1. Good Life Club Project System change to embed self-management. Jill Kelly

2. Today…. Briefly describe project model Briefly describe project model Description of Transition Phase of program Description of Transition Phase of program Highlight learnings Highlight learnings

3. 3 year Demonstration Project Telephone coaching by Allied Health Practitioners & general practice nurses Telephone coaching by Allied Health Practitioners & general practice nurses Promotion of Multi-disciplinary care planning/self-management plan Promotion of Multi-disciplinary care planning/self-management plan Client Website www.goodlifeclub.info Client Website www.goodlifeclub.info Club activities Club activities Client newsletter Client newsletter & email newsletter

4. Transition Phase – 2 years Action Plans to embed CDSM Action Plans to embed CDSM Organisational support Organisational support Train the Trainers Flinders Uni model Train the Trainers Flinders Uni model Regional Practitioners network Regional Practitioners network Stanford course leader Stanford course leadertraining

5. Central Administration, Co-ordination and Development  Leadership for capacity building initiatives  Source of expertise in chronic Condition self-management  Central marketing role  Promoting chronic Condition self-management to GPs & other health providers  Facilitating skills training for Allied Health Practitioners and volunteers  Evaluation & dissemination of evidence and results  Financial administration  Engaging other stakeholders eg. Dept of Veteran Affairs, Council of the Ageing Embedding Telephone coaching for chronic Condition in partner agencies Flexible models of delivery in fitting with structure of organisation. Support for the organisational change management process PDSA $ GLC Club activities Integrate more fully with existing activities in community. Activities “Branded" as GLC "endorsed" to create a common identity across community Facilitate training at Regional level Stanford model Flinders Uni model Health Coaching Building capacity in general practice e.g. chronic illness clinics & coaching for PN’s. Pilot initiatives to match current chronic condition initiatives e.g MBS items Organisational capacity building.skills training for AHP Change management support Regional Practitioners Group

6. SUSTAINABILITY “PROJECTS” Trialled different models of coaching Trialled different models of coaching Barriers and facilitators identified Barriers and facilitators identifiedFacilitators Supportive and proactive management Supportive and proactive management Consultant approach Consultant approach Organisational and health professional behaviour change supported Organisational and health professional behaviour change supported Regional Practitioners Group – at team leader level Regional Practitioners Group – at team leader level PDSA cycles PDSA cycles

7. Sustainability Projects Follow-up telephone coaching 4 months post diabetes education group Follow-up telephone coaching 4 months post diabetes education group Using the Wagner Assessment in Chronic Illness Care tool Using the Wagner Assessment in Chronic Illness Care tool Division – establish self-management in 2 Asthma Clinics in general practice Division – establish self-management in 2 Asthma Clinics in general practice Establish Volunteers in Chinese Good Life Club Establish Volunteers in Chinese Good Life Club Trial Flinders Uni CDSM tool in SRS Trial Flinders Uni CDSM tool in SRS Action planning in Diabetes Education group Action planning in Diabetes Education group Acute sector – planned to establish use of Flinders Uni tools Acute sector – planned to establish use of Flinders Uni tools

8. What worked… Small $ grants for Action Plans Small $ grants for Action Plans PDSA cycles PDSA cycles Regional practitioner group – at Team Leader level Regional practitioner group – at Team Leader level Training – Stanford, health coaching/motivational interviewing Training – Stanford, health coaching/motivational interviewing Good Life Club Trademarked Good Life Club Trademarked Promoting evaluation – HEI-Q Promoting evaluation – HEI-Q $ support to Chinese Health Foundation of Australia $ support to Chinese Health Foundation of Australia Consultant/leader at regional level Consultant/leader at regional level Regional Practitioners Group – at Team Leader Level Regional Practitioners Group – at Team Leader Level

9. What didn’t work…. Difficult engaging some Managers/Team leaders Difficult engaging some Managers/Team leaders Engaging acute health/HARP Engaging acute health/HARP Flinders model implementation Flinders model implementation Difficult to plan for sustainability Difficult to plan for sustainability Context – no DHS policy or $ for CDM Context – no DHS policy or $ for CDM Lacked broader principles & elements of Wagner model of CDM Lacked broader principles & elements of Wagner model of CDM

10. What’s happening now… Two resources being developed: 1. Development of a practical guide to implementing self-management and chronic disease systems 2.Research and develop an Information Package on nurse-led chronic disease clinics in General Practice

11. More Information www.goodlifeclub.info www.goodlifeclub.info www.goodlifeclub.info (see Health Professionals/Resources) Australian Journal of Primary Health Australian Journal of Primary Health Vol. 9 2&3 2003 Vol. 9 2&3 2003