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Tuesday, May 15, 2012

New Health Council Report - Self-Management Support (SMS) for Canadians with Chronic Conditions

Patrick McGowan, PhD, is a professor at the University of Victoria - Centre on Aging, and Director of Self-Management Programs. He has been implementing and researching SMS programs for 26 years and trains health professionals to use SMS strategies. Patrick participated on the Expert Advisory Panel in the development of this report.
This report really does represent the collective wisdom on self-management support. Being relatively new in Canada (less than 25 years), there has been confusion of what it is and how it is implemented. This report provides a good description of what is known about SMS. It highlights emerging, promising, and leading practices, and makes a few clear recommendations.
Why is SMS important?
SMS is important because people with chronic health conditions usually need education, coaching, and other interventions to help them gain knowledge, skills, confidence, and motivation to manage their condition. SMS can take place at three levels: the patient and family level; the primary health care provider level; and at the health system manager and policy-maker level. Self-management support is an integral component of the Chronic Care Model and should be anchored in primary health care.

SMS delivered to Groups and Individuals  
At the patient and family level, SMS programs tend to be more successful if they are integrated into primary health care, address multiple chronic conditions, and involve informal caregivers. Accessibility is enhanced if the programs can be delivered on a one-to-one and group basis, can be delivered in the home and in community settings, are available in person (e.g., peer coaches), by telephone or online, and are targeted to underserved populations.  Some SMS programs are delivered by volunteers, while others are led by both health professionals and volunteers. It is important to acknowledge that a single model for self-management support is unlikely to reach all people and a range of programs will be needed. The Health Council of Canada has established criteria to categorize innovative practices as emerging, promising, or leading practices. The Stanford Chronic Disease Self-management Program, currently offered in most Canadian provinces and territories, was designated a LEADING PRACTICE program.

SMS provided by health providers
Health care providers can deliver SMS by using behaviour-change strategies as part of their regular practice. Various models are available, such as: The 5As, The Flinders Program, Motivational Interviewing, and each includes shared decision-making between patients and health care providers and strategies to help patients develop skills. Shared medical appointments (a.k.a. group visits) is another SMS strategy. These are led by health professionals and combine clinical care, self-management support, and peer interaction. Group visits also provide active follow-up and link patients to evidence-based community programs. The report found that primary health care providers need more focus on learning and using these strategies in their practice. The Health Council of Canada designated the 5As model a PROMISING PRACTICE.

Can SMS be delivered online?
Online SMS programs currently exist and hold promise as a method of delivering various kinds of SMS, but there are concerns about a “digital divide” between patients and caregivers who are able to use this technology effectively. It would be a great way for people with chronic conditions to share information, provide emotional support to one another and communicate with health providers. However, as it is still early days in the evolution of online tools for self-management of chronic conditions and questions and concerns persist.

A System-Wide Approach to SMS
In the UK, a group SMS program called the Expert Patients Programme (a version of the Stanford CDSMP) had been widely delivered for some years, but the program was achieving only modest results. Therefore, to create a whole-system approach, the UK Co-creating Health initiative was undertaken. It is an innovative approach providing a systematic linkage through primary health care: clinicians refer patients to the community-based self-management programs, patients are engaged in process redesign with their primary health care providers, and their providers receive advanced training in communication tools and techniques to support the self-management process. The Health Council designated Co-Creating Health: An integrated approach to self-management support as an EMERGING PRACTICE.

SMS Policy in Canada
Canadian governments have made forays into building SMS into their chronic disease strategies; some have gone further and are integrating information and tools for SMS into primary health care, to embed the principles of SMS across their health systems. If successful, patients will have a better quality of life, primary health care providers will have the tools and time to help patients succeed, and resources that once went to treating preventable complications can be reinvested in a range of other critical services that support a healthy population.  The opportunity to invest in SMS at the individual and population health levels holds the promise of big dividends in improving the health of Canadians and the sustainability of our health care system.
The Health Council recommends that health care systems across Canada move actively to provide self-management supports in a more systematic way by:
1)    creating an integrated, system-wide approach to self-management support;
2)    enabling primary health care providers to deliver self-management support as a routine part of care;
3)    broadening and deepening efforts to reach more Canadians who need self-management supports; and
4)    engaging patients and informal caregivers as a key part of any systematic approach.

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