Education Module

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THE FLINDERS PROGRAM
of CHRONIC CONDITION MANAGEMENT
FLINDERS HUMAN BEHAVIOUR HEALTH RESEARCH UNIT
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• Importance
• Confidence

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Welcome and Introductions

• Current Role
• Client Group
• Interest in Chronic Condition Management
• Expectations of the Workshop

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The Program

• Day 2
• Review of Day 1
• Additional Resources for Interviews (Stages of
  Change, Motivational Interviewing)
• Volunteer Interview
• Planning for Practice Change

• Day 1
• Background Evidence
• The Flinders Program

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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

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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

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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

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Professional Development

• This workshop has been endorsed by The Royal
  Australian College of General Practitioners
  (RACGP) The Royal College of Nursing, Australia
  (RCNA) according to approved criteria.
• RACGP QACPD activity
• Category 1 - Attendance 2 days Certificate of
  Competence completed- 40 points
• Category 2 - Attendance day 1only- 12 points
• RCNA Attendance attracts 11.5 Continuing Nurse
  Education (CNE) points as part of RCNAs Life
  Long Learning Program (3LP).

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History of Flinders Program
Coordinated Care Trials SA Health Plus 1997-1999
Flinders Program developed
Sharing Health Care Initiatives Cwealth Dept
Health Aging 2001 - 2004
Partners In Health scale trialed and
standardised 2001
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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.

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Flinders Program in Context
WHO identify chronic conditions as major
health impact 2002-2003
SA Chronic Disease Strategy 2004
National Primary Care Collaboratives From 2004
National Chronic Disease Strategy From 2005
Australian Better Health Initiative 2006- 2010
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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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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_02.0
  1.pdf

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Chronic Condition under an Acute Model

• Poor Outcomes due to-
• Delays in detection of complications or decline
• Failures in self-management, or increased risk
  factors as a result of client passivity or
  ignorance
• Reduced quality of care
• Undetected or inadequately managed psychological
  distress
• (Wagner et al, 1996)

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed Activated Patient
Productive Interactions
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www.improvingchroniccare.org
Improved Outcomes
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Self-Management Whos
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.

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Activity Brainstorm

• What are the characteristics
• of people who self-manage well?

What barriers might they experience?
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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.

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Definition of a Good Self- Manager

• 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.

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Principles of Self-Management

• 1. Know your condition
• Be actively Involved with the GP health workers
  to make decisions navigate the system
• Follow the Care Plan that is agreed upon with the
  GP and other health professionals

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Principles of Self-Management cont.

• 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
• 7. Readily access Support Services

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Principles of Self-Management

• K
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• MR
• I
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• S

Knowledge
Involvement
Care Plan
Monitor and Respond
Impact
Lifestyle
Support Services
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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

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Activity Brainstorm

• What are the capabilities
• of those who support others
• to self-manage well?
• What barriers might they experience?

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Characteristics of Successful Self-Management
Support

• 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)
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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)
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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

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(Battersby Lawn, 2009)
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Group Discussion

• How does your current management of chronic
  conditions support clients to
• self-manage?
• What would you like to change?

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Research Projects

• Noarlunga (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 (plt0.001)
• - Goal rating 5.35- 3.55 (plt0.001)
• - Mental Health Summary Score SF12
• Reduced hospital admission rates

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• RGH (Chronic Complex Lung Disease)
• Prospective unblinded, RCT, 12 months follow up
• Respy rehab with and without Flinders Program
• Statistically significant improvement
• - in 6 minute walk (plt0.05)
• - the impact scale of the SGRQ (plt0.05)
• Clinical Improvement
• - in 6 minute walk (gt54m)
• - QOL Score (SGRQ total score)

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• 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 (plt0.001)
• - Goal Rating 7.26- 5.42 (plt0.001)
• - Mean HbA1c 8.74 8.08 (plt0.001)

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• Sharing Health Care Whyalla
• Participants - People with complex chronic
  illness
• Aboriginal people gt 35 years of age
• Non-Aboriginal people gt 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 plans

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Harvey, 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.
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PIH
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PIH
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Hospital admission
 
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• Vietnam Veterans
• Alcohol Related Chronic Conditions
• 9 month RCT n77
• Usual Care vs Usual Care FP /- Stanford
• Statistically significant improvement
  (intervention n46)
• i) Alcohol dependence as per DSM-IV
• Baseline 61 gt 9 months 41 gt 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

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Internal report
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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

