Symposium 4.3

How can Divisions of General Practice support primary care in their efforts to engage patients in self-care.

A/Prof Larry Baker (USA/UK), A/Prof Michael Greco (Australia/UK), Lead Trainers for Advanced Development Program for Clinicians, Health Foundation Co-creating Health Initiative, CFEP Surveys, UK

Chris McAuliffe, Board President Brisbane South Division of General Practice, QLD, Australia
Leanne Wells, Acting Deputy CEO Australian General Practice Network, Australia
Vicki Poxon, CEO Brisbane South Division of General Practice, QLD, Australia

The management of chronic diseases among the Australian population, is placing an increasingly heavy burden on primary healthcare providers. Chronic Disease Management (CDM) programs have been developed and implemented by the Divisions of General Practice to strengthen primary care practitioners' involvement in chronic care by promoting best practice diagnosis and patient management programs. Further gains can be sought however when combining these programs with self management principles. Evidence has emerged from the UK and the USA which suggests that patients with effective self-management skills make better use of health professionals' time and have enhanced self care.

Leanne Wells will provide a national overview of the work being conducted by the Australian divisions of general practice with regard to chronic disease self management and prevention. Taking a case study approach, Vicki Poxon and Dr Chris McAuliffe will discuss what prompted a local division to integrate self care into all their programs.

A/Profs Michael Greco and Larry Baker will provide delegates with an insight into their experiences with the implementation of training schemes for clinicians in enhancing patient self-care/management in the primary care environment. They will share key insights they have gained into the clinician-patient interaction, specifically how to enable patients and ensure changes are sustained. Delegates will be assisted to identify hurdles that may need to be jumped, and be provided with insightful strategies to consider.

A question and answer session will provide the delegates with the opportunity to delve deeper into the topics discussed.

Laurence H. Baker, Ph.D., a clinical psychologist, provides training, coaching, and consultation in communication and leadership in health care. He is the Western Regional Consultant for the Institute for Healthcare Communication, a clinical Associate Professor of Medicine at the Oregon Health and Sciences University, and Director of Professional Development with the Client Focused Evaluation Program.

He trains doctors and medical staff in the psychological aspects of health care and has 22 years of clinical experience in primary care clinics, a chronic pain program, behavioral medicine clinics, and substance abuse treatment. As a Visiting Professor with the Royal Australian College of General Practitioners, Dr. Baker helped establish a national faculty for training doctors in communication techniques. Consulting with the US Veterans Health System, Dr. Baker led the development of both “Treating Patients with C.A.R.E.” and “Coaching for C.A.R.E.” programs to improve health care service among front line employees in the world's largest health system.

Dr. Baker conducts research and publishes on psychological features of medical illness, health care, and health resource utilization. Recent articles include, “Effects of a physician communication intervention on patient care outcomes” with Sandra Joos, David Hickam, and Geoff Gordon in the Journal of General Internal Medicine, 1996, “'What else?' Setting the agenda for the clinical interview” with Daniel O'Connell and Frederic Platt in the Annals of Internal Medicine, 2005. “Improving doctors' communication skills: teaching what is measured” with Michael Greco, Mark O'Brien, and Sarah Squire recently won the award for best poster at the European Association for Communication in Healthcare meeting in Brugge, Belgium 2004.

Keynote 2.1

Patient Perspectives on Key Public Health Messages:  Positioning Self Management Education, Physical Activity, and Weight Control Messages for Success.
Clinical and public health professionals have vested interest in fostering self management activities such as being physically active, losing weight, and attending self management education classes. However there is a sizable gap between professional understanding of the importance of these activities and patient participation in the activities. It is crucial to understand the perspectives of people with chronic diseases toward key self management activities so that these activities can be positioned in ways that are most like to engage patient participation. The purpose of this session is to synthesize qualitative audience research conducted by the US Centers for Disease Control and Prevention's Arthritis Program to identify similarities and differences in patient attitudes toward, motivators for, and barriers to key self management activities. The presentation will review findings from focus groups exploring the value patient place on self management education, focus groups and in-depth interviews exploring attitudes toward physical activity, and focus groups exploring motivators for weight loss. This information can be useful in determining marketing approaches to packaged self management programs as well as motivating patient participation through self management support activities and provider counseling.

