PCP Integrated Chronic Disease Management - Case study BHSM
Details of PCP contact
Name of PCP /Central West Gippsland PCP
Contact Person / Liz MeggettoPosition/Title / Projects Coordinator
Phone No. / 03 5127 9159
Email Address
/Identified Partners
Partner Organisation / Roles and responsibilities with regard to the project / Contact person details(name, position)
Latrobe Community Health Service (LCHS) / Provide Chronic Disease Self- Management Courses and information to clients with long term health conditions. / Nicolina Lowe, Karyn Thomas and Robert Metcalf (Latrobe Community Health Service Care Coordinators)
West Gippsland Healthcare Group (WGHG) / Provide Chronic Disease Self- Management Courses and information to clients with long term health conditions. / Kate Palmer (Community Allied Health Manager)
Wellington Primary Care Partnership (WPCP) / Provide ongoing post training support at Wellington Better Health Self- Management Leaders Network meetings. / Angie Collins (Project Worker)
East Gippsland Primary Care Partnership (EGPCP) / Provide ongoing post training support at East Gippsland Better Health Self- Management Leaders Network meetings. / Kelly Day (Acting Executive Officer)
Central West Gippsland Primary Care Partnership (CWGPCP) / Provide ongoing post training support to Central West Gippsland and facilitate BHSM Leaders Network meetings. Provide training, mentoring and expertise on relevant topics. / Liz Meggetto (Projects Coordinator)
Case Study Title /
Taking a collaborative approach in self-management support.
Summary/Abstract (200 words)
In 2009 the Stanford University Better Health Self-Management (BHSM) program was implemented in Gippsland as a means of increasing self-management capacity of CDM workers.Key long term outcomes have been thedevelopment of a sustainable BHSM program as part of the Early Intervention in Chronic Disease initiative at LCHS, and as part of client chronic disease management at WGHG.
Key outcomes over the last 12 months that have built on the quality of the program to date. These have included;
•Piloting the BHSM Leaders Manual at WGHG and LCHS
•Embedding an extensive, best practice evaluation methodology and data collection process for the BHSM program
•Astrong partnership has been forged between CWGPCP and LCHS Primary Intervention team.
•Facilitation of an annual forum to provide clients with follow up support, as well as gain medium-long term health improvement measures from past clients.
This project has successfully contributed to the improvement of client outcomes and improved their ability to self-manage their chronic conditions. It has also increased CDM workers ability to plan, deliver and evaluate the course to capture the improvements that their clients experience as a result.
Future work will look at the integration of the Interdisciplinary Referral Tool (IRT) in the care coordinators daily operations as well as implementation of electronic care planning for clients with chronic diseases.Background
Name of Project / Better Health Self-Management course continuing quality improvement.Target client group / Health Professionals working collaboratively to benefit clients living with long term health conditions and/or their partner/carers or other interested family members.
DHS ICDM expectations
2012-13 / Developing local service systems (focused on a common client cohort) that provide coordinated, best-practice clinical care and support for self-management. This work should (where appropriate):
o consider continuity of care and the provision of proactive and ongoing support;
oclearly articulate communication and information sharing arrangements within and between agencies (including feedback and communication with general practice and relevant private providers).
oextend the breadth and depth of the ICDM network across the partnership or agency
Background / In 2007 the state-wide Self-Management Mapping Survey highlighted a deficit both in the skills base and in organisational support for the practice of chronic disease self-management and a regional solution was devised. A training plan was established to build the capacity of staff delivering services to clients with chronic diseases, by Gippsland ICDM Workers in 2008.
In July 2009 the Training Follow-up Survey found that the project delivered on building the capacity of the Gippsland health practitioners to provide Self-Management support for clients with a chronic disease. This was a major deliverable for the 4 Gippsland PCP’s Strategic Plans for 2006-2009, and 2009-2012. This work was selected to continue into the PCPs bridging year of 2012-13.
The last twelve months have seen a clear focus on sustainability through the pilot of the BHSM manual.
Objectives /Specific objectives over the last 12 months were to:
Facilitate collaborative communication, information sharing and capacity building arrangements within and between agencies.
Continue to improve evaluation process of the BHSM course in accordance with best practice
Provide follow up client support through the facilitation of a BHSM annual forum, November 2012
Conduct a 12 month BHSM Manual pilot to build a consistent, coordinated approach to the BHSM program set up/delivery/marketing/evaluation catchment wide
Expand the BHSM Manual roll out Gippsland Wide
Promote the work of this project and the BHSM program to other service providers (ICDM Networking forums).
