11 of CHRONIC CONDITION MANAGEMENT FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT THE FLINDERS PROGRAM ™

11

of

CHRONICCONDITION

MANAGEMENT

FLINDERS HUMAN BEHAVIOUR & HEALTH

RESEARCH UNIT

THE FLINDERSPROGRAM™

22

Welcome and Introductions

• Current Role • Client Group• Interest in Chronic Condition

Management• Expectations of the Workshop

33

The Program

Day 1

• Background & Evidence

• The Flinders Program

Day 2

• Review of Day 1

• Additional Resources for Interviews (Stages of Change, Motivational Interviewing, Problem Solving)

• Volunteer Interview

• Planning for Practice Change

44

Aims

To enable participants to:

• Better understand effective chronic condition management including self-management

• To understand and use the Flinders Program and tools

• Plan for practice change

55

Learning Objectives

Conduct interview with a person using the Flinders Program to:

• Assess Self Management capacity• Identify significant Problem & mid/long term

Goal• Develop Flinders Program Care Plan

66

The Flinders Program

• Certificate of Competence

Part of a Quality Assurance Process

Submit a minimum of 3 care plans

Licence to use the Flinders Program

77

History of Flinders Program

Flinders Program developed

Coordinated Care TrialsSA Health Plus

1997-1999

Sharing Health Care Initiatives

C’wealth Dept Health & Aging2001 - 2004

Partners In Health scale trialed and

standardised2001

8

Valuable Learnings:• Service Coordinators did not base their case

management decisions on severity of condition/s but rather on how well clients self-managed

• Therefore needed an objective way of assessing a patients self management knowledge, behaviour and barriers.

1010

National Chronic Disease Strategy (www.coag.gov.au)• Action Areas:

– Prevention– Early intervention– Integration and coordination– Self-management

• Priority recommendations– Clinicians receive education in self-management

support– Self-management support is incorporated into routine

clinical care

1111

Why Do We Need To Change?• Disease burden has changed towards chronic conditions

around the world. Health systems have not.

• Effective interventions exist for most chronic conditions, yet patients/clients do not receive them.

• Current health systems are designed to provide episodic, acute health care and fail to address self-management, prevention and follow up.

• Chronic conditions require a different kind of health care (mismatch).

WHO Health Care for Chronic Conditions team (CCH) http://whqlibdoc.who.int/hq/2002/WHO_NMC_CCH_02.01.pdf

12

Chronic…

What characterises :

Acute…care models ?

1414

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

SystemsSelf-

Management Support

Health System

Resources and Policies

Community Health Care Organization

Chronic Care Model

www.improvingchroncicare.org

1515

Self-Management: Who’s Responsible?

Self-management - is what the person with a chronic condition does by taking action to cope with the impacts of their condition.

Self-management support - is what others such as services, health professionals, family, friends and carers do to support the person to self-manage. They may do this by providing physical, social or emotional support to the person.

1616

Activity – Brainstorm

What are the characteristics

of people who

self-manage well?

What barriers might they experience?

1717

Definition of a Good Self-Manager

The Centre for Advancement in Health (1996) proposes the following definition:

“[the person with the chronic disease] engaging in activities that protect and promote health, monitoring and managing of symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes.” (p.1)

1818

Kate Lorig (1993) states that self-management is also about enabling:

“Participants to make informed choices, to adapt new perspectives and generic skills that can be applied to new problems as they arise, to practice new health behaviours, and to maintain or regain emotional stability”.

Definition of a Good Self- Manager

1919

6 Principles of Self-Management 1. Know your condition

2. Be actively Involved with the GP & health workers to make decisions & navigate the system

3. Follow the Care Plan that is agreed upon with the GP and other health professionals

2020

4. Monitor symptoms associated with the

condition(s) and Respond to, manage and cope with the symptoms

5. Manage the physical, emotional and social

Impact of the condition(s) on your life

6. Live a healthy Lifestyle

6 Principles of Self-Management cont.

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Principles of Self-Management K

I C

MRIL

KnowledgeInvolvementCare PlanMonitor and RespondImpact

Lifestyle

2222

Self-Management …• Does not reduce the cost of care by

reducing services

• Is not “SELF-TREATMENT”

• Will not discourage visits to the doctor

• Does not increase the risk of becoming unwell

• Need not threaten workers’ role and expertise

2323

Activity – Brainstorm

What are the capabilities

of those who support others

to self-manage well?

