As part their involvement in the Health Foundation’s ambitious Co-creating Health programme, Cambridge University Hospitals NHS Foundation Trust has redesigned its existing pulmonary rehabilitation programme to incorporate self-management education and skills training.
The challenge: embed self-management support
Cambridge University Hospitals NHS Foundation Trust was one of eight organisations to take part in the Co-creating Health programme, which aimed to improve how people with long-term conditions are supported to self manage. The team in Cambridge focused on supporting patients with chronic obstructive pulmonary disease (COPD).
The first phase of Co-creating Health introduced training in self-management skills for patients, as well as training to help clinicians develop skills in self-management support. During the second phase of the programme, the team decided that rather than running separate courses for patients, they would redesign their existing pulmonary rehabilitation programme to incorporate self-management education and skills training.
Dr Jonathan Fuld, Respiratory Consultant, explains: ‘Our existing rehab programme had good results, but attendance was often irregular and feedback showed that the positive impact of training was largely lost after one year, with patients reverting to old behaviours. We also knew the style was quite instructive and tutor-led, and didn’t always enable people to take control of their own condition.’
The enhanced programme
To address these issues, the team designed the Enhanced Pulmonary Rehabilitation (EPR) programme. This is provided over 12 sessions and combines exercise, education and self-management support. The programme is delivered by a physiotherapist and supported by a self-management tutor. Support is also provided by a patient with expertise in self-management who leads a session on their personal experience, the skills they use, and how these help to manage their condition.
Unlike standard pulmonary rehab courses, the new programme has an extra focus on helping participants to set their own health goals. At its heart is a ‘personal health plan’. Patients have a one-to-one discussion with the physiotherapist before they start the programme to discuss their goals, and the personal health plan is then a key tool to support behaviour change during and after the programme. Patients can record agendas, goals, action plans, diaries and logs, and can use it to monitor and plan their activities.
Peer support is a strong element of the programme, and patients are encouraged to share their skills and experience in goal setting and in managing their condition.
Improved confidence, skills and knowledge
Patient feedback about the redesigned course has been very positive and tutors say that the group involvement in goal setting and follow-up really helps to engage patients. Even the most ambivalent and reluctant patient has now set a personal goal. One patient said that the programme had changed her life to the extent that she was close to giving up smoking, something that she never previously thought possible.
A formal evaluation of the redesigned programme was carried out by Frances Early, Research and Evaluation Lead, earlier this year. Following completion of the course, there was an improvement in patients having the confidence, skills and knowledge to manage their condition, as well as the improved exercise capacity you would expect from a pulmonary rehabilitation course.
While the team have successfully embedded self-management support content into the programme, they do not have evidence of the benefits lasting longer than during conventional pulmonary rehabilitation. As Frances explains, ‘Patients still reported difficulty in maintaining increased exercise levels after the course finished, with some not managing to integrate exercise into their daily life. The evaluation also found that while the goal setting and action planning provided motivation while attending the programme, patients weren’t necessarily going on to use these techniques in their everyday lives.’
Ongoing improvement process
The team are now working with physiotherapist teams to further refine the course, using learning from the evaluation. In particular they want to strengthen the skills training provided to patients around goal setting, as well as incorporating the latest knowledge and research around behaviour change.
‘We’re realising that behaviour change and behaviour maintenance are slightly different things, needing different approaches. It’s not just about putting in effort to meet set goals, but also about breaking old habits and forming positive new ones,’ says Frances.
Jonathan also agrees there is more to be done. ‘One thing we’ve realised is that self-management support as an approach is so multifaceted that one single intervention is unlikely to be sufficient by itself to meaningfully change outcomes. It needs to be part of a health system where all cogs are operating with the same ambition, and where there is shared understanding about the value of self-management support across all providers involved in supporting patients.’
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