Describe the project and evaluation methodology and approach
During the last twelve months delivery of the BHSM program has continued across the Central West Gippsland catchment area with collaborative communication, information sharing and capacity building arrangements within and between agencies. The evaluation processes have continued to be improved in accordance with best practice. Follow up client support has been provided through the facilitation of a BHSM annual forum for clients.A consistent, coordinated approach to the BHSM program set up/delivery/marketing/evaluation has taken place catchment wide, through the piloting of the BHSM user manual. Once this is completed the BHSM Manual will be rolled out Gippsland Wide.
Promotionof the work of this project and the BHSM program to other service providers has taken place through PCP ICDM Networking forums and plans have been developed for the next step in chronic disease care through the introduction of the Interdisciplinary Referral Tool (IRT) - see appendix.
Resources used during the project include:
BHSM Manual (LCHS & WGHG versions)
BHSM tools from Stanford University
Wagner Chronic Care Model
Arthritis Victoria Evaluation Tools
Survey Monkey data collection database
Arthritis Victoria Training Facilitators
Continuous quality improvement strategies employed:
The BHSM Leaders Manual (see appendix) was developed by CWGPCP and LCHS, with the support from WGHG and the Stanford Patient Research Centre. The manual is designed to help Leaders deliver Self-Management courses in a coordinated, streamlined and efficient approach. It covers every aspect of course delivery from the initial steps of planning through to the final steps of evaluation and reporting. It is hoped that this manual will allow Leaders to take a consistent approach to how they plan, deliver and evaluate BHSM programs within their agencies. The manual is currently undergoing a pilot period within LCHS and WGHG. The manual will be made available to all of Gippsland early 2014.
Project integration with other areas of PCP activity:
The project was integrated though all key areas of the PCP portfolios. Service Coordination, IHP, and ICDM were integrated by providing training and networking opportunities around care coordination, self-management and evaluation. The Expanded Chronic Care Model emphasised the importance of the interaction of these three elements to build supportive and empowering environments for optimum chronic illness care.
The implementation of the IRT within the LCHS CDM team has demonstrated best practice client care through its ability to deliver improved care coordination for clients with chronic disease, through facilitating a consistent approach to service coordination.
Communication strategies employed:
Gippsland PCP ICDM Coordinators are committed to enhancing existing relationships between the CDM practitioners in and between their catchment areas through the existing BHSM Leaders Network. Informal information sharing has also taken place at training sessions, including the BHSM lead update training held in March 2013 which was attended by 15 Gippsland BHSM facilitators. The PCP ICDM workers meet regularly throughout the year to communicate on the agency staff’s behalf. The involved agencies have reported this to be more beneficial to them.
Engagement strategies employed with General Practice:The General Practices (GP) were engaged through the promotion of the programs in the Gippsland Medicare Local newsletters. A promotional presentation to the Practice Nurse Managers is planned for 2014.
The BHSM manual includes a GP feedback letter, based on the best practice GP Feedback form developed by WGHG in consultation with Baw Baw GPs as part of the WGHG PDSA project in 2011. This one page letter is provided to clients GPs after completion of the course (if client consent is given).
Brochures and flyers are dropped to all GP clinics in Latrobe by the BHSM Volunteer Leaders.
At the completion of the BHSM course all participants are encouraged to write a letter to their GP information them of the BHSM program and their own personal experience. One such letter can be seen in the ‘Client Vignette’ section.
Evaluation methodology and approach:
Over the previous 12 months (2011-2012) the BHSM leaders were provided with training in evaluation processes and data recording systems. The project also re-developed how the BHSM course is evaluated to ensure it is being rigorously assessed in accordance with best practice. The revised methodology (see appendix) consists of process evaluation as well as impact/outcome evaluation. Both the process and impact/outcome evaluation components were comprised of qualitative and quantitative data collection.
This re-developed evaluation has been embraced by the BHSM leaders and has been integrated seamlessly into their program delivery.
The 6 week BHSM course is evaluated using the Stanford pre & post self-efficacy evaluation tool on a 10 point likert scale (Impact/outcome evaluation). The coordination and delivery of the course is assessed using the Arthritis Victoria Course Evaluation including likert scale questions and open answer questions, course and client numbers are also recorded (process evaluation).
The follow up evaluation is used to find out what clients have retained from the 6 week course they participated in earlier in the year. It is conducted at the beginning of the annual forum (held at the end of each year). The BHSM forum is evaluated using a standard process and feedback evaluation tool. Forum numbers are also recorded (process evaluation).
Results
Service improvement and innovation / Collaboratively, with CWGPCP the WGHG version of the BHSM manual was developed and began its 12 month pilot phase in April 2013.The number of BHSM courses ran in CWG in 2009:2, 2010:2, 2011:6, 2012:7 and 2013;6. This shows a continued commitment to delivery of the course each year.
