Dr Carol AtmoreClinical Director

Long Term Conditions

Ministry of Health

Dunedin

14:00 - 14:55 WS #111: Patient Self Management in a Technological Era

15:05 - 16:00 WS #122: Patient Self Management in a Technological Era

(Repeated)

Patient Self management in a Technological Erawhere do you start?

Dr Carol AtmoreClinical Director,

Long Term ConditionsMinistry of Health, New Zealand

Overview

• Self management and why is it important

• Technology enabling good health - examples

• Obesity, weight management & how to help

Wagner’s Chronic Care Model

Self Management

“..greater control in looking after themselves, … and inpartnership with health professionals and communityresources.”

Key features:– Patient and whānau centred– Empowering– Coaching– Navigation– Health Literacy

Evidence:– Increases sense of wellbeing– Improved health outcomes– Decreased secondary care use

• Examples:

– Flinders, Partners in Health– Stanford, Living a Healthy Life

Average NZer’s has 40 mins with GP per year

Self management currently

Self Management in future

Wider Health and Social System

Immediate Care Team

Patient and Whānau

RelationshipsProcesses

Information Technology

Patient Portal – rate of uptake -December 2016

Portals where to from here• Good uptake by practices- 45 % offer portals

• Patients love them

• RNZCGP survey –portals improve service

• Next steps:

• Increase patient enrolments, functionalities

• Secure messaging

• Open notes

• Website: https://patientportals.co.nz/

patientportals.co.nz

Some projects MOH involved in

• SMS4BG

• Beta Me

• Mental Health Diabetes projects

– Tairawhiti

– Northland

• Supporting self management project

SMS4BG

National Institute of Health Innovation (Auckland) and Waitemata DHB

• Text message based self management program

• RCT 366 patients with poor diabetes control

• Targeting Maori, Pacific and rural NZers

Findings to date

• 96% messages useful

• 95% good way to deliver program

• 96% culturally appropriate

• 98% age appropriate

• 81% impacted on their management

• 76% improved glycaemic control

• 2% choose to end messages early

“Thank you for your support. I have found it immensely helpful.”

HRC – Beta Me• Prof Diana Sarfati (Otago) and Melon Health

• Midlands and Wellington, 3 years

• RCT pre/diabetes (usual care or care + tech)

• Adding app for coaching, goal setting, private social networks, health hacks, data integration, resource library, modular education programs and video appointments

Mental Health Diabetes projects

• Rationale: Improving mental health and wellbeing has the potential to improve both quality of life and glycaemic control

• The projects aim to improve access to primary mental health services for people with poorly controlled diabetes

• Situated in Northland and Tairāwhiti DHBs

• Malatest evaluating the project

Tairawhiti approach - Targeted

•Māori or Pacific person with poorly controlled Diabetes (HbA1c level of 64mmol/mol or more) and an indication of potential mild to moderate mental health issues:• poorly controlled diabetes

• low/non-attendance

• low/non-adherence with medication regimes

• living in socially isolated situations

• pressing issues (wider than health)

17

Tairāwhiti – a case study

BeforeNo interest in preparing meals

Difficulty shopping

Little contact with whānau

Overweight (127kg),

No exercise

Uncontrolled diabetes (HbA1c 86)

Felt hopeless

Wanted to lose weight and sort out his lounge.

“Mark” (in kaiāwhina programme):

Now – three months laterEngaged in sandwich club

Kaiāwhina supermarket tours, gaining confidence in buying right food within his budget

Losing weight (125kg)Joined lunchtime walking groupReducing HbA1c (now 75)

Feeling happier, more self confident

Has a plan towards new lounge suite.

Northland DHB•Three programmes – the tamariki, the rangatahi, the adult programme

Tamariki programme• Whānau with child newly diagnosed with T1 DM in

previous year• Whānau with Child with poorly controlled T1 DM high

HbA1c• Kaiawhina key; co-ordinates and supports tamariki and

their whanau

Early feedback

• Newly diagnosed whānau had a lot of questions about T1DM, and welcomed the opportunity to meet other whānau to share experiences.

• Most whānau found the kaiawhina to be a lifeline in providing information, or finding out who to talk to with questions.

• Whānau from the poorly controlled group wished they had the opportunity to access information and support from the kaiawhina early in their diabetes journey instead of later, when they were struggling.

