Ko Awatea has published a guide to enabling self-management support which describes programme options to deliver this type of support and the patient, clinician and service activators that enable these options.
The guide, Enabling self-management support, is based on learning from Ko Awatea’s Manaaki Hauora – Supporting Wellness campaign, which aimed to provide self-management support for people living with long-term conditions in Counties Manukau.
The area has over 67,000 people living with long-term conditions, more than a quarter of whom have two or more co-existing conditions.
The Manaaki Hauora – Supporting Wellness campaign covered 16 collaborative teams in different settings and clinical contexts, each of which worked towards a unique aim that contributed to the overall campaign goal. Ten of the teams, whose projects demonstrated the greatest reach and impact, are featured in the guide.
Self-management support options that demonstrated reach and impact in the Manaaki Hauora – Supporting Wellness campaign include the use of peers to engage with and support patients, personalised self-management support, health passports, the use of health coaches, generic and condition-specific group-based self-management support, group care planning, and ongoing support.
These options work well when the patient, the clinician and the healthcare system are activated.
“We identified listening, offering patients a choice of options, providing language- and culture-specific support, setting self-identified goals, service coordination, and developing peer-professional partnerships as effective patient activators,” says Diana Dowdle, delivery manager for the campaign.
To activate clinicians and healthcare teams, we need to provide training and coaching for staff to practice self-management support, enable multidisciplinary teamwork by using shared care plans and holding regular multidisciplinary meetings, provide access to resources, build relationships with clinicians, and establish effective referral and screening processes, she says.
The campaign also identified six system-level enablers which must exist in complement with factors that activate patients and clinicians to establish and deliver self-management support services that work well and make a difference for people with long-term conditions.
“The support of senior managers to address barriers is important, as is making resources available. The use of co-design and collaborative methodology provides quality improvement teams with a framework for ensuring that services and resources meet the needs of patients and their families and putting improvement initiatives into practice. Quality improvement project teams also need passionate leadership, and they are more likely to succeed if staff turnover is low during the project period or succession planning is in place,” says Ms Dowdle.
Enabling self-management support is available for download from the Ko Awatea website.