Change 4: Educate and empower individuals to manage their health and wellbeing

This change supports Goal 1: prevent crisis and Goal 2: stop crisis becoming an admission.

Making it Real statements

I am in control of planning my care and support. If I need help with this, people who know and care about me are involved."

We work with people as equal partners and combine our respective knowledge and experience to support joint decision-making."

Tips for success

• Peer support and health coaching interventions have been found to be effective in helping to develop coping mechanisms. Health and social care commissioners should consider aligning or jointly commissioning.
• Train and support staff to promote self-management as part of their routine practice and to trust people’s ability to manage their health and wellbeing. Be proactive in checking on individuals and their carers so they continue to feel supported to self-manage and know what to do if their condition changes. Use technology to support self-management and promote independence where appropriate. 
• Train frontline staff in communication techniques, such as motivational interviewing and patient activation, that engage people in honest conversations about their health and wellbeing. Be clear about the responsibilities that their health and social care teams hold for providing their care.
• Consider using a self-management measurement tool to evaluate individuals’ knowledge, confidence and skills to manage their own health conditions in order to personalise interventions, support and strength-based conversations.
• Work with unpaid carers to identify and address their needs so that they can continue to care. A breakdown in care can increase the risk of an unplanned or prolonged admission to hospital or care home.
• Help individuals access appropriate equipment and adaptations to make their home environment more suitable for managing their condition.
• Support those with complex conditions to be able to navigate their care networks efficiently, particularly when they receive care from multiple places.
• Personal assistants can enable people to be more independent and in control of their lives. Promote these benefits by providing advice and guidance about employing personal assistants to people, their families, and those who work with them. Consider creating support structures to facilitate informed decisions.
• Compassionate and timely advanced care planning can help people to plan and anticipate how to meet their current and future care needs.
• Encourage early conversations about advanced care planning, to be able to uphold people’s wishes should they have diminishing capacity, be receiving palliative care or are at the end of their life. 
• Ensure information and advice is available to help everyone regardless of their circumstances. This includes self-funders, to help them make informed choices about their care and how they will pay for it.
• Provide a range of accessible resources to educate people and their family and/or carers to understand and manage their medicines.
• Ensure timely translation of key messages and materials into the languages and formats that people can understand. Collaborate with partners, local community groups and networks to identify and engage community influencers, whom people trust, to deliver these messages, such as community leaders, religious leaders, or health or care workers.
• Promote health literacy by assisting individuals and their family and/or carers to access information and advice resources, both online and offline, that will help them manage their health conditions. Where appropriate, expand this offer to include digital self-management tools, educational interventions and one-to-one support that is tailored to the needs of the local population. Reducing digital exclusion, as well as social exclusion and associated health inequalities, will help more people to feel confident to use these tools.
• Provide opportunities to share and learn from others. Connect people to local support groups and informal networks that will help build their confidence and resilience.
• Invest in building capacity and confidence for self-management by digital means. Understand how well connected your target group is and address the barriers some people face in using digital tools.
• Allocate resources to reaching people who might be receptive to managing their health conditions and building their support networks through national initiatives such as Self Care Week (15-21 November 2021). 

Examples of emerging and developing practice

• “A Digital Health Hub is a trusted place, with trusted people accessing trusted information.” 100% Leeds Digital partnered with Cross Gates & District Good Neighbours scheme to launch a digital health hub in 2019 which has since supported people through lockdown.
• Essex County Council illustrates how care technology, including video care-phones, was rolled out rapidly in 2020 to keep vulnerable people connected and supported during COVID-19 and summarised their achievements in this infographic. 
• The Central and North West London Recovery and Wellbeing College provides educational courses, workshops and resources to people with mental health difficulties, their families, supporters and carers, and staff to give them the skills and confidence to manage their mental health, physical health and wellbeing and aim to promote recovery and social inclusion.
• Isle of Wight: Personal Assistant Hospital Discharge Initiative and PA Hub: The council has worked with partners to establish a personal assistant market that supports residents in their own homes and reduces avoidable admissions to care homes. LGA, December 2020.
• Huntingdonshire District Council: getting cancer and cardiac rehab patients active with self-care: case study about supporting good rehabilitation and self-care, LGA November 2018.
• Since it started to use the House of Care model to support people to self-manage their conditions, Leeds has continued to embed its person centred approach by providing training on collaborative care and support planning through ‘Better Conversations’ and its’ ‘Supporting people through kind conversations’ e-learning package.