Keynote 4.2

Facilitating translation of CDSM Research into Public Health Practice
Bridging the gap between research and public health practice is a critical challenge to the success of public health programs, policies, and practices. Self management education and self management support are two areas of chronic disease management where there is a wealth of research knowledge, but much of that knowledge fails to transition from research findings to actionable public health programs, policies or practices. Bridging this research and practice gap is one of the primary challenges facing clinical and prevention sciences, and is essential for effectively improving the health of the public. This presentation is designed to highlight processes essential to moving scientific discovery into widespread practice. The Translation Schematic developed by the National Center for Chronic Disease Prevention and Health Promotion at the U.S. Centers for Disease Control and Prevention (CDC) will be used as the organizing framework. Key translation processes include the decision to translate, transforming knowledge into products, active dissemination and engagement, the decision to adopt, and local practice or implementation. This presentation will explore key factors that influence the decision to translate, and supporting structures such as technical assistance, financial resources, and organizational capacity and evaluation that are critical to successful translation. Information from this presentation may be useful to guide the development or strengthening of processes to facilitate translation of research into practice, and to shape future research questions or agendas.

Teresa J. Brady is a Senior Behavioral Scientist with the Arthritis Program at the U.S. Centers for Disease Control and Prevention in Atlanta and has helped shape the public health approach to arthritis since the programs inception in 1999. Dr Brady has a PhD in Psychology, from the University of Minnesota.

Keynote 1.1

What is important when helping people become more effective self-managers of their health?
Health behaviour is poorly understood and almost impossible to predict from any existing theory or model. Experience has shown us that, at the level of the individual patient, ‘educating' or ‘counselling' is a weak method for helping people change. Systematic reviews have consistently recommended that ‘cognitive-behavioural' methods are slightly more effective producers of change than education alone: this portmanteau term is poorly understood, has no agreed definition and is often assigned to interventions that remain at heart mostly educational. Worse still most of the interventions that have been evaluated have had multiple elements making it difficult to determine which bits were helpful. This talk will list and present examples of a number of practical techniques that are commonly found to be associated with interventions that have produced worthwhile behaviour change and suggest why they may be important.

Keynote 4.3

How do we get the right patients to come to self-management programmes?
Most people want to be free of ill health and to have the best possible quality of life yet programmes that aim to help them achieve these goals vary widely in the extent of uptake and retention. Even after a frightening and life threatening event such as a heart attack many patients turn down the offer of cardiac rehabilitation a treatment that reduces mortality from all causes by 20% and cardiac mortality by 26% making it the most effective live extending treatment available. This seems somewhat bizarre. Interestingly the rate of refusal varies widely from programme to programme suggesting that the problem may not be the patients.

After a previous life as social worker Professor Lewin retrained as a clinical psychologist and from 1987 built up a large clinical health psychology department in Edinburgh working with people with chronic conditions. In this period he ran clinical trials of a number of innovative programmes including the Edinburgh Heart Manual a cognitive-behavioural self-management programme for people with heart disease that has since been widely implemented both in the UK and internationally. In 1995 he was appointed as inaugural Professor of Rehabilitation at the University of Hull subsequently moving to the same position at the University of York in 1998. Amongst many of his associated posts Prof. Lewin has directed the British Heart Foundation Care and Education Research Group since 1993 which currently consists of 18 full or part time researchers. He has consulted at both local and national level in the UK and other countries on chronic disease management and conducted 40 peer reviewed research projects and published more than 65 articles in peer reviewed journals.

Anne Kennedy joined NPCRDC in 1995 as a health services researcher. My research centres on self-management of long-term conditions. She co-authored a series of six self help guides for people. These were developed with patients and include both lay experiences and evidence based information and have been used in a number of randomised controlled trials.

Anne recently led and managed a national evaluation of the Expert Patients Programme (based on the Chronic Disease Self-management Programme).

What make CDSM successful on the ground?