Other innovative service improvements have been the inclusion of an annual BHSM follow up forum for clients to refresh their knowledge. This has also been an opportunity for the CDM workers to evaluate the effectiveness of the BHSM course in the long term, ie; have people been able to sustain their improved self-management practices?
To improve health practitioners’awareness of the BHSM course, including referral pathways, a marketing presentation is made 6 monthly at the ICDM provider networking forums. These forums as facilitated by the CWGPCP to allow agencies across CWG to come together and learn about what services other agencies offer and how these can be accessed. The forums are well attended with an average of 30 practitioners from approximately 20 different healthy and community services in CWG. Forum feedback shows that the forums lead to an increase in practitioner knowledge of local services. This has provided an ideal platform to promote the BHSM courses as all practitioners in attendance work with clients with chronic and/or complex conditions.
Outcomes /Five of the six project objectives were met, with the only objective not met being the roll out of the BHSM manual Gippsland wide. This roll out is planned for early 2014.
The BHSM course was presented at 2 ICDM provider forums, where CDM coordinators were able to share the fantastic client outcomes with a range of CWG agencies.
The 2nd annual BHSM forum was held for clients, the forum received positive feedback from all attendees.Evaluation of the BHSM sessions has become an integrated part of the CDM leaders work. This shows that the evaluation training and mentoring conducted in 2011-2012 has been sustained and embedded into the CDM workers everyday practices.
As a result of the reviewed evaluation process, the BHSM course is now a gold standard example of evaluation within the LCHS Primary Intervention team. This was so highly regarded by the LCHS Primary Intervention Manager that the CWGPCP ICDM Coordinator was asked to facilitate the evaluation component of their annual planning day.
BHSM user manual has been developed and currently in its pilot phase, due to be finalised late 2013.
For the financial year 2012-2013, 6 BHSM courses have been ran by LCHS, improving the self-management of 67 clients with chronic diseases.
Evaluation results from the LCHS BHSM courses run in 2013:
Using the Stanford Self Efficacy for Managing Chronic Disease six item scale;
100% of participants have increased their self-management skills as a result of attending the course.
On average, ALL participants:
- Increased their confidence and understanding in managing their condition/s resulting in a decreased need to see their doctor, on average, by 35%
- Increased their confidence to manage their symptoms with strategies other than just taking medication, on average, by 45%
- Increased their ability to manage fatigue, on average, by 46%
- Increased their ability to keep pain and discomfort from interfering with their daily tasks, on average, by 37%
- Increased their ability to stop other symptoms or health problems interfering with their daily tasks, on average, by 43%
- Decreased their emotional distress caused by their condition/s, on average, by 44%
- Overall the average total self-efficacy improvement was 42%.
“After doing the course I have a far better understanding of my condition and how to manage it.”
Using the Arthritis Self-management program questionnaire,
100% of participants reported:
- the information easy to understand.
- the topics mostly useful or very useful.
- Making positive changes to their lifestyle (5% planning to implement changes soon, 33% made minor changes, 51% made significant changes and 11% made dramatic changes).
- that their knowledge had been improved by the course.
- agreed the program was a good investment of their time.
Annual follow up evaluation of past BHSM clients
The follow up evaluation is used to find out what information and skills clients have retained from the 6 week course they participated in earlier in the year. 17 people completed the follow up evaluation. 30% had completed the course in the past 6 months and 70% had completed the course more than 6 months prior to the forum.
- 94% of respondents stated the 6 week course has improved how they manage their health
- 100% of respondents stated that attending the 6 week course was a good investment of their time
- 88% of respondents have been able to keep up the changes after the course finished
Past BHSM client Forum
At the end of 2012 a BHSM forum was held. All clients who had participated in the 6 week program were invited to attend. 25 people attended the forum.
- 100% of attendees agreed or strongly agreed that the forum:
- Reinforced learnings from the 6 week course
- Reinspired them to continue to self-manage their conditions
- was a good investment of their time
Client experience vignette / On completion of the 6 week course many clients write letters of support about the program. One such experience is summarised below:
Dear Doctor,
I have recently completed the ‘Better Health Self-Management Course’ at Moe Community health Centre.
Along with the book ‘Living a Healthy Life with Chronic Conditions’, I have found it to be a great help as I deal with my own Heart condition and other associated conditions.
The course suggests strategies to achieve the best results. It provides contact with other people who have Chronic Conditions, so no one needs to feel that they’re ‘doing it alone’.
The team leaders are highly qualified to run these courses and help with the motivation required.
I recommend classes such as these for anyone trying to live a better life whilst dealing with a Chronic Condition.
Kindest Regards,
LCHS BHSM Client.
Status and sustainability /
A number of participants who undertake the 6 week course are then motivated to become leaders themselves, which supports the sustainability of the paid leaders and their capacity to deliver the course.