Cardiovascular disease/Chronic Kidney Disease/Hypertension/Diabetes Self-Management Support Service

Descriptions

People with long term conditions spend less than 1% of their time in contact with health professionals. The rest of the time people, their carers and families manage on their own. This service has been developed in response to the unmet need for culturally sensitive self-management support for people with diabetes; CVD; CKD and/or hypertension. It looks to address this through education and support amongst the diverse communities of Tower Hamlets, including provision for service users who may have low English proficiency and people with complex and multiple co-morbidities and those with disabilities. The service will focus on increasing the knowledge, skills and confidence (activation) of its users to manage their condition(s) and to achieve the best possible health outcomes for themselves. In addition, the service will support service users to increase their resilience, feel empowered to increase self-care and to promote independence. The Provider will actively mitigate against the participants developing a dependency on the service by promoting independence and exploring ways for people to implement and sustain activity following programme end. Tower Hamlets has over 14,000 people diagnosed with type 2 diabetes and on the diabetes care package; over 11,000 people on the hypertension care package and approximately 3,000 people on the secondary prevention of CVD care package. There are currently 4,370 people with diagnosed CKD in Tower Hamlets and recent development of tools to identify those with undiagnosed CKD is likely to lead to an increase in the numbers. The presence of diabetes and/or hypertension leads to an increased risk of CKD so the overlap between these cohorts is significant. The self-management needs for these diseases are similar and comprise of education and awareness of disease; medication concordance; healthy diet or diet control; exercise and weight loss; smoking cessation and life style changes. People of South Asian, Chinese, African-Caribbean or black African origins are more likely to be affected by diabetes and this increases their risk of developing cardiovascular diseases and stroke five-fold compared to those who do not have diabetes. The risk of diabetes also increases for people with a severe mental health condition, such as depression, schizophrenia or bipolar disorder; as some medications used to treat these conditions are diabetogenic and/or due to lifestyle choices.