(Warsi et al, Newman et al.)
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Flinders Program Applications

• Distribution
• Australia New Zealand USA Canada Hong Kong
  Scotland Sweden
• 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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Principles of Self-Management

• K
• I
• C
• MR
• I
• L
• S

Knowledge
Involvement
Care Plan
Monitor and Respond
Impact
Lifestyle
Support Services
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The Flinders Program
Problems and Goals
Assess Self-Management

Psychosocial Support
Community / Carer Support
Self- Management
Medical Management
Care Plan Agreed Issues Agreed Interventions
Shared Responsibilities Evidence Based
Practice Review Process
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Partners In Health Scale

• Measures self-management capacity
• Completed by client independently
• Contains 12 questions covering the principles of
  self-management
• Takes 5 10 minutes to complete
• Can be used to record change over time

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Introduction
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CUE RESPONSE INTERVIEW V10 JUNE 2010
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Cue Response Interview

• A tool for GP / health professionals
• Covers the same 12 questions in the Partners in
  Health Scale
• Open-ended cue questions enable issues to be
  explored
• Answers are scored

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Cue Response Interview

• Cue questions need to explore
• Understanding / Knowledge
• What actually happens
• What are their Strengths
• What are the Barriers

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Open Questions

• Whats 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..

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(Rollnick et al,2008)
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Funnel Technique

• Begin with open ended questions
• Further explore with specific open questions
• Use closed questions to examine issues in more
  detail
• Summarise / Recap

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Funnel Technique
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In Pairs

• Turn to the person next to you.
• Use open ended questions to find out 3 things
  about this person.

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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

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Tips for Interviewing

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

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Cue Response Introduction
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Cue and ResponsePhysical Impact
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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

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Cue Response Summary Sheet

• May be used to record Health Professionals
  reflections about
• Issues for Care plan ie score 4 or below or
  discrepant 3 or more
• Interventions for the care plan
• Particular strengths/barriers
• Linking the Cue Response with Care Plan

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(No Transcript)
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Cue Response Discussion(discrepancy)
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Self-Management Assessment
Partners in Health Scale (PIH) Cue Response Interview (CR)
Quick Takes time
Self Assessment Health Professional tool
12 Questions Expanded with open-ended cue questions
Scored by client Scored by interviewer
Collaborative identification of issues Collaborative identification of issues
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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 CR Interview form
• Now transfer issues on to the Care Plan by
• Compare your scores with the interviewee scores
• Reinforcing areas of good self-management (high
  scores)
• Items with scores 4 and below go onto the issues
  section of the care plan
• Discuss scores with 3 or more difference and
  change scores if needed.

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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?

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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 clients own resources

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Brainstorm

• Why is using a scale/numbers useful?
• Why is comparing the scores useful?
• For the person?
• For the worker?

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The Flinders Program
Problems and Goals
Assess Self-Management

Psychosocial Support
Community / Carer Support
Self- Management
Medical Management
Care Plan Agreed Issues Agreed Interventions
Shared Responsibilities Evidence Based
Practice Review Process
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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

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Battersby M, Ask A, Marwick M, Collins J- A Case
Study using the Problems and Goals Approach.
Aus Journal Primary Health 20037(3)45-48 Batters
by M et al Health Reform through Coordinated
Care SA Health Plus. BMJ 2005330662-6
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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?

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Problem Statement

• 3 parts to a problem statement
• The Problem
• What happens to the client because of the
  problem?
• How this makes the client feel?

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Problem Statement

• The clients 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 effectively self-managing with
  minimal disability, they may not have a problem.

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Problem Measurement

• Problem Statement
• Because Im often short of breath I dont 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 8
• Not at Very little Somewhat a fair
  bit A lot
• all

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Problem Measurement

• Problem Statement
• Since my daughter moved I dont 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 8
• Not at Very little Somewhat A fair
  bit a lot
• all

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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

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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)

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Goal Statements
Repeated and S.M.A.R.T. Specific (doing
something) Measurable (observable) Action based
Realistic (not too reliant on others) Timeframe
(how long / how often)
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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

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Goal Measurement
Goal Statement I will catch the community bus to
the local community centre, twice a week for the
afternoon Craft Group Rating Scale My progress
towards achieving this goal is 0 1 2 3
4 5 6 7 8 No
50 Complete progress
success
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Goal Measurement
Goal Statement I will email my grandchildren
every week when I go to the library Rating
Scale My progress towards achieving this goal
is 0 1 2 3 4 5 6 7 8 No 50
Complete progress success
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• What is the purpose of scoring
• ?