In 2002 and the Department of Health set up the Expert Patients programme with the aim to evaluate effectiveness of CDSM and look at issues around implementing a national programme.

Evaluation of the programme showed some improvement in quality of life, self efficacy etc but did not produce significant change in health directed behaviours and service utilisation.

Take up of the programme post evaluation has been patchy despite ongoing investment and being highlighted in successive policy documents. The implementation raised key issues around a generic approach to CDSM and its effectiveness.

In 2006 the department of health set up and funded a community interest company (EPP CIC) to increase capacity of CDSMP to 100,000 places by 2012 and to develop and design programmes that will improve the efficacy of self care

The EPP CIC has had to address some key issues

•  Are CDSM programmes primarily vehicles for social inclusion, developing social capitol and reducing health inequalities?
•  Should they be primarily aimed at improving clinical outcomes?
•  Can they do both?
•  What is the optimal interaction between clinician and patient?
•  How best can self-management be Integrated across the care pathway?
•  What is the the role of disease specific, generic and ongoing support self-management support?
•  Can the EPP CIC successfully pperate in a commercial environment?
•  What form should a robust national quality standard take?

Jim Phillips has been integral to the development of self management in the UK over the last 10 years. He was part of the expert patients task force that laid out the direction for the development of a national self management programme in England – The Expert Patients Programme.

Professor Stanton Newman is at University College London Medical School. He specialises in psychological and social issues of physical illness and in particular the development and evaluation of self-management interventions. He has published over 200 research papers and chapters and 10 books. His latest book “Chronic Physical Illness: Self-management and Behavioural Interventions” is about to be published.

Are self management programmes for long term conditions part of the problem or part of the solution to inequalities in health?

Anne Rogers is Professor of the Sociology of Health Care, in the Primary Care Research Group, Manchester Medical School, The University of Manchester. She currently leads the research programme on self-management at the National Primary Care Research and Development Centre - a programme of research which has developed multi-disciplinary research over the last 10 years. The programme includes a number of randomised control trials, qualitative research exploring the role and experience of patients and lay people in undertaking self-care and living with a chronic condition, policy analysis. Her other research interests are in medical sociology and especially the sociology of mental health and illness.

Education of health professional - taking a systematic approach

Malcolm Battersby, M.B.B.S., FRANZCP, FAChAM, Ph.D., is Associate Professor in Psychiatry at Flinders University and director of the Flinders Human Behaviour and Health Research Unit. Dr Battersby has a strong interest in behavior change, at both the patient and the clinician level. He has worked extensively with general practitioners and other health professionals to develop a generic assessment and care planning approach for clinicians to assist patients with self-management of chronic conditions (The Flinders Model). In 2003-2004 he was awarded a Harkness Fellowship to study self-management in the United States and is a chief investigator of the National Health and Medical Research Council Centre for Clinical Research Excellence in Aboriginal Health.

As health systems worldwide confront and seek to address increasing rates of chronic disease, the concept of self-management has gained health policy prominence. Initiatives designed to enable people to engage in the active self-management of their conditions hold much promise, in terms of benefits for both for the health system and for the many individuals and families affected by chronic illness. But current approaches must be broadened to respond to the wide diversity of needs that exist in the community. A range of community-based approaches is required – no single or uniform approach will suffice. Optimising the role and impact of primary care to support self-management also requires a foundation for ensuring interventions and resources are well-integrated with the formal health system in order to address key issues including sustainability, appropriateness and access.

Associate Professor Fran Boyle is a social scientist and Head of the Health Systems & Economics Discipline Group in the School of Population Health at The University of Queensland. Fran's research focuses on social determinants of health, people's experiences of chronic illness and the development of consumer-responsive health systems and services.

Symposium 4.3

How can Divisions of General Practice support primary care in their efforts to engage patients in self-care.