What barriers might they experience?

2424

Characteristics of Successful Self-

Management Support1. Assessment of self management(learn what the client knows, their actions , strengths and barriers)

2. Collaborative Problem Definition (between client and health professionals)

3. Targeting, Goal Setting & Planning(target the issues of greatest importance to the client, set realistic

goals and develop a personalised care plan) (Von Korff et al, 1997; Battersby & Lawn,

2009)

2525

Characteristics of Successful Self-Management Support 4. Self-Management Training and Support Services(include instruction on disease management, behavioural support, & address physical & emotional demands of having a chronic condition)

5. Active and Sustained Follow-up(reliable follow-up leads to better outcomes)

(Von Korff et al, 1997; Battersby &

Lawn, 2009)

26

Core Skills for the Health Care Workforce

19 Capabilities for Supporting Prevention and Chronic Condition Self-Management

• 3 Sub groups of capabilities– Patient Centred– Behaviour Change– Organisational/System

Battersby & Lawn, 2009

2727

Brainstorm

• What does client / patient / person centred mean

• What skills are required for effective ‘partnering’

2828

Patient Centred Capabilities

• Ability to negotiate - see the issues from the patient’s point of view

• Share decisions• Collectively solve problems• Establish goals• Implement action• Clarify roles and responsibilities• Evaluate progress

29

Behaviour Change Capabilities

• Frameworks for behaviour change

• Collaborative problem definition

• Motivational interviewing

• Goal setting & Goal achievement

• Structured problem solving

Battersby & Lawn,2009

30

Organisational/System Capabilities

• Multi/Inter disciplinary teams

• Communication systems

• Evidence based practice

• Research

• Partnerships with community

3131

Group Discussion

How does your current management of chronic conditions support clients to

self-manage?

What would you like to change?

3232

Research ProjectsNoarlunga (Mental Health)

• 38 participants with severe mental illness

• Combined Stanford Groups & Flinders Program

• Significant improvement in - Partners in Health ratings

- Problem rating 5.19 – 3.16 (p<0.001)

- Goal rating 5.35- 3.55 (p<0.001)

- Mental Health Summary Score SF12

• Reduced hospital admission rates

3333

RGH (Chronic & Complex Lung Disease)

• Prospective unblinded, RCT, 12 months follow up• Resp’y rehab with and without Flinders Program • Statistically significant improvement - in 6 minute walk (p<0.05)

- the impact scale of the SGRQ (p<0.05)• Clinical Improvement

- in 6 minute walk (>54m)- QOL Score (SGRQ total score)

3434

Eyre Peninsula (Aboriginal Diabetes)60 Participants

• Modified Assessment Tools care planning• Resulted in improved

- Knowledge, treatment and lifestyle score (approx 46%)

- Problem Rating 6.22 – 5.28 (p<0.001)

- Goal Rating 7.26- 5.42 (p<0.001)

- Mean HbA1c 8.74 – 8.08 (p<0.001)

35

Sharing Health Care Whyalla• Participants - People with complex & chronic

illnessAboriginal people > 35 years of ageNon-Aboriginal people > 50 years of age(diabetes, CVD, asthma, osteoporosis, arthritis)

• Interventions -Flinders Program care planning-Condition specific programmes -Self-management courses (6 week

Stanford CDSM training)-Symptom management/action plans-Structured reminders, recalls & continuing

care plansHarvey, P. W., J. Petkov, G. Misan, K. Warren, J. Fuller, M. Battersby, N. Cayetano and P. Holmes (2008 ). "Self-management support and training for patients with chronic and complex conditions improves health related behaviour and health outcomes." Australian Health Review 32(2): 330- 338.