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Goal Setting
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Practical

• Role play
• Group Discussion

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(No Transcript)
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The Flinders Program
Problems and Goals
Assess Self-Management

Psychosocial Support
Community / Carer Support
Self- Management
Medical Management
Care Plan Agreed Issues Agreed Interventions
Shared Responsibilities Evidence Based
Practice Review Process
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Care Planning
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Flinders Care Plan

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

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Flinders Care Plan

• Contains
• Problem Goal Statements at head of care plan
  with scores
• Issues from the Cue Response Interview
  Problems and Goals
• What I want to achieve
• Agreed Steps to get there
• Review dates
• Sign off

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Identified Issues

• Ensure all Issues negotiated in the Cue and
  Response Discussion are listed on Care Plan
• score of 4 or below 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.

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What I Want to Achieve

• Not just the opposite of the issue.
• They are the clients personal aims
• What benefit will a change bring to me?
• What do I want to get out of dealing with this
  issue?
• It will be individualised and specific to the
  issue
• Can be more than one point per Issue

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Steps to Get There

• Steps to Get There
• What are the possible solutions to the identified
  issues?
• Which of these does the person choose to utilise.
• Small manageable steps to achieve the clients
  personal aims.
• 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

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Steps
External resources
Tools

• Symptom Action Plan
• Monitoring Diary
• Handbook
• Checklist
• Best Practice Guidelines
• Next Steps

Coping skills
Courses/Groups
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Steps
External resources
Tools

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

Coping skills
Courses/Groups
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Steps
External resources

• DASSA
• Walking and exercise groups
• Group Programs
• Self-help/ Support groups
• Education classes

Tools
Coping skills
CoursesGroups
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Steps
External resources
Tools

• Problem Solving
• Stress Management
• Anger Management
• Job re-entry
• Assertiveness training

Courses/Groups
Coping skills
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Review and Monitoring

• Specify date when each intervention is 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

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Structured Problem Solving
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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

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(Hawton Kirk, 1989)
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When would you use it?

• To teach problem solving rather than you solving
  it for them (collaborative not directive)
• When the person hasnt been able to achieve a
  goal from the care plan
• When barriers to self-management have been
  identified

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Steps to Problem Solving

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

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Practical

• Using the role play,
• complete the Care Plan

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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 we covered so far

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...Principles of Self-Management

• K
• I
• C
• MR
• I
• L
• S

Knowledge
Involvement
Care Plan
Monitor and Respond
Impact
Lifestyle
Support Services
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The Flinders Program

• Principles of Self-Management
• PIH Scale
• CR Interview
• PG 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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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

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...Characteristics of Successful Self-Management
Support

1. 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.

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(Von Korff et al, 1997Battersby and Lawn,2009)
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Feedback
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End of Day One
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(No Transcript)
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THE FLINDERS PROGRAM
of CHRONIC CONDITION MANAGEMENT
FLINDERS HUMAN BEHAVIOUR HEALTH RESEARCH UNIT
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Overview of Day 2

• Recap Flinders Program
• Volunteer Interview
• Care Plan Review
• Planning for Practice Change

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Summary of The Flinders Program

• Principles of Self-Management
• PIH Scale
• CR Interview
• PG 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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Principles of Self-Management

• K
• I
• C
• MR
• I
• L
• S

Knowledge
Involvement
Care Plan
Monitor and Respond
Impact
Lifestyle
Support Services
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Susan
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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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ENTER Particular behaviour problem (e.g.
drinking, smoking, over-eating)
Stages of Change
EXIT Long-term abstinence or moderation
Lapse
Maintenance
Pre-contemplation
Action
Contemplation
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Determination to change
(Prochaska DiClemente, 1986)
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Volunteer Interview
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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?

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Tips for Interviewing

• 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

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Volunteer Interview

• Introduce the Flinders Program to the client
• Client to complete Partners in Health
• Complete Cue Response interview
• Identify the issues and put them on the Care Plan
• Complete Problems Goals interview
• Complete the Care Plan together discuss
• Desired achievements
• Steps
• Whos responsible and put them on the Care Plan

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Feedback
How was the interview for the volunteer? How was
the interview for the interviewer?
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Thanks to the volunteers
for participating
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Feedback
What went well? What were the difficulties?
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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.