A/Prof Larry Baker (USA/UK), A/Prof Michael Greco (Australia/UK), Lead Trainers for Advanced Development Program for Clinicians, Health Foundation Co-creating Health Initiative, CFEP Surveys, UK

Chris McAuliffe, Board President Brisbane South Division of General Practice, QLD, Australia
Leanne Wells, Acting Deputy CEO Australian General Practice Network, Australia
Vicki Poxon, CEO Brisbane South Division of General Practice, QLD, Australia

The management of chronic diseases among the Australian population, is placing an increasingly heavy burden on primary healthcare providers. Chronic Disease Management (CDM) programs have been developed and implemented by the Divisions of General Practice to strengthen primary care practitioners' involvement in chronic care by promoting best practice diagnosis and patient management programs. Further gains can be sought however when combining these programs with self management principles. Evidence has emerged from the UK and the USA which suggests that patients with effective self-management skills make better use of health professionals' time and have enhanced self care.

Leanne Wells will provide a national overview of the work being conducted by the Australian divisions of general practice with regard to chronic disease self management and prevention. Taking a case study approach, Vicki Poxon and Dr Chris McAuliffe will discuss what prompted a local division to integrate self care into all their programs.

A/Profs Michael Greco and Larry Baker will provide delegates with an insight into their experiences with the implementation of training schemes for clinicians in enhancing patient self-care/management in the primary care environment. They will share key insights they have gained into the clinician-patient interaction, specifically how to enable patients and ensure changes are sustained. Delegates will be assisted to identify hurdles that may need to be jumped, and be provided with insightful strategies to consider.

A question and answer session will provide the delegates with the opportunity to delve deeper into the topics discussed.

Michael Greco is Director of Client-Focused Evaluations Program (CFEP) which has offices in Australia and the UK, and is involved primarily in the provision of patient and colleague feedback to clinicians and healthcare organisations. He shares his commitments between both countries, and recently received British citizenship after spending seven years there as the Director of Patient Experience for the National NHS Primary Care Team.

In the UK, CFEP is a lead provider of patient surveys in the British GP contract, and is working closely with the General Medical Council on its revalidation instruments and the Health Foundation in the training of clinicians in patient self-care skills. In Australia, CFEP works closely with Regional Training Providers of GP Registrars, the RACGP Quality Assurance and Continuing Professional Development Program, and the peak body in the accreditation of Australian general practices.

Chronic disease self-management in Australia

Prof John Horvath, Chief Medical Officer, Australian Government, ACT, Australia

John Horvath is Chief Medical Officer for the Australian Government and is the principal medical adviser to the Minister and the Department of Health and Ageing and is across the full range of professional health issues, including health and medical research, public health, medical workforce, quality of care, evidence-based medicine, biosecurity issues and an outcomes-focused health system. In this role he has participated in numerous reviews on behalf of the Department and is a member of a wide number of committees and organisations that relate to the broad activities of the Department of Health and Ageing.

Prior to his appointment as Chief Medical Officer in September of 2003, Professor Horvath was a Professor of Renal Medicine at the University of Sydney and a specialist renal physician at the Royal Prince Alfred Hospital. He was awarded an Order of Australia in January 2001 for his services to medicine.

Professor Horvath plays a key role in emergency health protection and is the key medical adviser to the Australian Health Protection Committee.

Presentation summary

Chronic diseases are estimated to be responsible for 80 per cent of the burden of disease in Australia. This number will only increase with the ageing population. This means there is a need to focus on the prevention and management of chronic disease, especially considering that a number of these diseases are preventable. This burden is potentially avoidable through addressing risk factors, such as overweight/ obesity, tobacco use, alcohol consumption and physical inactivity.

The Commonwealth Government is committed to identifying practical and achievable approaches:
•  to develop Australia's health system to meet current and future demand for chronic disease prevention and management; and
•  improve the health related quality of life for people with chronic diseases.

This presentation will focus on:
•  the ‘chronic disease' issue in Australia;
•  its impact on the Australian community;
•  exploring what the Commonwealth Government is broadly doing to mitigate the growing burden of chronic disease; and emerging challenges.

The Workplace: An opportunity for self-management?

