Self-management is about patients becoming the managers of their illness, with vital input provided by their health care team. When patients begin to make informed decisions about their care and engage in the behaviours which have a positive impact on their health, they are likely to see an improvement in their health. They become active rather than passive participants, taking responsibility for strategies regarding disease management, handling emotional impacts and making changes to daily life.

Although many patients are aware of the impact of their actions on their health, they may choose not to engage in healthy actions. This reluctance may be due to due to other knowledge gaps, poor understanding, low motivation, poor problem-solving skills or low self-efficacy.

In diabetes for example, treatment may take the form of dietary control, regular exercise and appropriate use of medication. The patient needs to be responsible for these actions in order to maintain their health.

They may be prevented from self-managing diabetes however if they don’t fully understand what makes their blood sugar levels go up or down, and what to do to prevent damage to their nerves and blood vessels. While health practitioners frequently focus on diet, exercise and medication, patients also need to develop an understanding of what is going on in their body, including the relevant causes and effects.

Janette Gale, founder and CEO of HealthChange Australia, argues that without this level of understanding, patients can’t truly self-manage their illness. Information alone isn’t enough, as patients may in fact receive far too much information. Information instead needs to be tailored to the patient. They need to have a knowledge and understanding of their illness, an appreciation of why the clinical knowledge is relevant, an awareness of how to avoid the avoidable consequences of the condition and an appreciation for how this might be personally beneficial.

While many practitioners provide information about illnesses to their patients, they don’t recognise that what they’re providing and how they are providing it is not always effective.

HealthChange Australia is an organisation which implements person-centred practice change in health service delivery organisations. Their focus is on training practitioners, case managers, government departments, insurers and healthcare organisations to provide the information required by patients in a way that the patients can use it to self-manage. They teach practitioners how to align their consultations with the self-management and behaviour change needs of their patients. They’ve trained over 10,000 people in enabling patients towards self-management during the past ten years.

We spoke to Janette to gain a better understanding of how treaters and case managers can utilise skills in self-management support to treat their patients.

WHAT OCCURS IN THE CURRENT APPROACH TO HEALTH CARE THAT DIMINISHES SELF MANAGEMENT?

Over-treatment by doctors remains a problem, as highlighted in a September 2015 episode of ABC’s Four Corners. Unnecessary treatments frequently occur as patients want a ‘quick fix’, with the opportunity for self-management barely considered. The challenge is in getting patients and medical practitioners to ‘buy in’ to self-management. They may not only avoid the cost of unnecessary medical treatments, but they may also gain better long term results. 

In cases of cardiac disease for example, there may be numerous tests undertaken quickly which indicate that an operation may correct the issue – but the outcome of the operation may not be optimal. Both patients and doctors tend to be overly optimistic about the likely outcome. Rather than conducting an operation, effective self-management may yield better results. In the case of cardiac disease, this may involve actions such as an exercise and healthy eating plan and taking medications effectively.

One of the challenges in altering this medically focused approach is the fee for service structure currently in place, with practices incentivising quick consultations. This significantly reduces the amount of time spent on helping patients to understand the importance of self-management. Policy-makers may need to look at fee structures to ensure that there is an allowance made for self-management explanations being given to patients. 

When treaters are busy, ensuring that patients understand and enabling them to ask questions is often overlooked. Many treaters tend to be focused on the treatment alone, with patients placed in a passive situation. They’re told what to do without necessarily understanding why. Change, in these scenarios, becomes much more difficult to achieve.

Information which allows patients to have a clear understanding of their disease and how to manage it on a daily and long-term basis helps patients to make decisions about what they need to change in order to address their situation most effectively. 

Janette believes that patient or worker engagement in health is not currently successful within the rehabilitation system. “The way that interaction occurs doesn’t meet a human being’s needs for information. It’s about health literacy – their knowledge and understanding of what’s going on in their body and the system and how that might impact on them personally, and their knowledge and understanding of what they can do about it, and why that might be beneficial for them,” she said.

In addition to the benefits of taking action, further work also needs to go into people understanding the consequences of not taking action.

Janette believes that it comes down to the way health practitioners are trained. They need to learn to engage people on a human level and provide them with the missing information.

HOW CAN TREATERS BE TRAINED TO ENHANCE SELF-MANAGEMENT?

Many people think it’s too difficult to change the behaviour of physiotherapists or doctors, and they aren’t addressing the fundamental problem of how treaters interact with people.