36

PIH

37

PIH

38

Hospital admission

0 1 2 3

time

0.25

0.30

0.35

0.40

39

Vietnam VeteransAlcohol Related Chronic Conditions

• 9 month RCT n=77 • Usual Care vs Usual Care + FP +/- Stanford• Statistically significant improvement (intervention n=46)

i) Alcohol dependence as per DSM-IV• Baseline 61% > 9 months 41% > 18 months 35%• At 9 months alcohol dependence was ~ 8x more likely in control group

compared to intervention

ii) ‘Risky alcohol-related behaviours’ on mean AUDIT scores for intervention compared to control at 9 months sustained to 18 months

40(Warsi et al, Newman et al.) 38

Benefits of self-management programs

• Better clinical outcomes

• Improved health & QOL

• Reduced hospital admissions,

unplanned GP visits, emergency visits

• Increased self-efficacy

• Increased satisfaction with service

• More efficient clinical practice

4141

Flinders Program Applications

• Distribution:– Australia; New Zealand; USA; Canada

• Population Groups include:-– Indigenous Health; Child Health; Aged Care; Mental Health; Disability; War

Veterans; Renal Services; MS Society; General Practice Networks; Rural & Remote.

• RACGP- GPMP & TCA Care Planning Templates based on the Flinders Program principles of self-management– http://www.racgp.org.au/clinical resources/templates

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4343


I C

MRIL


Lifestyle

4444

Care PlanAgreed Issues

Agreed Interventions Shared Responsibilities

Evidence Based PracticeReview Process


Problems and Goals+

AssessSelf-Management

PsychosocialSupport

Community / Carer Support

Self-Management

MedicalManagement

4545

4646

Partners In Health Scale

• Measures self-management capacity• Completed by client independently• Contains 13 questions covering the 6

principles of self-management• Takes 5 – 10 minutes to complete• Can be used to record change over time

47

Introduction

4848

4949

5050

Cue & Response Interview

• A tool for GP / health professionals

• Covers the same 13 questions in the Partners in Health Scale

• Open-ended cue questions enable issues to be explored

• Answers are scored

5151

Cue & Response Interview

Cue questions need to explore:

• Understanding / Knowledge

• What actually happens

• What are their Strengths

• What are the Barriers

5252

Open ended questions

Affirmations

Reflective listening

Summaries

(Moyers & Rollnick, 2002)

Key Skills for Communication

5353

Guiding - Specific Open Questions

• “What’s most on your mind today about your illness?’

• “What concerns you most about these medicines?”

• “What exactly happens when you get the pain”

• “Tell me more about……..”

Rollnick et al (2008)

5454

Funnel Technique• Begin with open ended questions

• Further explore with specific open questions

• Use closed questions to examine issues in more detail

• Summarise / Recap

5555

Funnel Techniquegeneral open questions

specific open questions

closed questions

answers

accurate problemidentification

Clarifyand

checkback

5656

In Pairs

Turn to the person next to you.

Use open ended questions to find out 3 things about this person.

5757

Tips for Interviewing

• Collect enough information to know if this is or is not an issue

• Flag issues for follow-up rather than giving solutions on the way

• You are discovering what the person knows, what actually happens, their strengths & any barriers

5858


• Use open ended questions• Use reflective listening• Use culturally appropriate language • Focus the interview• Record in clients own words• Remember to score

59

Cue & Response Introduction

60

61

Cue and Response

Physical Impact

6262

6363

Cue & Response Discussion

• Underpins the care plan• Compares client and health professional

ratings- checks assumptions• Negotiates care plan issues according to client

priorities and health professional concerns• Motivates client - builds confidence

64

Cue & Response Summary Sheet

May be used to record Health Professionals reflections about:

• Issues for Care plan ie score greater than 4 or discrepant over 3

• Interventions for the care plan

• Particular strengths/barriers

• Linking the Cue & Response with Care Plan

65

Cue & Response Discussion(discrepancy)

6666

6767

Self-Management Assessment

Partners in Health

Scale (PIH)

Cue & Response Interview (C&R)

Quick Takes time

Self Assessment Health Professional tool

13 Questions Expanded with open-ended cue questions

Scored by client Scored by interviewer

Collaborative identification of issues

6868

Activity – Role Play• Case study

• In pairs using the case study, nominate to be either the ‘client’ or the ‘health professional’

• The ‘client’ completes the PIH Scale

• The ‘health professional’ interviews ‘client’ using the C&R Interview form

Now transfer issues on to the Care Plan by:• Comparing your scores with the person’s scores

• Reinforcing person’s areas of good self-management (low scores)

• Items with scores 4 and above go onto the issues section of the care plan

• Discuss scores with 3 or more difference and change scores if needed.

6969

Group Brainstorm

• What is happening in the Cue and Response interview that is different from a usual clinical interview?– For the person?– For the health worker?

7070

Impact of Cue and Response

• The relationship is changed– Client feels listened to– The language is non medical– The health worker has to listen rather than lead

• Strengths and Barriers to self-management are discovered

• Solutions emerge from the client’s own resources

7171

Brainstorm

Why is using a scale/numbers useful?

Why is comparing the scores useful?

– For the person?– For the worker?

7272

7373





Problems and Goals+


PsychosocialSupport


Self-Management

MedicalManagement

74

Problems and Goals Approach

• Adapted from the therapeutic assessment & intervention used in the behavioural psychotherapy field (Isaac Marks)

• Used with 3115 intervention patients in SA Health Plus CCT (1997-99)

• 60% of patients improved their problem rating score

• Up to 60% made progress with goals

74

Battersby M, Ask A, Marwick M, Collins J- A Case Study using the “Problems and Goals Approach”. Aus Journal Primary Health 2003;7(3):45-48Battersby M et al – Health Reform through Coordinated Care: SA Health Plus. BMJ 2005;330:662-6

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Problems and Goals Approach

A motivational tool

• What does the client see as being the biggest problem?

• What goal(s) could he / she work towards that might impact on the problem?

76

Why do we want to know the problem

?76

7777

7878

Problem Statements3 parts to a problem statement

• The Problem

• What happens to the client because of the problem?

• How this makes the client feel?

7979

The Problem Statement• The client’s problem is based on 3 open-ended questions

• A short sentence (guided by the health professional) written by the client- problem, impact, feeling

• Can be clearly and simply evaluated using the 0 – 8 scale

• If the person is a effectively self-managing with minimal disability, they may not have a problem.

8080

Problem MeasurementProblem Statement“Because I’m often short of breath I don’t go out much and I feel frustrated and angry”

Rating Scale How much of a problem is this for me?

0 1 2 3 4 5 6 7 8Not at Very little Somewhat a fair bit A lot

all

8181

Problem MeasurementProblem Statement“Since my daughter moved I don’t see my grandchildren and I feel sad and useless”

Rating Scale How much of a problem is this for me?

0 1 2 3 4 5 6 7 8Not at Very little Somewhat A fair bit a lot

all

8282

Goal Statements

• Goals are linked to the problem statement

• Achieving goals may result in improved problem rating because of changes to

- The problem

- What happens because of the problem

- How the problem makes the client feel

8383

Goal Statements• Client goals (not Health Professional)• Should be written positively + be a personal reward• They are long / medium term and involve a degree of

challenge (Locke, 1996)• Can be clearly and simply evaluated using the 0 - 8 scale• Can be maintenance goals for people effectively self-managing

Avoid• “One off” goals and • “I wanna’ be happier, skinnier, prettier, richer”

Are not clinical interventions (e.g. referral or blood tests)

8484

Goal StatementsRepeated and S.M.A.R.T.

