THE FLINDERS MODEL CHRONIC CONDITION SELFMANAGEMENT FLINDERS HUMAN

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

Positive Policy Environment Links Community P r e p a r e d Health Care Organization Patients and Families 2 WHO’s Health Care for Chronic Conditions team (CCH) http: //whqlibdoc. who. int/hq/2002/WHO_NMC_CCH_02. 01. pdf Better Outcomes for Chronic Conditions

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

National Chronic Disease Strategy • Action Areas: – – (www. coag. gov. au) Prevention Early intervention Integration and coordination Self-management • Priority recommendations – Clinicians receive education in self-management support – Self-management support is incorporated into routine 4 clinical care

History of Flinders Model Coordinated Care Trials SA Health Plus 1997 -1999 Sharing Health Care Initiatives C’wealth Dept Health & Aging 2001 - 2004 Flinders Model developed Partners In Health scale trialed and standardised 2001 5

History of The Flinders Model WHO identify chronic conditions as major health impact 2002 -2003 National Primary Care Collaboratives From 2004 Australian Better Health Initiative 2006 - present SA Chronic Disease Strategy 2004 National Chronic Disease Strategy From 2005 6

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

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) 8

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) 9

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

• Researched & Published outcomes 11

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

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

What is new? 14

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 15

Further Information Flinders Human Behaviour Health Research Unit Phone: (08) 8404 2323 Fax: (08) 8404 2101 Email: self-management@fmc. sa. gov. au http: //som. flinders. edu. au/FUSA/CCTU/Home. html • http: //www. improvingchroniccare. org • http: //www. health. gov. au/internet/wcms/publishing. nsf/Content/pqncds 16 • http: //www. who. int/chp/knowledge/publications/icccreport/en/