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Review of Care Plan
Time to reflect and critique your care plan done
with the volunteer
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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)

(Moyers Rollnick, 2002)
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Five Key Principles

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

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(Moyers Rollnick, 2002)
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Undertaking the Interview

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?

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And.

1. Highlight any discrepancies
2. Get the client to rate both importance and
   confidence on a scale of 1 to 10
3. Summarise
4. Look to the future. Is the good / not so good
   balance going to change?

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How does the Flinders Program motivate people
to change?
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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 (CR)
• Encouraging clients to explore barriers to change

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Motivational Elements

• Client generated PG statements that are linked
  to behaviour change
• Collaborative development of the Care Plan with
  agreed issues and steps to take
• Increasing self-confidence in achieving small
  gains (PG, Care Plan steps)
• Shared responsibility / accountability
• A sign off on the Care Plan
• Monitoring and review

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• Change is more likely if people make decisions
  themselves instead of in response to external
  pressure
• (shared Care Plan)

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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

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(Battersby Lawn, 2009)
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Patient Centred Capabilities (underpin the
Flinders Program)

• Ability to negotiate - see the issues from the
  patients point of view
• Share decisions
• Collectively solve problems
• Establish goals
• Implement action
• Clarify roles and responsibilities
• Evaluate progress

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Behaviour Change Capabilities (underpin 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 planning

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Battersby Lawn,2009
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Organisational/System Capabilities

• Multi/Inter disciplinary teams
• Communication systems
• Evidence based practice
• Research
• Partnerships with community

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System Change

1. Health Care System (National/State)
2. Organisation Health Care Model (Local)
3. Individual Health Practitioner

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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
• National Healthcare Agreement

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
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www.improvingchroncicare.org
Improved Outcomes
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2. Organisation - Health Care Model
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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?

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Experience of Change

• Dynamic view
• Non-linear
• Revolutionary incremental
• Continuous
• About learning
• Turbulent
• Uncontrollable/Unpredictable
• Creative
• Full of opportunity
• Normal

• Traditional view
• Linear
• Disruptive
• Cause effect
• Incremental
• An event
• Calamitous
• Controllable
• Abnormal

(Lawn,2008McMillan,2004)
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Tips for embedding change

1. Change needs Champions! Facilitating change
   within complex system.
2. Fit in the context of the Wagner Model
3. Tailored to individual team and individuals
   within teams.
4. Need clear role definition
5. Collaborative motivational approach

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• Peer learning and modelling is important
• Facilitation and support within the team
• Training and competency development is one
  component
• Linking of long term aims with shorter action
  plans. Not a linear process. No magic formula.
• Structured approach with a variety of tools and
  processes.

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Example processes.
skills audit
team formation
service audit
training
Change Facilitator
goal setting
client journey mapping
process mapping
improvement cycles
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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

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Bonomi, AE., Wagner E., et al (2002)
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Example
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(Bonomi et al, 2002)
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KIC MR IL Audit

• Knowledge 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
Plan

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

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

Study
Do

• Complete analysis of
• the data
• Compare data to
• predictions
• Summarise what was learned

• 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.i
  nfo) written by Jill Kelly and Naomi Kubina

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Chronic Disease Items for Care Planning
MORE INFORMATION http//www.health.gov.au/epc Inf
o on Allied Health Items http//www.medicareaustra
lia.gov.au/providers/incentives_allowances/medicar
e_initiatives/allied_health.shtml
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3. Individual Health Practitioner Change

• What am I going to do in the next week?
• Enablers
• Barriers
• How do I plan to get my Certificate of Competence
  in 3 months time?

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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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The Flinders Program training possibilities

• Flinders Program for Prevention of Chronic
  Conditions- Living Well
• 2 day workshop post w/shop activities
• 1 day bridging workshop post w/shop activities
• Follow-up and ongoing support

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The Flinders Program training possibilities

• Communication and Motivation skills enhancing
  self-management support.
• 1 day workshop supplements all workshops.

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The Flinders Program training possibilities

• Online
• Grad Cert In Health (Self-Management)
• Grad Dip in Chronic Condition Management
• Masters of Public Health (Self-Management)

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Further Information

• Flinders Human Behaviour Health Research Unit
• Phone [phone]
• Fax [phone]
• Email self.management_at_flinders.edu.au
• 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/iccc
  report/

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Personal Plan

• Use the PDSA Worksheet for Testing Change to Plan
  the 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 Competence

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• Importance
• Confidence

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• What is the most useful thing you have gained
  from this workshop?

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• Please complete your evaluation forms
• Thank You

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