GUIDE FOR SELF-MANAGEMENT GOAL SETTING - DOC

							              GUIDE FOR SELF-MANAGEMENT GOAL SETTING
                     FOR B.C. CHF COLLABORATIVE

Draft #1-July 7,2003       Prepared by Chris Rauscher

Self-management by people living with chronic diseases is central to chronic
disease management. This is recognized in the Collaborative with two self-
management measures: 1. goal setting and, 2. patient-managed diuretic titration
according to weight (for those patients on diuretics for systolic heart failure).
Philosophically, the person plays a key role in managing their chronic disease as
part of the team.

Terminology and practice in this area is evolving and can be confusing. We have
the opportunity in the Collaborative to gain a better practical understanding of
how best to support our patients so that they can manage their chronic diseas es
and improve their health. This can be framed as:

Self- Management Training + Health Education  Self-Efficacy  Self-Care
Behaviours  Improved Health, Emotional Well-Being and Quality of Life +
Decreased Health Care Utilization

Self-Management training is delivered through the B.C. Chronic Disease
Management Program (CDSMP) which is to be made available to every patient
in the Collaborative through their practice team. The CDSMP teaches the
following skills:
     How to get started to engage in specific behaviours (i.e. those taught
       through health education)
     How to problem solve
     How to communicate effectively with health care professionals and with
       family
     How to work effectively with health care professionals
     How to deal with anger, fear and frustration, depression and fatigue
     How to evaluate treatment options.
The skills training is reinforced through the tools of mastery learning, modeling,
reinterpretation of symptoms and social persuasion and also through peer
support. People thus increase their levels of self-efficacy in their ability to
manage their chronic diseases and their overall health. The Program is lay-led
with trained lay leaders (who also have chronic disease) and is delivered in
groups of 10-15 persons with (often different) chronic diseases for 2 ½ hours
once weekly x 6 weeks. The strength of the CDSMP is in the general skills
development reinforced though provision of the tools, peer support and follow-up.
Health education, which also works with self-efficacy through provision of
information and practising of technical skills, is necessary for the development of
self-care behaviours for specific chronic diseases. There is the opportunity to
combine the CDSMP approach and health education in the Collaborative. At the




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practice team level, this will be supported by the Health Educators in each Health
Authority.

Collaborative Goal Setting
We all set goals in our lives to achieve the things that we feel we need to do to
satisfy needs, wishes, desires. We set goals that we feel are important
(conviction, motivation) and for which we have some confidence that we can
achieve. So, goal setting is not new, but goal setting for one‟s health and taking
personal responsibility, are often new concepts for both the person with chronic
disease and for the health professional. In addition, the person with chronic
disease has to have sufficient information to understand their disease in order to
appreciate the importance of setting a goal which often involves a change in
thinking and behaviour. This is a process that requires a specific discussion
about goal setting and follow-up support for goal achievement. A combination of
the CDSMP and health education approaches will greatly increase the likelihood
of successful goal setting and achievement. The CHF Collaborative Practice
Teams have as one task supporting their patients to set self-management goals.
The „Patient Reminder” sheet from the Heart Failure Care Guideline has been
designed to facilitate the process and has been adopted by the Collaborative as
the standardized basic resource sheet.

Principles:
     Assessment is key- ask as well as inform
     Build rapport- Express empathy and understanding
     Elicit goals and preferences
     Tailor information to match motivational readiness
     Accept where the patient is
     Discuss options and support choices and goals
     Build self-efficacy and confidence
     Take a long term view

Suggested Steps in Goal Setting For Patients and Practice Teams
   1. The Practice Team sets up a specific visit to discuss self-management
      goal setting using the patient reminder sheet as the basis for discussion
      (in most primary care teams the physician would do the complete process
      unless there were other team members available)
   2. Early in the process, the patient would be given the information for the
      CDSMP (if available in their area) and encouraged to attend to give them
      the basic skills and confidence for self-management (often at the end of
      the initial discussion outlined in #3 above)
   3. The initial discussion would be around an introduction of the concepts of
      self-management and personal responsibility for health, the concepts of
      heart failure and a brief review of the patient reminder sheet -this is a lot of
      information and may take more than one visit and reviewing the patient‟s
      basic understanding of the discussion would be important to determine the
      next step



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   4. After the initial discussion, the next steps would include:
           Exploring what the patient may see as problems/issues that they
              may want to deal with through a discussion of the impact of the
              illness, symptoms, and the feelings associated with their situation
           Have the patient select one or two issues that they feel are most
              important to deal with initially and help the patient determine
              concretely how the situation would appear if it were improved
           Determine motivation- help the patient clarify whether or not they
              are committed to changing the situation (can use 0-10 scale)
           Support the patient to make short-term action plans: “what are you
              going to do over the next week”, “how much, when, how often”; also
              barriers and how to overcome barriers
           Identify confidence: “how confident” (scale 1-10: with 1 meaning
              patient is certain that they can‟t accomplish the plan to 10 being
              certain; goal for confidence level to be between 6 and 9- if 10, plan
              may be too easy, if less than 6, review the plan and see if there is a
              way to boost confidence)
           Initiate plan, monitor and evaluate
   5. Provide the patient with supplemental information and tools pertaining to
      the goal(s) that they have selected such as logs for monitoring weight or
      information sheets specific to certain health behaviours (the Health
      Educators are working on selecting such standardized resources for the
      Practice Teams).

The utility of following the suggested steps to support self-management with the
patients in the Collaborative can be implemented by the Practice Teams and
evaluated over the course of the Collaborative. Early feedback from certain
teams has indicated great interest from the patients and initial progress in self -
management goal setting.




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