Specific (doing something)

Measurable (observable)

Action based

Realistic (not too reliant on others)

Timeframe (how long / how often)

8585

Problem & Goals Monitoring Record v9 Sept 2009 Name: ………………………………… Patient ID [ ] [ ] [ ] [ ] [ ] [ ]

DATE

Client / Patient Problem Statement: SCORE

Client / Patient Goal Statement: SCORE

Sub-goals: SCORE

SCORE

SCORE

1. Write the Problem and Goal onto the record.2. The scores for both the Problems and Goals are rated using the scales at the bottom of this page.3. Make sure the date is put at the top of the scoring column that you are using each time you want to record a score.4. When the client tells you their score for their Problem and Goal, write down their score under the date.

How much of a problem is this for me:

0 1 2 3 4 5 6 7 8 Not at Very somewhat a fair a lot all little bit

My progress towards achieving this goal:

0 1 2 3 4 5 6 7 8 complete 75% 50% 25% no success success

86

Sub-Goal Sheet

• Used when sub-goals are required to achieve main Goal

• Provides opportunity to score sub-goal to motivate and monitor progress

• Sub-goals appear as interventions to main Goal on the Care Plan

• Optional 86

8787

Goal MeasurementGoal Statement

“I will catch the community bus to the local community centre, twice a week for the afternoon Craft Group”

Rating ScaleMy progress towards achieving this goal is:

0 1 2 3 4 5 6 7 8Complete 50% No success success

8888

Goal MeasurementGoal Statement

“I will email my grandchildren every week when I go to the library ”

Rating ScaleMy progress towards achieving this goal is:

0 1 2 3 4 5 6 7 8Complete 50% No success success

89

Why do we

score

? 89

90

Goal Setting

91

9292

Practical

• Role play

• Group Discussion

9393

9494





Problems and Goals+


PsychosocialSupport


Self-Management

MedicalManagement

9595

Care Planning

9696

9797

Flinders Care Plan

• Identifies health care needs / management aims• Vital for communication• Informed by evidence based guidelines• Includes

– Planned Services– Medication lists

9898

9999

Flinders Care PlanContains• Problem & Goal Statements at head of care plan

with scores• Issues from the Cue & Response Interview &

Problems and Goals• ‘Management Aims’• Agreed ‘Interventions/Actions’• Review dates

• Sign off

100100

Identified Issues

• Ensure all ‘Issues’ negotiated in the Cue and Response Discussion are listed on Care Plan– score of 4 or above after discussion– scores discrepant by 3 or more after discussion– prioritised by client

• Include the main problem, if not already covered by any other ‘Issues’, to plan progress towards achieving their Goal Statement.

• Non judgemental, person centred language.

101

• Not just the ‘opposite of the issue’.

• They are the client’s aims – – ‘What benefit will a change bring to me?’ – ‘What do I want to achieve in relation to this issue?’

• It will be individualised and specific to the issue

• Can be more than one aim per issue101

Management Aims

102102

InterventionsInterventions• What are the possible solutions to the identified issues?• Which of these does the person chose to utilise.• Small manageable steps to achieve the aim.

Who is Responsible• Primarily the client.• Can include a range of people to support self management;

including family, health workers and other services.

Sign off• By both client and health professional

103103

Interventions• Symptom Action Plan• Monitoring Diary• Handbook• Checklist• Best Practice

Guidelines• Next Steps

Tools External resources

Courses/Groups

Coping skills

104104

Interventions• Other health

professionals• Community activities• Support packages• Help lines i.e. Quitline• Libraries• Internet


Courses/Groups

Coping skills

105105

Interventions

• DASSA• Walking and exercise

groups • Group Programs• Self-help/ Support

groups• Education classes


CoursesGroups

Coping skills

106106

Interventions

• Problem Solving

• Stress Management

• Anger Management

• Job re-entry

• Assertiveness training


Courses/Groups

Coping skills

107107

Review and Monitoring• Specify date when each intervention to be

reviewed– highest priorities to be reviewed first

• Monitoring is an important component – Provides support and motivation for the client– Supports partnership– Success noted– Problem solving

• Active document

108108

Structured Problem Solving

109109

What is Structured Problem Solving?

