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

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CHRONIC CONDITION

SELF-MANAGEMENTFLINDERS HUMAN

BEHAVIOUR & HEALTH RESEARCH UNIT

THE FLINDERSMODEL

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Positive Policy Environment

Community Health Care OrganizationPP

rreeppaarreedd

Patients and Families

Better Outcomes for Chronic Conditions

Links

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

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Positive Policy EnvironmentStrengthen PartnershipsSupport legislative frameworks

Promote consistent financingDevelop and allocate human resourcesIntegrate policies

Provide leadership and advocacy

CommunityRaise Awareness

Encourage better outcomes through leadership and supportMobilize and coordinate

resources Provide complementary

services

Promote continuity and coordinationEncourage quality through

leadership and incentives

Organize and equip health care teams

Use information systems

Support self-management and prevention

Health Care OrganizationPP

rreeppaarreedd

Patients and Families

Better Outcomes for Chronic Conditions

Links

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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

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History of Flinders Model

Flinders Model 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

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History of The Flinders Model

WHO identify chronic conditions as major health impact

2002-2003

SA Chronic Disease Strategy

2004

National Chronic Disease Strategy

From 2005

National Primary Care Collaboratives

From 2004

Australian Better Health Initiative

2006- present

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Self-Management: Who’s Responsible?

Self-management

Self-management support

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Characteristics of Successful Self-

Management Support1. 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)

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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)

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Principles of Self-Management K

I C

MRIL

KnowledgeInvolvementCare PlanMonitor and RespondImpactLifestyle

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• Researched & Published outcomes

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Care PlanAgreed Issues

Agreed Interventions Shared Responsibilities

Review Process

The Flinders Model

Problems and Goals+Assess

Self-Management

PsychosocialSupport

Community / Carer Support

Self-Management

MedicalManagement

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The Final Product : The Care Plan

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

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What is new?

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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

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Further InformationFlinders Human Behaviour Health Research Unit

Phone: (08) 8404 2323 Fax: (08) 8404 2101

Email: [email protected]://som.flinders.edu.au/FUSA/CCTU/Home.html

• http://www.improvingchroniccare.org• http://www.health.gov.au/internet/wcms/publishing.nsf/Content/

pq-ncds  • http://www.who.int/chp/knowledge/publications/icccreport/en/