Supporting Self-management in Primary Care with Tools it’s Workforce Needs

Health Economies have made progress in changing the health workforce to meet the problems it faces. Mental Health and an ever growing population of people living with Long Term (Chronic) Conditions (typically known as Non Communicable Diseases – NCD) have been recognised as areas where the model of care can be changed and enhanced. 

Our changing environment, social pressures, cultural and behaviour changes have led to the need for more support in real time. As populations diversify and age, long term conditions become more of a burden on an already stretched health system. Many countries have introduced HIPs (Health Improvement Practitioners) and Health Coaches as part of the health workforce – they have well defined models of care to integrate into primary practice.

That said, the model of care is often clinic based and therefore episodic. Many clients are expected to make their way to the clinic where support is delivered. The reality is that people experience the difficulties in managing their mental health or LTC/NCD in their day to day lives, or at home, and that is where (and when) they need support. We have a once in a generation opportunity to radically transform what it means to deliver healthcare services moving from a “find and fix” model to a “predict and prevent” model. The key to success here is patient/client engagement – the patient being an integral part of the health solution, rather than the receiver of health advice.

Care can be elevated from episodic to continuous care using remote support and monitoring. Continuous care is near instant and occurs at the time a person experiences a problem. People can most benefit from support at or near the moment they face a challenge or difficulty. A key feature of continuous care is also that it takes place in the environment where self-management needs to occur.

With continuous care and monitoring, HIPs and Health Coaches receive timely signals indicating their patients might benefit from immediate support. A simple message inquiring about their challenge and the coach/HIP can work from there to engage with, and support, their patient/client. This, by the way, is the promise of asynchronous care – where a coach has a queue of ‘signals’ to attend to, and can manage that load efficiently.

This timely delivery of care creates trust and the perfect timing with which to share and impart skills for managing the everyday situations patients encounter. 

The good news is that remote coaching technology has been shown to have improved  outcomes. Great clinicians like Dr. John Moore have gone before us and demonstrated results, for example:

Hypertension – 75% of those patients receiving remote technology support care achieved BP control vs 32% in the controlled health coaching group that received normal health coaching support. Baseline systolic BP was 164mmHg. Those on the tech-supported coaching group demonstrated an additional 13mmHg additional Sys BP reduction vs control. 

Type 2 Diabetes – Those patients receiving remote technology supported care demonstrated a 35 point drop in HbA1C (mmol/mol), improved satisfaction with care, and outcomes demonstrably better than most medicines alone.

Not only were the outcomes exceptional, the productivity increase in the workforce was demonstrable – coaches using the tech platform could manage nearly twice as many patients.

These tools exist right now to support these emerging workforces. Health Coaches and Health Improvement Practitioners are a workforce making a meaningful difference in areas that have long been ignored or under-resourced. Digital support tools, such as Pukeko Health, have been shown to improve both productivity rates of coaches by > 50%, and substantially improve health outcomes.