When aiming for behaviour change in clinicians or case managers, Janette believes in the importance of getting people into a room so their thinking can be challenged, and colleagues heard. She finds it to be an important way of raising their issues and challenges. The training cannot occur didactically. It’s about changing practitioner behaviour and not just about providing them with additional knowledge.

HealthChange’s methodology uses the literature available on the subject but distils it down to a practical level for clinicians and health services. The training helps them to track through the needs of the patient in the sequence needed.

Their methodology is to provide:

1. A simple, evidence-informed, conceptual behaviour change pathway: to help service providers to quickly assess client or patient readiness to take action on recommendations.
2. A set of clearly defined Person-Centred Practice Principles: to operationalise person-centred care and communication and make these measurable.
3. A functional way of thinking about barriers to action and facilitators for change: to enable health service providers to recognise and understand the most common types of barriers to engaging in treatment recommendations.
4. A set of Essential Behaviour Change Techniques: to identify and address potential barriers to action when they are present.
5. A 10 Step Decision Framework to guide health service providers: to know when and why a patient or client is unlikely to adhere to recommendations and to apply the appropriate principles and techniques to help them to understand their conditions and treatment options; identify personal motivators; make fully-informed decisions; take actions, and self-regulate for improved outcomes.
6. A simple set of consultation tools: to guide categorise, clarify and document treatment, lifestyle and referral actions to be taken by patients or clients.
7. A set of skills development, quality assurance and capacity building tools and mechanisms: for frontline staff and organisations to assist, measure and track staff transfer of training into practice and to capture client behaviour change data for correlation with clinical outcomes.

SOME OF THE CHALLENGES FACED IN IMPLEMENTING CHANGE 

Janette has found that there is generally a progression of strategies used to address the problems of patient adherence to treatment and lifestyle recommendations, but many organisations still don’t have the answer because few fundamental changes are being made to the way that clinical health care is delivered by clinicians.

The standard progression of strategies is:

1.  
2. Give patients more information - Although this is necessary, education alone doesn’t tend to work well.
3. Discussion about self-management for patients – Again, this is necessary, but the conversation and methodology to give the responsibility, skills and information people need to self-manage is not integrated into health practitioner training in a way which enables it to transfer into clinical practice.
4. Motivational interviewing and other skills training for clinicians – This is a positive step, but much of this training does not align with clinical consultation needs and clinicians have difficulty using what they have been taught. This is just one skill required in a broader skill set and it doesn’t address health literacy needs very well.
5. Health coaching programs as an add-on to clinical interventions and as a population-based approach to lifestyle change – These are usually delivered by large service providers such as health insurers and commercial providers or by community health in conjunction with chronic disease management programs. Organisations have been finding it expensive to run specialised health coaching programs and difficult to fund, as well as requiring equipment, skilled people and systems, although usually these latter components are outsourced to the big providers. The results may not be strong enough to warrant it. 
6. Focus on delivery of self-management support for chronic condition self-management by patients via patient-centred care planning and care coordination – This is generally located in primary care and delivered by general practice nurses, public health community health workers and practitioners and also by health insurers/commercial service providers. Some still use the ‘health coaching’ terminology to do this. However, they focus on care coordination and navigation with a self-management focus. This is where the (public health) market is putting its funding currently. Primary care is at the centre of the approaches which have moved away from health coaching programs. There is a lot of training/upskilling of practice nurses currently happening in particular, aimed at improving patient self-management in conjunction with care planning and care coordination.

Janette believes that the behaviour change ultimately needs to come from the health care professionals to encourage patients to engage in their own recovery. Health coaching programs which add on self-management support are never going to be as effective as they aim to be whilst the rest of a patient’s care team are still using a traditional approach. The fundamental problem is that the way that clinicians are taught to deliver information is not conducive to supporting self-management, if they are taught about self-management at all.

While HealthChange can’t prove the difference which their methodology makes, they have anecdotally received reports of enormous outcome improvements. The challenge is that most organisation evaluate their programs and not the methodology in place behind it.

PRACTICAL BENEFITS OF ENGAGING THE END USER (PATIENT OR WORKER)

The benefits of enabling self-management in patients are enormous. When given an understanding of their condition and the factors which can have an impact, patients are more willing to take charge of their recovery. They may change their diet, alter their habits, be more willing to seek treatment, and generally be more proactive in their own health care.

If treaters are trained to further enable this change in patient psychology, the health outcomes are likely to be better.

Motivational interviewing has been gaining some traction among insurers and rehabilitation specialists, with training undertaken by some organisations, such as the TAC in Victoria. However such approaches are not widespread.  

It is easier to tell than engage, however engagement can pay off in the medium to long term.

Further information about HealthChange can be found here.