1 CHRONIC CONDITION SELF-MANAGEMENT FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT THE FLINDERS MODEL

2 Positive Policy Environment Community Health Care Organization Prepared Prepared Prepared Prepared Patients and Families Better Outcomes for Chronic Conditions Links WHO’s Health Care for Chronic Conditions team (CCH)

3 Positive Policy Environment  Strengthen Partnerships  Support legislative frameworks  Promote consistent financing  Develop and allocate human resources  Integrate policies  Provide leadership and advocacy Community  Raise Awareness  Encourage better outcomes through leadership and support  Mobilize and coordinate resources  Provide complementary services  Promote continuity and coordination  Encourage quality through leadership and incentives  Organize and equip health care teams  Use information systems  Support self-management and prevention Health Care Organization Prepared Prepared Prepared Prepared Patients and Families Better Outcomes for Chronic Conditions Links

4 National Chronic Disease Strategy ( 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

5 History of Flinders Model Flinders Model developed Coordinated Care Trials SA Health Plus Sharing Health Care Initiatives C’wealth Dept Health & Aging Partners In Health scale trialed and standardised 2001

6 History of The Flinders Model WHO identify chronic conditions as major health impact SA Chronic Disease Strategy 2004 National Chronic Disease Strategy From 2005 National Primary Care Collaboratives From 2004 Australian Better Health Initiative present

7 Self-Management: Who’s Responsible? Self-management Self-management support

8 Characteristics of Successful Self-Management Support 1. Collaborative Problem Definition (between client and health professionals) 2. 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)

9 Characteristics of Successful Self-Management Support 3. Self-Management Training and Support Services (include instruction on disease management, behavioural support, & address physical & emotional demands of having a chronic condition) 4. Active and Sustained Follow-up (reliable follow-up leads to better outcomes) (Von Korff et al, 1997)

10 Principles of Self-Management K I C MR I L Knowledge Involvement Care Plan Monitor and Respond Impact Lifestyle

11 Researched & Published outcomes

12 Care Plan Agreed Issues Agreed Interventions Shared Responsibilities Review Process The Flinders Model Problems and Goals + Assess Self-Management Psychosocial Support Community / Carer Support Self- Management Medical Management

13 The Final Product : The Care Plan An active document that supports: –Communication –Organisation –Partnership –Motivation –Planning and follow-up –Outcome measurement

14 What is new?

15 Summary of The Flinders Model 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

16 Further Information Flinders Human Behaviour Health Research Unit Phone: (08) Fax: (08) ncds -ncds