Dr Carol Atmore. Clinical Director Long Term Conditions Ministry of Health Dunedin

Transcription

1 Dr Carol Atmore Clinical Director Long Term Conditions Ministry of Health Dunedin 14:00-14:55 WS #111: Patient Self Management in a Technological Era 15:05-16:00 WS #122: Patient Self Management in a Technological Era (Repeated)

2 Patient Self management in a Technological Era where do you start? Dr Carol Atmore Clinical Director, Long Term Conditions Ministry of Health, New Zealand

3 Overview Self management and why is it important Technology enabling good health - examples Obesity, weight management & how to help

4 Wagner s Chronic Care Model

5 Self Management..greater control in looking after themselves, and in partnership with health professionals and community resources. Key features: Patient and whānau centred Empowering Coaching Navigation Health Literacy

6 Evidence: Increases sense of wellbeing Improved health outcomes Decreased secondary care use Examples: Flinders, Partners in Health Stanford, Living a Healthy Life Average NZer s has 40 mins with GP per year

7 Self management currently

8 Self Management in future Wider Health and Social System Immediate Care Team Relationships Patient and Whānau Information Technology Processes

9 Patient Portal rate of uptake - December 2016

10 Portals where to from here Good uptake by practices- 45 % offer portals Patients love them RNZCGP survey portals improve service Next steps: Increase patient enrolments, functionalities Secure messaging Open notes Website:

11 patientportals.co.nz

12 Some projects MOH involved in SMS4BG Beta Me Mental Health Diabetes projects Tairawhiti Northland Supporting self management project

13 SMS4BG National Institute of Health Innovation (Auckland) and Waitemata DHB Text message based self management program RCT 366 patients with poor diabetes control Targeting Maori, Pacific and rural NZers

14 Findings to date 96% messages useful 95% good way to deliver program Thank you for your support. I 96% culturally appropriate have found it immensely 98% age appropriate helpful. 81% impacted on their management 76% improved glycaemic control 2% choose to end messages early

15 HRC Beta Me Prof Diana Sarfati (Otago) and Melon Health Midlands and Wellington, 3 years RCT pre/diabetes (usual care or care + tech) Adding app for coaching, goal setting, private social networks, health hacks, data integration, resource library, modular education programs and video appointments

16 Mental Health Diabetes projects Rationale: Improving mental health and wellbeing has the potential to improve both quality of life and glycaemic control The projects aim to improve access to primary mental health services for people with poorly controlled diabetes Situated in Northland and Tairāwhiti DHBs Malatest evaluating the project

17 Tairawhiti approach - Targeted Māori or Pacific person with poorly controlled Diabetes (HbA1c level of 64mmol/mol or more) and an indication of potential mild to moderate mental health issues: poorly controlled diabetes low/non-attendance low/non-adherence with medication regimes living in socially isolated situations pressing issues (wider than health) 17

18 Before No interest in preparing meals Tairāwhiti a case study Mark (in kaiāwhina programme): Now three months later Engaged in sandwich club Difficulty shopping Little contact with whānau Overweight (127kg), No exercise Uncontrolled diabetes (HbA1c 86) Felt hopeless Wanted to lose weight and sort out his lounge. Kaiāwhina supermarket tours, gaining confidence in buying right food within his budget Losing weight (125kg) Joined lunchtime walking group Reducing HbA1c (now 75) Feeling happier, more self confident Has a plan towards new lounge suite.

19 Northland DHB Three programmes the tamariki, the rangatahi, the adult programme Tamariki programme Whānau with child newly diagnosed with T1 DM in previous year Whānau with Child with poorly controlled T1 DM high HbA1c Kaiawhina key; co-ordinates and supports tamariki and their whanau

20 Early feedback Newly diagnosed whānau had a lot of questions about T1DM, and welcomed the opportunity to meet other whānau to share experiences. Most whānau found the kaiawhina to be a lifeline in providing information, or finding out who to talk to with questions. Whānau from the poorly controlled group wished they had the opportunity to access information and support from the kaiawhina early in their diabetes journey instead of later, when they were struggling.

21 Rangatahi programme Innovative ways to engage with youth with diabetes A series of workshops delivered by the Company of Giants theatre group The workshops aim to be fun and provide clinical and social support to rangatahi with diabetes. Three cohorts of young people, third group just starting

22 Adult programme Mixed model including workforce development, group sessions, e therapy and specialist support in primary care

23 Supporting self management project Health Literacy New Zealand and Health Navigator New Zealand working with 8 practices to develop tools, resources and training to enable people with LTC to self manage Training modules being developed, practice teams supported to test modules Modules include care planning and health literacy 23

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25 What we know Over 165,000 health apps! Around two-thirds of Kiwis aged 15 and over now own a smartphone million smart phone users in NZ Important opportunity, but very little guidance available and very few clinicians recommending apps

26 Acknowledgements: Health Navigator Health Apps

27 App quality assessment

28 View online at: Publication

29 Example

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31 Where to next? The known knowns collecting and translating good ideas The known unknowns identifying gaps in understanding in NZ context and testing solutions The unknown unknowns looking out for disruptive ideas that can improve self management

32 Sharing the learnings MOH website Conferences, Annual workshop for PHO and DHB Long Term Conditions teams What methods would work for you?