Practical approach that assists people to:

• Identify problems

• Recognise their resources

• Learn a systematic method of overcoming problems

• Enhance their sense of control over problems

• Tackle future problems

(Hawton & Kirk, 1989)

110110

When would you use it?• To teach problem solving rather than you solving

it for them (collaborative not directive)

• When the person hasn’t been able to achieve a goal from the care plan

• When barriers to self-management have been identified

111111

Steps of Problem Solving

• Define the problem• Generate and list solutions• Evaluate each alternative solution• Choose the best solution• Plan the implementation• Review progress and evaluate

112112

Practical

Using the role play,

complete the Care Plan

113113

The Final Product : The Care Plan

An active document that supports:– Communication – Organisation– Partnership– Motivation– Planning and follow-up– Outcome measurement

114114

What we covered so far…

115115


I C

MRIL


Lifestyle

116116

What we covered so far…• 6 Principles of Self-Management• PIH Scale• C&R Interview• P&G Assessment• Care Plan• Systematically supports the patient to achieve

self-management • Provides a process for implementing planned

care for chronic conditions

117

Flinders Stanford• Generic - one to one • Taught by accredited health

professionals to health professionals

• Doctor patient partnership with patient sharing decisions and taking responsibility

• Assessment and care planning, behavioural change (goal setting)

• Provides a way of increasing referrals to Stanford course

• Based on cognitive and behavioural principles and techniques

• Generic - group• Taught by health professionals

and peers to patients

• No change in doctor/patient relationship

• Generic skills – goal setting, problem solving, symptom management

• Based on cognitive and behavioural principles and techniques

118118

Characteristics of Successful Self-

Management Support1. Assessment of self-management

2. Targeting, Goal Setting & Planning

3. Collaborative Problem Definition

4. Self-management training and support services

5. Active and sustained follow-up.(Von Korff et al,

1997); Battersby and Lawn,2009

119

Core Skills for the Primary Health Care Workforce

19 Capabilities for Supporting Prevention and Chronic Condition Self-Management

• 3 Sub group– Patient Centred– Behaviour Change– Organisational/System

120

Feedback

121121

122122

End of Day One

123123

Overview of Day 2

• Additional Resources for Interviewing (Stages of Change, Motivational Interviewing)

• Volunteer Interview• Care Plan Review• Planning for Practice Change• Follow up

124124

Summary of The Flinders Program

• 6 Principles of Self-Management• PIH Scale• C&R Interview• P&G Assessment• Care Plan• Systematically supports the patient to achieve

self-management • Provides a process for implementing planned

care for chronic conditions

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I C

MRIL


Lifestyle

126

‘Susan’

126

127127

Stages of Change

“People would rather die, than change

and most do”

Mark Twain

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Stages of Change Model

• Prochaska and DiClemente (1986) developed a model to describe the way people change their behaviour

• Applied to a range of health behaviours (e.g. smoking, drinking or weight control)

• The process is often circular in nature with people moving through the various stages

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Stages of ChangeEXIT: Long-

term abstinence or moderation

ENTER: Particular behaviour problem (e.g. drinking, smoking, over-eating)

(Prochaska & DiClemente, 1986)

Lapse

Maintenance Pre-contemplation

Action Contemplation

Determination to

change

130130

Open ended questions

Affirmations

Reflective listening

Summaries


Key Skills for Communication

131131

Volunteer Interview

132132

Volunteer Interview

• Confidentiality• What happens with the information?• How will you introduce the interview? The

concept of CCSM? • How do you guide the interview?• What if I think I need to do something?

• If we need help?

