Chapter 2 - Foundations of SME and SMS Flashcards
(26 cards)
Define: Patient-centered care
Care provided in a manner that respects and reflects the individual’s needs, preferences and values; a patient’s values direct decisions
Define: Self-management
The active participation of individuals in achieving their best health and wellness. This involves gaining the confidence, knowledge and skill to manage physical, social, and emotional aspects of life in partnership with health-care teams and community supports
Define: Self-management education
A systematic intervention that involves active patient participation in self-monitoring of health parameters and/or decision making (managing).
It involves the ongoing process of facilitating the knowledge, skills and ability necessary todevelop self-care behaviours. It is recognized that a collaborative patient-provider approach with the application of problem solving skills is an essential component in this process
Define: Self-management support:
A range of activities offered by organizations, communities and providers that support self-management behaviours across the lifespan and are not necessarily specific to educational processes. These may include behavioral, educational, psychosocial and/or clinical strategies
Define: Self-management training
Teaching the skills necessary to manage diabetes.
What does CCM stand for and what is it?
Chronic Care Model
- model that defines the relationships between various elements involved in chronic disease management
- “multifaceted, interdependent framework to improve health-care delivery from prevention to advanced management”
- need for partnerships between health systems and communities
See figure 1 in chapter 2
Give examples of:
Delivery-system design/reorient health services
• Multidisciplinary teams, expanding roles of educators, case management, system navigators
• Cluster visits, shared care linking providers
• Technology support, telehealth, reminder systems
Give examples of
Self-management/ develop person skills
. “Behaviorally sophisticated self-management support that gives priority to developing patients’ confidence and skills so that they can be the ultimate manager of their condition” (7)
• Delivery focused around SME
• Individual portals, websites, interactive technology
Give examples of:
Decision Support
Prompted access to clinical practice guidelines, decision algorithms, etc.
Give examples of:
Information Systems
• Shared clinical information among all care providers through electronic medical records, registries
• Reminders, tracking systems
Give examples of:
Health system organization of health care
• Provincial strategies, funding policies
• Outcome evaluation systems, accreditation
• Standards
Give examples of:
Strengthen community action
Resources available
Community supporters
Community partnerships
Give examples of:
Build healthy public policy
Provincial strategies, funding policies
Outcome evaluation systems, accreditation
Standards
Give examples of:
Create supportive environments
Parks available with bicycle paths
Green spaces for safe walking
ICP and IPE
Interprofesional collaborative practice (ICP)
Interprofesional education (IPE)
Compliance vs. Empowerment approach
Compliance - a prescription defined by the healthcare provider to follow.
Empowerment- a process designed to facilitate self-directed behaviour change
“Adults are more likely to make and maintain behaviour changes if changes are personally meaningful and freely chosen”
Empowering interventions a include:
• Acceptance (unconditional, positive regard)
• Affect (exploring the emotional content of a problem)
• Autonomy (decision-making by the person with diabetes)
• Alliance (providing help and information for informed decision-making)
• Active participation (participation and active listening by both/all parties)
4 key times when people with diabetes require assessment/reassessment and/or changes in their treatment plan:
1.) Diagnosis
2.) Annual Assessment
3.) Development of Complications
4.) Transition Periods (pregnancy, insulin initiation, etc)
Goal of SME:
Personal engagement for informed, effective diabetes self-management
Key Principles:
(SME) interventions should:
Be collaborative and interactive
Be individualized to address a patient’s needs
Share knowledge technical skills and problem-solving
Enhance self-care training skills
Facilitate motivation and confidence to take action and Improve one’s quality of life
Be repeatedly reinforced
5 Elements of SME
Assess
Educate
Collaborate
Set goals
Follow-Up
Interventions:
- monitor
- manage
- promote
Intervention areas:
- Nutrition
- Exercise
- Psychological
- Medication
Define: self management support (SMS)
Diabetes self management support is defined as strategies that augment in individual Silletti to self manage their diabetes
SMS include activities that support the implementation and maintenance of behaviours for ongoing diabetes self management.
SMS also refers to the policies and people that support self-management behaviours across the lifespan, not necessarily specific to educational processes.
Define: Health Coaching
(Individual or group)
Engagement, where there is, health related, education, behavior change, and support by health care professionals
Diabetes health coaching has been shown to decrease A1c by up to 0.5% compared to structured education and usual care
Technology enabled self-management (TES) - 4 key components the most successful technologies share:
1.) two-way communication between patient and provider
2.) patient generated health care data analysis
3.) education
4.) feedback
Andragogy
“The art and science of helping adults learn”
Malcom’s Knowles - father of adult education