33 Weight management and raising healthy kids

34 The causes of obesity are complex Behaviour Genes Environment

35 Childhood obesity in New Zealand Maori vs. non-maori: arr=1.59 ( ) Pacific vs. non-pacific: arr=3.87 ( ) Most deprived vs. least deprived: arr=3.02 ( ) *least deprived arr= adjusted rate ratio NZ Health Survey 2015/16

36 Adult obesity in New Zealand Maori vs. non-maori: arr=1.69 ( ) Pacific vs. non-pacific: arr=2.38 ( ) Most deprived vs. least deprived: arr=1.70 ( ) *least deprived arr= adjusted rate ratio NZ Health Survey 2015/16

37 Perceptions of Children s Weight Under weight Healthy weight Unhealthy weight Very unhealthy weight

38 Perception of adults weight Adult perception Perception of weight was influenced by the respondents' weight status and gender Obese Under weight Healthy Weight Overweight Under weight Healthy weight Over weight Class I Obesity Class II Obesity Class III Obesity Harris et al. International Journal of Obesity (2008) 32, ;

39 What to do?

40 STEP 1 - Monitor Growth in children Regularly measure height and weight to calculate BMI using ageand sex-specific growth charts Weight in adults Regular weight measurements (and a height, if this is not already known)

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42 Monitor Assess Manage Maintain

43 Tackling Obesity No single intervention need to address the obesogenic environment as well as a life-course approach. Three critical time periods in the life-course: preconception and pregnancy infancy and early childhood older childhood and adolescence. WHO: Report of the Commission on Ending Childhood Obesity

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45 1. Monitor Growth NZ-WHO Growth Charts

46 Intervene Early Intervene here A change of centile channel is an indicator that the child s growth trajectory needs to be watched and an early intervention is likely to be more straightforward and effective Z score (SD): st Centile th Centile Acknowledgement: Dr Pat Tuohy

47 My child exercises every day of the week with horse riding and running and as you should know muscle weighs heavier than fat. If you look at the rest of his activities and family members then his natural weight and body size is large. Having the conversation. There are much fatter children out there and my son isn t that bad! He is very short for his age and I feel he will even out as he grows. Gillison et al Public Health Nutrition 2013: 17(5),

48 Our findings highlight a mismatch between health professionals perceptions of how difficult these discussions are and reality, in that most parents are receptive to the information if delivered well. Dawson et al. Pediatr Obesity, 2016

49 Having the conversation. Show concern, rather than professional detachment Be confident and caring Allow time for questions Provide written information to parents Value the child and respect the parents The most important aspect of these conversations is to make the experience positive and nonjudgmental The style in which this feedback is provided appears to be less important. Mikhailovich & Morrison, Journal Of Child Health Care (4) Dawson et al. Pediatr Obesity, 2016

50 2. Assess History Pregnancy (obesity, diabetes, birth weight) Feeding (breast, bottle weaning) Early weight trajectory Current eating habits Developmental milestones Physical activity (& screen time) Sleep (enough of it, snoring) Medications (steroids) Family Examination Watch the child walk into the room Talk to the child Growth chart (height, weight, BMI) Dysmorphic features Blood pressure

51 3. Manage Food Activity Behavioural Strategies Nutritionally balanced diet Appropriate portion sizes Family meals Slower eating Avoid snacking Play and physical activity Reduce screen time (esp TV) Sleep time Infants: Toddlers: Preschoolers: Change what is available at home Keep treats out of site Increase easy accessibility to healthy options

52 Tips

53 4. Maintain Review opportunistically Accept setbacks maintain positivity Encourage family activities and sport Link with local Regional Sports trust Encourage cultural initiatives e.g. Kapa-Haka Support communities Healthy Families NZ Iron Maori Community gardens/kai Atua

54 Childhood obesity health target Raising Healthy Kids A new health target has been implemented from 1 July 2016: By December 2017, 95% of obese children identified in the Before School Check (B4SC) programme will be offered a referral to a health professional for clinical assessment and family based nutrition, activity and lifestyle interventions. The target was selected as the B4SC focuses on early intervention to ensure positive, sustained effects on health. The target defines obesity as a BMI above the 98 th centile on the NZ-WHO growth chart.

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56 Quarter 1 Quarter 2 Quarter 3

57 Raising Healthy Kids Target B4SC Staff Primary Care Staff Measurements Having a conversation Referral GP/PN visit By December 2017, 95% of obese children identified in the Before School Check (B4SC) programme will be offered a referral to a health professional for clinical assessment and family based nutrition, activity and lifestyle interventions. Healthy Lifestyle Support Services Feedback

58 Commonly selected goals Increase in fruit and vegetables Less junk food, more healthy snacks Decrease sugary drinks Drink more water Proportionate hand-based portion sizes Active play at least 60 minutes each day

59 Adult expectations of weight loss Foster et al middle aged obese women BMI > 35 Their goal weight loss Dream weight Happy weight Acceptable weight Disappointed weight Dream Happy Acceptable Disappointed % of baseline weight lost 38% 31% 25% 17% Foster GD, et al. J Consult Clin Psychol 1997;65:79-85.

60 Weight loss at 48 weeks No one achieved their dream weight loss Foster GD, et al. J Consult Clin Psychol 1997;65:79-85

61 Realistic expectations Most people cannot achieve their ideal weight, even with the most aggressive approaches Most cannot maintain losses >15% of initial body weight without surgery Loss of 5% to 10% of body weight is realistic, and associated with significant health improvements

62 Success What people think it should look like What it really looks like

63 Overweight healthcare professionals? Medscape Physician Lifestyle Report, 2016

64 What do patients think? Survey of 600 overweight or obese adults Patients estimation of doctors weight Trust* advice on weight control Normal (n=118) Overweight (n=312) Obese (n=170) 76% 85% 85% Trust advice on diet 77% 87%** 82% Trust advice on physical activity 79% 86% 80% * Rated a great deal or a good amount of trust **Significantly greater than normal weight (p=0.04) Bleich et al (2013) Preventive Medicine 57:

65 Conclusion The solution to obesity is multi-faceted Health care professionals have an important role to play Although the conversations can be difficult, they are worthwhile