Registed Nurses' Association of Ontario

Evidence Booster: Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients

In Canada, approximately half of the population is living with at least one chronic condition and more than one in four is diagnosed with two or more chronic conditions.1 The costs associated with lost productivity and health care expenditures is more than CAD $90 billion. Due to inflation that cost has risen to over $97.8 billion (in 2018). Self-management supports and strategies are vital to the health and well-being for persons living with chronic condition(s).

Practice Changes

The Telehomecare BPSO employed several strategies to support guideline implementation. Chart audits were conducted to determine pre-existing diagnosis of depression and a screening tool was used to support routine assessment. Specifically the Spotlight Assessment Guide that includes green, yellow and red zones to indicate stable, contact health provider and call 911, respectively was implemented.

To support practice changes the Ontario Telehomecare BPSO implemented several strategies including: mandatory in-person training as part of onboarding, with additional subject matter expert led webinars on key self-management support topics, just-in-time education and behaviour change support of persons with chronic illness to promote consistent and accurate self-monitoring techniques, and documentation of scheduled regular health coaching sessions. Guideline implementation was further facilitated by using the SMART (Specific, Measurable, Achievable, Results-Focused and Time Bound) goal framework. This helped health providers and persons with chronic conditions to collaboratively determine effective approaches to self-management.