Elizabeth Kendall, PhD , Griffith Abilities Research Program. Research Centre for Clinical and Community Practice Innovation (and Centre of National Research on Disability and Rehabilitation Medicine), Griffith University, QLD, Australia

Workplace health has become an issue of great concern over the last decade, both internationally and nationally. Given the value of work in this society, the amount of time spent at work and the current changes that are affecting the nature of work, it is not surprising that the workplace is becoming a site of interest in the fight against chronic disease.

Management of chronic disease has involved the creation of ‘healthy organisations', a concept that was first researched in the 1960s (e.g., Argyris, 1964). It has been suggested that a healthy organisation is one that has created and maintained a relatively stress-free and health promoting environment where secondary and tertiary management is unnecessary. As this optimal situation is not likely to be achieved, researchers have suggested that healthy organisations are those that can maintain a relatively well ‘balanced' scorecard (Robson, 1999). A healthy organisation as one that balances the needs and demands of all stakeholders, namely consumers, stockholders, governments, societies and employees at all levels. Healthy organisations re-focus the responsibility for health to the organisation, but simultaneously give more responsibility to workers by encouraging their participation in change management, job re-design, open communication, and understanding of the political or economic constraints within which the organisation operates.

Elizabeth Kendall has a BA in psychology and special education and a PhD in psychology. Her research has focused on the area of traumatic injury and disability for over 20 years, and she completed her PhD on adjustment following traumatic brain injury. She was the foundation Research Director of the Centre for Human Services (Rehabilitation) where she managed and supervised the development of an international research agenda in community rehabilitation funded by the Motor Accident Insurance Commission. In 2001, Elizabeth was appointed as a Chair in Community and Vocational Rehabilitation at Griffith University, also funded by the Motor Accident Insurance Commission through the Centre of National Research on Disability and Rehabilitation. Her research currently focuses on self-management, comprehensive models of service delivery and settings-based approaches to health.

Jenni Livingston is a Senior Research Fellow at the Centre for Rheumatic Diseases at the University of Melbourne. She is a health program evaluator with interests in the use of evaluation to design evidence based programs, work health, workplace training, bioethics and organisational change.

Health Literacy – a fundamental of self care and participation in healthcare which calls for a major policy and program reform

Most chronic disease self-management programs utilise written materials in one form or another. Many are dependent on printed worksheets, manuals, textbooks and written materials on web pages. Chronic disease self-management programs using these formats immediately exclude a large number people with low literacy, which may be a result of specific conditions or disability, low education or a result of specific cultural customs. Whether a person is interacting directly with healthcare professionals or trying to navigate the healthcare system more broadly, the capacity to recognise and act on health messages is paramount for the optimisation self-management and self-care activities. Fundamental to this is a person's ‘health literacy', namely their ability to seek, understand and utilise health information and how this affects a range of health-related behaviours such as healthcare service utilisation, self-management and adherence to medication regimens and health instructions. Health literacy is relevant in the prevention of disease, maintenance of good health, reducing risk factors as well as understanding how best to deal with current health problems. It is therefore a key concept that must pervade the thinking of all groups concerned with ‘health' – policymakers, healthcare professionals, NGOs and many others. Do you consider the health literacy of your clients or the targets of your health policy (whether they be health consumers or those providing self-management support)? Are you personally sufficiently health literate to optimise your current health or deal with a sudden health crisis of your own?

This presentation will review what self-management programs might hope to achieve in both individuals and populations and will consider limitations of programs in meeting the needs of a broad spectrum of individuals both in the short term and the long term. The reasons for this will be explored through an examination of ‘self-management support' programs.

Associate Professor Osborne BSc, PhD is an Epidemiologist and Health Services Researcher at the AFV Centre for Rheumatic Diseases at the University of Melbourne. He leads a broad research portfolio across population health epidemiology, health program evaluation, clinical trials as well as outcomes measurement development and validation. He is Director of the Victorian Orthopaedic Elective Waiting List Reform Initiative and he is also Director of the Australian WorkHealth Program-Arthritis, a whole of system model of health education in the workplace. From first principles he has developed, validated and disseminated several questionnaires including the well known heiQ (Health Education Impact Questionnaire) which is embedded as a quality and monitoring system for self-management programs in several countries. His training and experience gives him considerable insight into research/program design, the nature of interventions, and outcomes assessment. He sits on several Australian and State government committees relating to arthritis, public health and chronic disease management generally. He is coordinating editor of a recent Medical Journal of Australia supplement on CDSM and publishes widely on CDSM evidence, policy and practice.

