia) n=468 SBP <140 (<130 DM) (Hypertension) n=64 Outcome 25 Absolute Change HbA1c (Diabetes) Mean Leve All (N=730) High Risk (N=121) Population baseline 12-months *High Risk (9.0% or higher at baseline) All High Risk p < Utilization Outcomes Visits per 1000 patients ED Visits/1000 pts n=2550 P< % IP Admissions/1000 pts n= % ED Visits/1000 pts (High Risk 2/yr) n=281 75% IP Admissions/1000 pts (High Risk 2/yr) n=113 Baseline 12 mos 27 9

30 Exercise: 6-Month Outcomes Variable Weight (kg) BMI 6MWT (m) BP (mmhg) Sit-to-Stand Baseline / mo Change -4.8* -2.1* +24.8* -4.5/-2.1* +1.7* * p< Calgary COPD & Asthma Program Asthma, COPD, chronic cough and smoking cessation education & spirometry Specialty clinics, primary care, community health centres, in-patients Certified Respiratory Educators 29 Next Steps Add new education topics Incorporate CDM Key Performance Indicators Implement process improvements to increase access Roll out Chronic Cough to primary care 30 10

31 Questions Living Well with a Chronic Condition 31 11

32 Self - Management Row Your Own Boat Presented by: Doris Listoe, Coordinator I identify no real or potential conflicts of interest to disclose 2 Definition of self-management Self-management relates to the tasks that an individual must undertake to live well with one or more chronic conditions. 3 Asthma/COPD Day, March 26,

33 Self - Management Self-management Tasks 1. To take care of your illness 2. To carry out your normal activities 3. To manage your emotional changes 4 Core self-management skills 1. Problem solving 2. Decision making 3. Knowing how to find and utilize resources 4. Forming partnerships with health care providers 5. Taking action 5 Row Your Own Boat Program 6 weeks, 2 ½ hours / week Small group format Peer led by volunteers and/or staff: Leaders have chronic condition or are caregivers Trained as per Stanford program Follow a carefully scripted course 6 Asthma/COPD Day, March 26,

34 Self - Management Row Your Own Boat Program Regular workshop offered for adults 18 years and over in English, Punjabi and Cantonese Adolescent in Transition workshop offered for transitioning youth (ages 15 25) and separate workshop for parents / caregivers 7 Be Your Own Boss* CSDMP was adapted by CDSMP Trainers and youth in the Edmonton area. Workshop adapted specifically for adolescents and young adults living with long term illnesses Separate workshop adapted for parents of adolescents with long term illnesses (*called Row Your Own Boat in Calgary area) 8 Objectives of program: Help participants gain self-confidence in their ability to control their symptoms Help participants learn the skills to manage their health problems 9 Asthma/COPD Day, March 26,

35 Self - Management Topics include: Goal setting Problem solving Using your mind to manage symptoms Medication management Healthy eating Exercise guidelines Communication Working with your healthcare professional Self-Management Toolbox 12 Asthma/COPD Day, March 26,

36 Self - Management Core Assumptions People with different chronic diseases have similar self-management problems and disease-related tasks People can learn to take responsibility for the day-to-day management of their disease(s) 13 Core Assumptions Trained lay persons with chronic conditions can effectively deliver a structured patient education program Confident, knowledgeable persons practicing self-management will experience improved health status and use fewer health care resources 14 Row Your Own Boat Program* Utilization-Focused Evaluation Quantitative CDSMP Survey baseline, 6 month, & 1 yr Qualitative Participant Feedback Post-workshop surveys & letters Ongoing Communication with Leaders & Participants *Regular English Program 15 Asthma/COPD Day, March 26,

37 Self - Management Demographics Age Gender Percentage Age of Participants Gender Male 24% 0 45 or younger Fe m ale 76% Age n = 193 n = Demographics Chronic Condition Mood Disorders Pain Asthma COPD Hypertension Heart Disease Diabetes Arthritis n = 195 Percentage 17 Survey Results Baseline to 6 month surveys Less limitations to daily activities More self-confidence for managing chronic conditions Less health distress Less physical disabilities Better coping with symptoms 18 Asthma/COPD Day, March 26,

38 Self - Management Survey Results Effects maintained to 1 year Better coping with symptoms Less limitations to daily activities More self-confidence for managing chronic conditions 19 What participants valued most: Making an Action Plan / Problem solving Discussion with other participants Learning skills to better manage condition Learning how to work with your healthcare professional 20 Participants most important things learned : Making an Action Plan / Problem solving Discussion with other participants Learning I was not alone I can make a difference for myself Learning skills to better manage condition Be positive 21 Asthma/COPD Day, March 26,

39 Self - Management RYOB Contact information Regular workshop: Call 9-HEALTH Youth or parent workshop call: Marielle LeClair (Currently collecting names on a wait list) 22 Main references: What is Self-Management? Flinders Human Behaviour & Health Research Unit Lorig, K., Holman, H. Self-Management Education: History, Definition, Outcomes, and Mechanisms. Annals of Behavioral Medicine 2003, 26(1):1-7 McGowan, Patrick, PhD, Self-Management: A Background Paper. New Perspectives: International Conference on Patient Self- Management 23 Websites (includes extensive bibliography re. self-management) 24 Asthma/COPD Day, March 26,

40 Self - Management Questions / Comments? Questions 25 Asthma/COPD Day, March 26,