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Creating self-management teamlets in a primary care clinic; the successes of a clinical-peer team


Leona Pearl Didsbury ,

Nirvana Health Group, NZ
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David Anthony Codyre

Nirvana Health Group, NZ
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Background to current teamlet model: The _Kia Kaha: Manage Better, Feel Stronger_ collaborative (supported by the Nirvana Health Group in partnership with the Beyond 20,000 Bed Days Campaign, Ko Awatea) utilised improvement science methods to create a change package that addresses mental health needs and supports self-management education for people with 2 or more long term conditions and 2 or more recent emergency care (EC) presentations. Within the first year patient's EC presentations were reduced by 42%. With the addition of self-management trained peers on the team, engagement rates with patients climbed from 50% to 93%.

Next Steps: Based on these results resources were obtained to further expand peer support programs to develop and test a _Wheel of Support_ based on _Building peer support programs to manage chronic disease: seven models of success_ (California Healthcare Foundation, 2006). The current teamlet working in the Otara Locality which is an ethnically diverse high needs community within South Auckland, now consists of two part time health psychologists, 8 employed peer health coaches and 10 volunteer self-management leaders with six language abilities which include: Maori, Hindi, Tongan, Samoan, Mandarin and English. Group self-management education (The Chronic Disease Self-Management Program from Stanford University, is now being offered in multiple languages by this team.

Individual self-management support is commencing with health coaches trained in the Center for Education in Primary Care (CEPC) _Health Coaching Curriculum_ (Bodenheimer & Ghorob, 2014) working with patients with diabetes. These coaches are working in a teamlet which includes the GP, nurse, behavioural health and other clinic staff. Coaches are supervised and supported by a health psychologist. Health coaching is also being offered in multiple languages.

Preliminary results:

"Feedback from GP:" General practitioner in the teamlet has expressed the positive impact of the health coaching on his consults with patients understanding more about concepts related to their diabetes such as the definition of diabetes, HbA1c and lifestyle goals.

"Psychological distress:" Observed significant reductions in anxiety, depression and somatisation.

"Patient Activation" Increased health behaviours and understanding of health information as measured on the Health Education Impact Questionnaire (hei-q)and as observed in further engagement with other self-management opportunities

"Patient satisfaction and feedback" Qualitative thematic analysis related to social support, connection, self-esteem and confidence

"Health outcomes" Modest to significant improvements on HbA1c, Blood pressure, weight and cholesterol

"Healthcare utilisation" Decrease in unplanned primary care visits
How to Cite: Didsbury LP, Codyre DA. Creating self-management teamlets in a primary care clinic; the successes of a clinical-peer team. International Journal of Integrated Care. 2017;17(3):A122. DOI:
Published on 11 Jul 2017.


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