Chronic Disease Self Management

It has been called the health care equivalent of global warming.  The impending collision of the demographic wave comprised of an aging chronically ill population and the healthcare shoreline supported by aging healthcare providers using scarce health system resources could have a catastrophic impact on the communities in which we live.

According to the World Health Organization chronic diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are by far the leading cause of mortality in the world, representing 60% of all deaths.  Furthermore if the major risk factors for chronic disease were eliminated, at least 80% of heart disease, stroke and type 2 diabetes would be prevented; and 40% of cancer would be prevented.

Sykes Assistance Services’ multidisciplinary clinician team can deliver customized disease self management and prevention programs that provide valuable information, advice and counselling to patients or informal caregivers.  By working in partnership with an individual and his/her healthcare provider team, our Carecoaches® assist with the development of individualized plans and provide multi-channel 24/7 support to patients and providers alike. 

Links to Primary Care:

Our model of disease prevention and self management is based on the premise that the telehealth centre will work best when it acts as a natural extension and support to the relationship already established between an individual and his or her primary care team - What Wagner and others have referred to as the relationship between an informed activated patient and a prepared proactive provider team. 

We believe that we can convert what in many cases have been episodic and sometimes unlinked care processes into a care management program where the reach of the provider is extended both in terms of time and place.  We can provide evidence based outreach, support decision making and counsel for behaviour change all within the context of the existing relationship between a patient and his or her primary care team.  In many ways what we do is move the front door of the health system into the home of the person seeking care or advice.

Self Management / Self Care:

Continuing on the theme of an activated or engaged  patient; we believe that for both people that have been diagnosed with a chronic illness and for those who are at risk of developing one we must help them take their proper place as the owner / operator of their health.  By taking advantage of even brief opportunities we can implement a coaching process that identifies the readiness, confidence and ability of an individual and then help them set goals, and build personal action plans that have a realistic chance of success.

Supporting Informed Decision Making:

People make decisions about their health the same way that they do for most other decisions in their lives. They actively participate or are influenced by others based on a complex set of beliefs, values, skills and knowledge. Providing information to everyone in the same way will not meet the needs of the individuals involved.  We believe that the best clinical course will be achieved when one considers the person being coached and what makes them unique.  Sykes CareCoaches® perform in-depth assessments and listen to the client to make sure that the care approach is based on the person who must lead the process; the individual being coached.  They will provide information and support to people who are making difficult decisions about courses of therapy or about processes like quitting smoking or starting to exercise.  This approach, centred around the individual, provides a more satisfactory experience for the client and counsellor alike.