Rangatahi programme

Innovative ways to engage with youth with diabetes

• A series of workshops delivered by the Company of Giants theatre group

• The workshops aim to be fun and provide clinical and social support to rangatahi with diabetes.

• Three cohorts of young people, third group just starting

Adult programme

•Mixed model including

•workforce development,

•group sessions,

•e therapy and

•specialist support in primary care

Supporting self management project

• Health Literacy New Zealand and Health Navigator New Zealand working with 8 practices to develop tools, resources and training to enable people with LTC to self manage

• Training modules being developed, practice teams supported to test modules

• Modules include care planning and health literacy

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What we know

• Over 165,000 health apps!

• Around two-thirds of Kiwis aged 15 and over now own a smartphone - 2.5 million smart phone users in NZ

• Important opportunity, but very little guidance available and very few clinicians recommending apps

Health Apps

Acknowledgements: Health Navigator

App quality assessment

PublicationView online at: www.healthnavigator.org.nz/apps/

Example

Where to next?

• The known knowns – collecting and translating good ideas

• The known unknowns – identifying gaps in understanding in NZ context and testing solutions

• The unknown unknowns – looking out for disruptive ideas that can improve self management

Sharing the learnings

• MOH website

• Conferences, Annual workshop for PHO and DHB Long Term Conditions teams

• What methods would work for you?

carol_atmore@moh.govt.nz

Weight management and raising healthy kids

•Behaviour

•Genes

•Environment

The causes of obesity are complex

Childhood obesity in New Zealand

*least deprivedaRR= adjusted rate ratio

Maori vs. non-Maori: aRR=1.59 (1.25-2.02)Pacific vs. non-Pacific: aRR=3.87 (3.17-4.74)Most deprived vs. least deprived: aRR=3.02 (1.90-4.81)

NZ Health Survey 2015/16

Adult obesity in New Zealand

*least deprivedaRR= adjusted rate ratio

Maori vs. non-Maori: aRR=1.69 (1.58-1.82)Pacific vs. non-Pacific: aRR=2.38 (2.21-2.56)Most deprived vs. least deprived: aRR=1.70 (1.50-1.94)

NZ Health Survey 2015/16

Perceptions of Children’s Weight

Under weight

Healthy weight

Unhealthy weight

Very unhealthy weight

Perception of adults weight

Under weight

Healthy weight

Over weight

Class I Obesity Class II Obesity Class III Obesity

Under weight

Healthy Weight Overweight

Obese

Perception of weight was influenced by the respondents' weight status and genderAdult perception

Harris et al. International Journal of Obesity (2008) 32, 336–342;

What to do?

STEP 1 - Monitor• Growth in children

• Regularly measure height and weight to calculate BMI using age-and sex-specific growth charts

• Weight in adults

• Regular weight measurements (and a height, if this is not already known)

http://www.health.govt.nz/system/files/documents/publications/weight-management-2-5-year-oldsv2.pdf

MonitorAssess Manage

Maintain

• No single intervention – need to address the obesogenic environment as well as a life-course approach.

• Three critical time periods in the life-course:

– preconception and pregnancy

– infancy and early childhood

– older childhood and adolescence.

Tackling Obesity

WHO: Report of the Commission on Ending Childhood Obesity

http://www.health.govt.nz/system/files/documents/publications/weight-management-2-5-year-oldsv2.pdf

1. Monitor Growth

NZ-WHO Growth Charts

Intervene Early

• A change of centile channel is an indicator that the child’s growth trajectory needs to be watched and an early intervention is likely to be more straightforward and effective

Intervene here

Z score (SD): +1.3 91st Centile+2.0 98th Centile

Acknowledgement: Dr Pat Tuohy

Having the conversation….

‘My child exercises every day of the week with horse riding and running and as you should know muscle weighs heavier than fat.’

Gillison et al Public Health Nutrition 2013: 17(5), 987–997

‘If you look at the rest of his activities and family members then his natural weightand body size is large.’

‘He is very short for his age and I feel he will even out as he grows.’

‘There are much fatter children out there and my son isn’t that bad!’

“Our findings highlight a mismatchbetween health professionals

perceptions of how difficult these discussions are and reality, in that most

parents are receptive to the information if delivered well.”