133133


• Collect enough information to know if this is or is not a problem

• Flag issues for follow up rather than giving solutions on the way

• Remember: you are discovering what the person knows, what actually happens & any barriers

134134

Volunteer Interview1. Introduce the Flinders Program to the client

2. Client to complete Partners in Health

3. Complete Cue & Response interview

4. Identify the issues and put them on the Care Plan

5. Complete – Problems &Goals interview

6. Complete the Care Plan together – discussAims

Interventions

Who’s responsible and put them on the Care Plan

135135

Feedback

How was the interview for the

volunteer?

How was the interview for the

interviewer?

136136

Thanks to the volunteers

for participatin

g

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Feedback

What went well?

What were the difficulties?

139

Care Plan Critique Exercise

• In pairs critique an example care plan using the checklist provided in your manual.

• Report back to the group on the points which– complement the process.– limit the effectiveness of the care plan.

* Please hand back example care plans.139

140140

Review of Care Plan

Time to reflect and critique

your care plan done with the

volunteer

141141

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Motivational Interviewing

“is a person-centred, directive method for enhancing intrinsic motivation to change

by exploring and resolving ambivalence” (and procrastination)


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• Express empathy • Develop discrepancy • Avoid argumentation• Roll with resistance • Support self-efficacy


Five Key Principles

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1. Examine the good things about the target behaviour

2. Examine the less good things and compare the two

3. Systematically explore how much of a concern the negatives are

4. Ask the client: ‘How does this concern you?’

Undertaking the Interview

145145

And….

5. Look to the future. Is the good / not so good balance going to change?

6. Highlight any discrepancies

7. Get the client to rate both importance and confidence on a scale of 1 to 10

8. Summarise

146146

How does the Flinders Program

motivate people to change?

147147

Motivational Elements of the Flinders Program

• Awareness raised by PIH self-rating

• Reflective listening

• Transparency in comparison of ratings allows exploration of issues

• Helping explore ambivalence (C&R)

• Encouraging clients to explore barriers to change

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Motivational Elements of the Flinders Program

• Client generated P&G statements that are linked to behaviour change

• Collaborative development of the Care Plan with agreed issues and interventions

• Increasing self-confidence in achieving small gains (P&G, Care Plan interventions)

• Shared responsibility / accountability• A sign off on the Care Plan• Monitoring and review

149149

Change is more likely if people make decisions

themselves instead of in response to external

pressure(shared Care Plan)

150

Behaviour Change Capabilities (underpinning the Flinders Program)

• Knowledge of evidence based models of behaviour change

• Motivational interviewing• Collaborative problem definition• Goal setting and goal achievement• Structured problem solving and action

planningBattersby & Lawn,2009

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1. Health Care System (National/State)

2. Organisation – Health Care Model (Local)

3. Individual Health Practitioner

System Change

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1. Health Care System Change

• Chronic Disease Items give higher Medicare rebate

• Projects were funded to trial better Chronic disease management (Coordinated Care Trials, Sharing Health Care projects)

• National Primary Care Collaboratives • Australian Better Health Initiatives• National and State Chronic Disease Strategies

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Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community Health Care Organization

Chronic Care Model

www.improvingchroncicare.org

155155

2. Organisation - Health Care Model

156156

Planning for Organisational Change

• What changes could be made in your organisation?

• Which of these do you have influence over?

• Who are the people you will contact?

• Does the Flinders Program fit with the changes you want to make and where?

157157

Assessment of Chronic Illness Care: (ACIC)

“A practical quality improvement tool to help organisations identify the strengths & weaknesses of their delivery of care for chronic illness in the areas of:

• Organisation of Care• Community Linkages• Self-Management Support• Decision Support• Delivery System Design• Clinical Information Systems”

Bonomi, AE., Wagner E., et al (2002)

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Part 1: Organisation of the Health Care Delivery System

Chronic illness management programs can be more effective if the overall system in which care is provided is oriented & led in a manner that allows for a focus on chronic illness care.

