Ongoing monitoring of the condition should also be based on the person’s own concerns and goals for health care. Support programs and clinical trials now often assess quality of life, functional health status and patient satisfaction to gain a measure of effects that is meaningful to patients.

In asthma treatment, traditional end-points (symptoms, reliever use, forced expiratory volume in one second per cent predicted, morning peak expiratory flow, airway hyperresponsiveness) do not fully capture treatment benefits from the patient’s point of view.¹⁹ More important measures for patients might include days missed from work due to asthma or ability to exercise without symptoms.

Develop teamwork with other services

Teamwork is recognised as an aspect of patient-centred care.²⁰ One service provider, e.g. GP, cannot feasibly undertake all aspects of a person’s care such as comprehensive motivational interviewing, patient education for self-management, dietary assessment or coaching to achieve behavioural change. General practice can better ensure that a wide range of patients’ needs are met by working with other providers such as local asthma educators, local diabetes centres, allied health professionals, community agencies (e.g. ancillary community services) and support groups (e.g. Diabetes Australia, Asthma Foundations Australia, arthritis foundations).³

Offer referral to self-management programs

Patients need support to successfully manage the impact of long-term conditions on their lives. Self-management programs specifically developed for people with complex care needs generally involve these guiding principles:

• Allow and encourage the patient to define health problems.

• Explore options for dealing with these problems.

• Offer choice and respect the person’s choice – rather than directing and prescribing.

• Collaboratively set goals and action plans to address problems or adopt/maintain health-related behaviours.

Approaches that recognise and act in partnership to manage patient-defined problems are the most successful, regardless of the mode of delivery.²¹ Well-defined approaches such as the Stanford Chronic Disease Self-Management Program and the Flinders Model of chronic disease self-management are based on these principles. Health coaching in chronic disease is an emerging approach based on person-centred care principles. These models focus on action plans set by the person with the condition. Coaching generally involves a health professional, other than the main prescriber or clinician, who provides individualised support for self-management. This approach has been applied mainly in areas of diabetes and cardiovascular conditions including coronary heart disease.

Conclusion

In all disciplines and health services, patients benefit where health professionals pay attention to the principles of collaborative partnerships with patients, offering patients an opportunity to make informed decisions about their health care based on effectively communicated medical evidence and setting mutually agreed goals for care. Many primary care health professionals are already practising within such a person-centred framework, which acknowledges that the proper focus of health care is the person, not the condition. 

Content Updated 20 March, 2006