Self-management refocused: An examination of critical components, outcomes and forgotten populations.

Prof. Tanya Packer, PhD, BSc(OT), Director, Centre for Research into Disability and Society, Curtin University of Technology, WA, Australia

Prof Packer is the Director, Centre for Research into Disability and Society, School of Occupational Therapy , Curtin University of Technology in Western Australia . With extensive experience is development and evaluation of self-management programs in the health and non-government sectors her goal is to impact on both practice and policy.

Self-management of chronic disease has grown from a few specific and structure programs to a plethora of protocols, approaches and in some settings used as a “model of care”. Randomized control trials and systematic reviews abound, however, we are still unable to answer basic questions such as “what are the critical components?”, “why are people with disabilities, neurological and mental health conditions under-represented in self-management programs?”. This presentation will argue that the development of self-management as a complex intervention has been largely driven by effectiveness studies with insufficient attention paid to understanding the active ingredients, the appropriate outcomes and the people served. Finally, this presentation will propose a new framework – the pARTicipation framework – with the intention that it will help to refocus research, practice and policy. The framework proposes that participation, as defined by the WHO, should be the outcome of interest in self-management interventions, underpinned by the ART of managing A ctivities, R elationships, and T reatment.

Prof Packer is the Director, Centre for Research into Disability and Society, School of Occupational Therapy, Curtin University of Technology in Western Australia. With extensive experience is development and evaluation of self-management programs in the health and non-government sectors her goal is to impact on both practice and policy.

CDSM for young people: Why adolescent development matters

Prof Susan Sawyer MBBS MD FRACP, Director, Centre for Adolescent Health, Royal Children's Hospital; Department of Paediatrcs, The University of Melbourne; and Murdoch Childrens Research Institute, VIC, Australia

WHOLE OF COMMUNITY APPRAOCHES TO OBESITY PREVENTION IN ADOLESCENTS

Boyd Swinburn

WHO Collaborating Centre for Obesity Prevention, Deakin University, Melbourne

Obesity prevention in adolescents should be a priority for research and public health action because the evidence base on effective interventions is very limited but the need for them is urgent. Pacific populations have the highest obesity prevalence rates in the world. The Pacific OPIC (Obesity Prevention In Communities) Project is a large, 4-country study of obesity prevention in adolescents in Geelong, Auckland, Fiji, and Tonga. The intervention studies aim to determine the effectiveness of 3 year whole-of-community programs on reducing unhealthy weight gain in adolescents. Intervention studies used quasi-experimental designs with baseline (2005/6) and follow-up measurements of anthropometry (including body composition, n>17,000), behaviours, attitudes, environments, and community capacity. Multiple interventions were based in schools, communities and churches using a community capacity building approach. The interventions had varying success rates of implementation, uptake and sustainability. Student ownership and implementation of the activities was critical to the capacity building activities and the implementation of many of the school-based initiatives. The findings from the baseline studies, including extensive socio-cultural data, have created a better understanding of the determinants and potential intervention points for preventing unhealthy weight gain in adolescents. The effectiveness of the interventions will be analysed in 2009. The process of involving the students in the initiatives to increase healthy eating and physical activity has been one of the key successes in all of the programs.

Boyd Swinburn is Professor of Population Health and Director of the WHO Collaborating Centre for Obesity Prevention at Deakin University in Melbourne. He trained as a specialist endocrinologist in Auckland and his research career began with metabolic and clinical at the National Institutes of Health in Phoenix, Arizona and at the University of Auckland. He was the Medical Director of the National Heart Foundation in New Zealand from 1993-2000. His major research interest at Deakin University is now centred on obesity prevention particularly in children and adolescents. He has developed and supported a number of community-based demonstration projects in the Barwon-South West region of Victoria and these are linked to similar projects in Melbourne, Auckland, Fiji, and Tonga.