Dawson et al. Pediatr Obesity, 2016

• Show concern, rather than professional detachment

• Be confident and caring

• Allow time for questions

• Provide written information to parents

• Value the child and respect the parents

Mikhailovich & Morrison, Journal Of Child Health Care 2007 11(4)

Having the conversation….

The most important aspect of these conversations is to make the experience positive and non-judgmental

The style in which this feedback is provided appears to be less important.

Dawson et al. Pediatr Obesity, 2016

2. Assess History

•Pregnancy (obesity, diabetes, birth weight)

•Feeding (breast, bottle weaning)

•Early weight trajectory

•Current eating habits

•Developmental milestones

•Physical activity (& screen time)

•Sleep (enough of it, snoring)

•Medications (steroids)

•Family

Examination

•Watch the child walk into the room

•Talk to the child

•Growth chart (height, weight, BMI)

•Dysmorphic features

•Blood pressure

3. Manage

• Nutritionally balanced diet

• Appropriate portion sizes

• Family meals• Slower eating• Avoid snacking

• Play and physical activity

• Reduce screen time (esp TV)

• Sleep time

• Infants: 12-15 • Toddlers: 11-14• Preschoolers:

10-13

• Change what is available at home

• Keep ‘treats’ out of site

• Increase easy accessibility to healthy options

Food Activity Behavioural Strategies

http://www.health.govt.nz/your-health/healthy-living/food-and-physical-activity/obesity

Tips

4. Maintain

• Review opportunistically• Accept setbacks – maintain positivity• Encourage family activities and sport

• Link with local Regional Sports trust• Encourage cultural initiatives

• e.g. Kapa-Haka• Support communities

• Healthy Families NZ• Iron Maori• Community gardens/Kai Atua

Childhood obesity health target –Raising Healthy Kids

• A new health target has been implemented from 1 July 2016: • By December 2017, 95% of obese children identified in the Before School

Check (B4SC) programme will be offered a referral to a health professional for clinical assessment and family based nutrition, activity and lifestyle interventions.

• The target was selected as the B4SC focuses on early intervention to ensure positive, sustained effects on health.

• The target defines obesity as a BMI above the 98th centile on the NZ-WHO growth chart.

Quarter 1 Quarter 2 Quarter 3

Raising Healthy Kids Target

MeasurementsHaving a

conversationReferral GP/PN visit

Healthy Lifestyle Support Services

B4SC Staff Primary Care Staff

Feedback

By December 2017, 95% of obese children identified in the Before School Check (B4SC) programme will be offered a referral to a health professional for clinical assessment and family based nutrition, activity and lifestyle interventions.

Commonly selected goals

• Increase in fruit and vegetables

• Less junk food, more healthy snacks

• Decrease sugary drinks

• Drink more water

• Proportionate hand-based portion sizes

• Active play at least 60 minutes each day

Adult expectations of weight loss

• Foster et al 1997– 60 middle aged obese women

– BMI > 35

• Their goal weight loss– Dream weight

– Happy weight

– Acceptable weight

– Disappointed weight

Foster GD, et al. J Consult Clin Psychol 1997;65:79-85.

Dream Happy Acceptable Disappointed

% of baseline weight lost 38% 31% 25% 17%

Weight loss at 48 weeks

No one achieved their dream weight loss

Foster GD, et al. J Consult Clin Psychol 1997;65:79-85

Realistic expectations

• Most people cannot achieve their ideal weight, even with the most aggressive approaches

• Most cannot maintain losses >15% of initial body weight without surgery

• Loss of 5% to 10% of body weight is realistic, and associated with significant health improvements

What people think it should look like

What it really looks like

Success

Overweight healthcare professionals?

Medscape Physician Lifestyle Report, 2016

What do patients think?

Patients estimation of doctors weight

Normal (n=118) Overweight (n=312) Obese (n=170)

Trust* advice on weight control

76% 85% 85%

Trust advice on diet 77% 87%** 82%

Trust advice on physical activity

79% 86% 80%

• Survey of 600 overweight or obese adults

* Rated ‘a great deal’ or ‘a good amount’ of trust**Significantly greater than normal weight (p=0.04)

Bleich et al (2013) Preventive Medicine 57: 120-124

Conclusion

• The solution to obesity is multi-faceted

• Health care professionals have an important role to play

• Although the conversations can be difficult, they are worthwhile