__________________________________________________________________________________

Components Little Support Basic Support Good Support Full Support

___________________________________________________________________________________

Overall….. …does not exist …reflected in ..reflected by ..part of the

Organisational vision statement senior leadershipsystem long

Leadership in term plan

Chronic Illness Care

Score: 0 1 2 3 4 5 6 7 8 9 10 11

(Bonomi et al, 2002)

Example

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KIC MR IL AuditKnowledge of Condition

• Does the program provide disease-specific education?

• Is client education based on relevant clinical guidelines?

• Are clients linked to other relevant disease specific education in the community when needed

|____________|__________|____________| Not at all Somewhat Moderately Very well

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The PDSA Cycle (www.ihi.org)

Act

• What changes are to be made?• Next cycle?

Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)

Study• Complete analysis of the data

•Compare data to predictions

•Summarise what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data

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Using PDSA Cycles to Facilitate Change

• Incremental process – manageable, do-able steps• All staff can be more meaningfully involved and they

own the change• Change can be planned, tested and adjusted to meet

individual circumstances• Action comes from the ground up and is more realistic• Avoids ‘us and them’ culture

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A Couple of Great Resources• Chronic Disease Self-Management Support

Guide (http://sgrhs.unisa.edu.au/CDSM/) produced by The Eyre Peninsula Division of General Practice and the Spencer Gulf Rural Health School

• Navigating self management: a practical approach for Australian health agencies (www.goodlifeclub.info) written by Jill Kelly and Naomi Kubina

http://sgrhs.unisa.edu.au/CDSM/



http://www.goodlifeclub.info/

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Chronic Disease Items for Care Planning

MORE INFORMATION

http://www.health.gov.au/epc

Info on Allied Health Items

http://www.medicareaustralia.gov.au/providers/incentives_allowances/medicare_initiatives/

allied_health.shtml

http://www.health.gov.au/

http://www.health.gov.au/

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3. Individual Health Practitioner Change

• What am I going to do in the next week?– Enablers– Barriers

• Whom have I met here that I can contact for support?

• How do I plan to get my Certificate of Competence in 3 months time?

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KIC MR IL AuditKnowledge of Condition

• Does the program (my service) provide disease-specific education?

• Is client education based on relevant clinical guidelines?

• Are clients linked to other relevant disease specific education in the community when needed

|____________|__________|____________| Not at all Somewhat Moderately Very well

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The Flinders Program• The Flinders Chronic Condition Management

Program

Submit a minimum of 3 care plans within 3 months of the workshop

Licence to use the Flinders Program

Follow up and ongoing support

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The Flinders Program –training possibilities

• Trainer Accreditation

2 day workshop + post w/shop activities

Licensed as an Accredited Trainer

Follow-up and ongoing support

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• Flinders Program for Prevention of Chronic Conditions- Living Well

2 day workshop + post w/shop activities1 day bridging workshop + post w/shop activities

Follow-up and ongoing support

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• Communication and Motivation skills: enhancing self-management support.

1 day workshop – supplements all workshops.

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OnlineGrad Cert In Health (Self-Management)Grad Dip in Chronic Condition ManagementMasters of Public Health (Self-Management)

dhc200403

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Further InformationFlinders Human Behaviour Health Research Unit

Phone: (08) 8404 2323

Fax: (08) 8404 2101

Email: [email protected]

http://som.flinders.edu.au/FUSA/CCTU/default.html

• http://www.improvingchroniccare.org• http://www.health.gov.au/internet/main/publishing.nsf • http://www.who.int/chp/knowledge/publications/icccreport/

mailto:[email protected]

http://som.flinders.edu.au/FUSA/CCTU/default.html

http://www.improvingchroniccare.org/

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Personal Plan• Use the PDSA Worksheet for Testing Change to

Plan a first step for incremental change to one of the 3 aspects of self management support you would like to change

alternatively• Complete the Worksheet for the intention of

gaining your Certificate of Competence172

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Please complete your evaluation forms

Thank You

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Documents

11 of CHRONIC CONDITION MANAGEMENT FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT THE FLINDERS PROGRAM ™