Imagine you are experiencing a long-term health condition that is having a big effect on your life. While your doctor can tell you what your condition is and your treatment options, for many people it’s not until they talk to someone who has “walked in their shoes”, and has the time to listen and understand their individual circumstances, that they start to find ways to cope with, recover from, or live well with their condition.
This powerful tool of engagement is called Peer Support, and it’s being used by the Kia Kaha team, led by health psychologist Leona Didsbury at East Tamaki Healthcare, to change the way services connect with people who have long-term conditions, who are not managing well. I’m now joined by David Codyre, Psychiatrist and Clinical Lead Manaaki Hauora, Supporting Wellness Campaign to tell us more.
Coping with a long-term medical condition such as diabetes or arthritis can be a challenge. On top of the physical symptoms, many people also battle with the added stress of living with a mental health condition, such as depression and anxiety. These health issues are further complicated when there are social family and financial challenges. Addressing this complex mix of issues in a brief primary care consultation is challenging. Complicating this, social services, and specialist services for mental health, are provided separately to medical health services, and patients struggle to navigate the complex health and social service system. The Kia Kaha team discovered early in their work that many of these people ended up feeling “dis-engaged, de-activated and dis-connected” and effectively “gave up” on themselves, and the health system.
The Kia Kaha team wanted to turn this around and initially implemented two services with good evidence of improving health outcomes and reducing the need for costly health services, for these people. The first was access to a health education programme – “Stanford self-management education” (SME), which had been shown to help people manage stress better, learn about how to manage their condition, and work more actively with health services. The second was to ensure people with serious anxiety/depression had this recognised, and accessed evidence-based talking therapy (Cognitive Behaviour Therapy). Research had shown that if people with long-term conditions had any mental health issues recognised, and addressed via CBT, and were supported to self-manage better in the community, they could manage their condition and enjoy a better quality of life, free from frequent visits to hospital.
However, initially a lot of people we were trying to help weren’t interested in what we were offering. We found there was a real disconnect. On one side we had well-meaning clinicians who had got frustrated and were saying “no matter what we do this person doesn’t want to be well”, and on the other side patients getting frustrated at always being told what to do, by people who had no idea what was going on in their lives. The team decided to implement a trial of peer support to assist in outreach and engagement of these people. By employing two trained peer support workers, who had experienced what it was like to have a long-term condition, engagement rates climbed from 50% to 100% overnight. That was a real turning point – the beginning of what has become a “peer-professional partnership” model of care.
The Kia Kaha team initially found that there were two key requirements to get people engaged in working with them. The first was being flexible with where and how they met with people – offering initial assessment and support clinics, in the community, or in their home; and with or without family. The second was to start by hearing the person’s story and understanding what was important to them. The focus became “what matters to you” rather than “what is the matter with you”.
Talking and connecting with people who have been through what you have, but have recovered and are “living well”, is a great influencer in changing and motivating behaviours. It opens up opportunities for people to start to have hope for the future and take control of their own health. The group-based SME course then helps people realise they are not alone, gives them tools to manage better, and also builds stronger connections through friendships and mutual support from other course members. In some instances getting specialist peer support from people with directly relevant experience, helps people to learn how to manage their conditions and encourages them to work with their health team.
As they worked to improve the service, the team also learned from patients who had accessed the service, that for many cultural groups, offering both assessment and support, and SME courses, in their own language and delivered by someone who was of their culture, would improve engagement. Since then the team has acted on this and now have peers who reflect the main cultural groups the team works with, and delivers Tongan, Samoan, Hindi, and Kaupapa Maori versions of the SME course.
By focusing on peer engagement, self-management education, peer support, and more recently use of a model called “health coaching”, the team has seen a marked increase in engagement and participation of these people in working to improve their health and wellbeing, and better outcomes as a result. For the initial cohort of almost 100 people the team worked with (whose outcomes have been most closely tracked over time), the result has been a significant reduction in ED visits and hospital admissions (40-45% reduction sustained now for over three years).
One of the great things we have seen during this time, is that some of these people with long-term conditions who are managing better, want to “give back” to others, and are now training and becoming peer leaders themselves – initially volunteer peer leaders of the SME course, but increasingly employed peer health coaches. They have the training, confidence and tools they need to help others on their journey. That’s incredibly satisfying to see. We are also seeing growing interest both here and overseas with people seeing a place for peer support and health coaching in primary care.
We are now trialling embedding a peer health coach in four GP clinics, to work with the GP and Practice Nurse to improve diabetes outcomes. Working together as a “teamlet” they will seek to engage people who are over-weight with pre-diabetes to self-manage, get active and eat better, prevent progression to actual diabetes; AND to engage people with poorly controlled diabetes manage better.
My dream is to see a peer health coach in every clinic across our network. Working with people with long-term conditions, connecting them up with self management support, and with other community supports; and “coaching” them to work better with their clinical team to address their healthcare needs.
In the past the power of peer support has been an untapped resource outside mental health and addiction services. We hope to change that for the future.
David and Geraint
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