As part of a multidisciplinary team, a general practice team needs to encourage people to attend self-management support programmes and groups, and follow up and connect with community providers as needed. Clinicians also can gain the support they need to share control with patients. People with LTCs will have different levels of engagement with a multidisciplinary team, depending on own individual needs. Care planning Personalised care planning is a tool that enables people with LTCs to self-manage. It encourages them to choose their treatment goals and to work with clinicians to identify their specific needs for treatment and support. Together the patient and clinician make decisions, set goals and undertake action planning, with the aim of working out priorities agreeing realistic objectives, solving problems and identifying sources of support. With effective care planning, some aspects of the patient’s physical and psychological health and their ability to manage their condition can improve (Cochrane 2015). Figure 1 below describes the care planning approach developed and tested at Alliance Health Plus in 2013 (Flanagan et al 2014). Another tool available is the Common Core Principles to Support Self Care – a self care training manual and a questionnaire that can be used to help an individual take responsibility for their own health and wellbeing (Skills for Care 2015). Figure 1: Alliance Health Plus Self-management Practice Model 2013 Source: Flanagan et al (2014) Figure 2 sets out six steps in the care planning process. Figure 2: Six steps in care planning Care Planning ABCs’ created by Health Navigator NZ. More resources visit Table 2: ABCs of care planning for optimising care Assess Balance and agree Create Develop Early warning signs Follow-up Assess risk Balance patient and clinical perspectives Agree priorities Create a care plan and with wider team Develop skills Ensure patient understands their red flags and has a written action plan for earlier response Planned and proactive followup Assess medication concordance Optimise medical management Collaborative goal setting (patient’s choice) and action planning support network Blue card for COPD patients Chest pain plan, pain plan, etc Frequent calls / visits in initial phase (approximately 12 weekly) Assess capacity Based on shared decision making and agenda setting IT platform to enable 24/7 access to care plan (by HPs and patient) PHQ 2 screen for depression and anxiety Rescue meds at home – antibiotics ± steroids for COPD etc ACP conversations as appropriate
Source: J Bycroft, Health Navigator NZ, 2015. Appendix 2: Examples of current programmes and approaches Self-management groups Piki te Ora – Six-week Stanford chronic disease self-management programme at Whanganui DHB. Contact: Anne Kauika, email anne.kauika@wrpho.org.nz www.wrpho.org.nz/documents/self_management_workshop.pdf Kia Kaha – Self-management for mental health incorporating peer support. Led by East Health. Contact: Leona Didsbury, Senior Health Psychologist and Self-Management Trainer, East Tamaki Healthcare, email Integrated approaches Choose Change –- Auckland Region Sports Trusts (led by Harbour Sport) lifestyle intervention for people with prediabetes. Contact: Jay Martin, Active Communities Manager, email Healthy Village Action Zones – an innovative framework for collaborative action by key stakeholders and Pacific communities, joining together to improve health outcomes for Pacific peoples. Contact: Faimafili Tupu, Healthy Village Action Manager, tel 09 630 9943 ext 26470 or email Energize Practices – primary care practice staff supported to a variety of methods to encourage inpractice healthy lifestyle coaching. Led by Waikato Sports Trust Contact: Stephanie McLennan, email stephm@sportwaikato.org.nz At-risk individuals programme Counties Manukau DHB comprehensive programme of wraparound services for people with complex/multiple long-term conditions Counties Manukau Self Management Support Campaign Manaaki Hauora Contact: Diana Dowdle, email Diana.Dowdle@middlemore.co.nz