SelfManagement Support for Chronic Conditions The Flinders Model

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Self-Management Support for Chronic
ConditionsThe Flinders Model

• Flinders Human Behaviour and Health Research Unit
• Flinders University
• Malcolm Battersby

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Aims

• Background to the Flinders model
• Understanding the Flinders model
• Research
• Training
• Education
• Australian Better Health Initiative
• Evaluation

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Why is CCSM important? (Adherence)
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Acute Chronic

• Ongoing
• Incurable
• QOL highly dependent on pts self management and
  decision making
• QOL highly dependent on ongoing support services
• Pt often has more knowledge
• Short term goals to meet long term outcomes
• Compliance and self reliance expected

• Episodic
• Cure expected
• QOL highly dependent on professional care
• QOL highly dependent on short term services
• HP generally the expert
• Short term goals
• Compliance expected

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Sub-optimal PoorCare Outcomes

• 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, E., Von Korff, M., et al, Organising Care
  for Patients with Chronic Illness. The Milbank
  Quarterly, Vol. 74, No.4, 1996

• Irregularor incompleteor inadequate .or
  inconsistent assessment,
• treatment
• education, motivation, feedback and /or
  follow up.

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Patients are (already) the Primary Source of Care
People with chronic conditions are the
principal care-givers. Health care
professionals should be consultants supporting
them in this role. Each day, patients decide
what they are going to eat, whether they will
exercise and to what extent they will consume
prescribed medicines.
Bodenheimer et al, JAMA 2002
Patients are in control. No matter
what professionals say and do, they can and do
veto decisions a health professional makes.
Glasgow Anderson, Diabetes Care, 1999
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My Background

• Isaac Marks Inst of Psychiatry, London
  1987-1990
• Behavioural psychotherapy for anxiety disorders
  training and education of nurses
• Outcome measurement is integral to motivation for
  both patient and therapist, and provides
  competency, individual and service outcome
  measures
• Anxiety and Problem Gambling treatment service at
  Flinders Medical Centre (650 referrals annually)

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Background - SA HealthPlus

• SA HealthPlus Coordinated Care Trial
• 1997 1999
• Patients with chronic and complex illnesses
• 8 projects in 4 regions of South Australia
• 
  
• Hypothesis
• Coordinated Care would improve health outcomes
  for the same or less cost
• Battersby et al, BMJ, March 2005

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Model of Care

• Patient-centred approach (holistic)
• Behavioural change towards improved self
  management
• Evidenced based guidelines
• Prospective Care Planning
• Prevention focussed
• Improved coordination of care
• System change

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Training

• 4,500 patients randomised into Intervention
  (3000) and Control (1500) groups in 8 projects
• Training unit established to provide training
  for
• 100 Service Coordinators
• 295 General Practitioners

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Components of Training Program
1. Problems and Goals assessment, expressed in
behavioural terms 2. Generic Care Planning
process 3. Competency assessment 4. Regular
clinical supervision 5. Service Coordinator
Appraisal and Accreditation 6. Ongoing
skills training and development
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Achievement of Goal 1
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BACKGROUND -Year 1 review

• Problems and Goals worked well for most patients
• However the system designed to allocate
  coordination time according to level of severity
  (H/M/L) wasnt being used
• WHY?
• Because some people who had severe complicated
  conditions, but were good self-managers, had good
  supports and relationship with their GP, did not
  need coordinated care
• Service coordination was provided based on
  whether a person was a good self-manager or not
• Self management was not defined or
  operationalised

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Learning

• Self-management capacity is modulated by the
  illness and personal attributes as well as
  attributes of health providers and cultural and
  social factors
• Self-management ability needs to be assessed
  before the right intervention is offered
• Not all consumers need self-management
  interventions and those who do will respond to a
  wide range of learning methods, some group, some
  individual
• (Battersby et al, Milbank Quarterly, Dec 2006)

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Design a Clinician initiated, Generic, Chronic
Condition Self-management Program

• Literature search and review
• Stakeholder involvement/focus groups
• GP education for their input into program
  material and process
• Pilot project guidelines and timeframe
• Training of participants - patient, GP, and
  Service Coordinator.

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Brainstorm

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

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Definition of Self-Management

• The Centre for Advancement in Health (1996)
  proposed the following definition
• Involves 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.
  (p.1)

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• 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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Six Principles of Self-Management

• 1. Know your condition
• Have active Involvement in decision making with
  the GP or health workers
• Follow the Care plan that is agreed upon with
  the GP and other health professionals

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Six Principles of Self-Management

• 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

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Principles of Self-Management

• K Knowledge
• I Involvement
• C Care plan
• MR Monitor and Respond
• I Impact
• L Lifestyle

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Partners In Health ProgramTools/Interventions

• PIH (Partners in Health) Scale
• Cue and Response interview
• 3. Problem and Goals
• 4. Care Plan
• 5. Partners in Health Handbook
• 6. Symptom Action Plan (SAP)
• 7 Monitoring Diary
• 8 . Doctor visit Checklist

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Further training given to Service Coordinators to
assist in delivering the Program

• Motivational Interviewing Techniques
• Problem-Solving/Decision Making Skills
• Mental health symptom recognition -anxiety and
  depression
• Coping Strategies techniques
• Self-Management resources in the community

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Patient responses

• I am motivated to look after myself. I now feel
  confident about asking my GP questions. I plan
  ahead and am more thoughtful about my condition.
  I dont sit around feeing sick these days, I look
  for solutions.
• I dont drink as much as I did before. I
  exercise regularly and take my time - I gauge
  myself. I am more aware that I should live a
  healthy lifestyle.

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Conclusion

• Clinicians (and patients) could assess
  self-management knowledge, behaviours, barriers
  and target interventions and education to the
  individual

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What do Clinicians need to do to become true
Partners in Health?
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The Key is to integrate a Self Management Care
Plan with the Medical Care Plan and to
systematically Monitor and Measure Health Outcomes
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How can this be done systematically, in a patient
centred way, measuring progress in behaviour
change, as well as health outcomes, and that
ensures ongoing monitoring?
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The Flinders Model-Enhancing Self-management

• Assessment
• Partners in Health Scale
• Cue and Response Interview
• Problems and Goals Assessment
• Care Plan
• Identification of Issues and Goal Setting
• Schedule services
• Tools
• Symptom action plan
• Doctor visit checklist
• Patient Handbook
• Monitor and Review

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Harkness Fellowship 2003-4

• Ed Wagner, Michael Von Korff, Group Health,
  Seattle, Washington State
• Self-management of chronic conditions in
  indigenous and mental health populations

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Evidence for What Works in Chronic Illness
Management

• Wagner et al Center for Health Studies, Group
  Health, Seattle
• WHO, 2002
• 6 elements for achieving best outcomes for
  individuals and populations
• Self-management support is the most important of
  these elements

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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
Improved Outcomes
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Evidence for Self-Management

• Warsi et al, 2004, Archives of Int Medicine
• Newman et al, 2004, Lancet
• Effective self-management interventions in asthma
  and diabetes, equivocal in arthritis
• Small to moderate effect sizes and maintenance of
  effect over time varies
• Generic lay led programs (Lorig et al) Newbould
  et al, Chronic Illness 2006, small to moderate
  effect sizes up to 12 months

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12 Principles for Self-management Support
(Battersby, Von Korff et al)

• 1. Assessment clinical severity, function,
  self-management behaviours, goals, barriers
• 2. Information alone shows negligible effects
• ie - Education should be skills based
• 3. Counseling should be non-judgmental e.g,
  motivational interviewing
• 4. Defining Problems and Goal setting are
  effective

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Evidence-Based Principles for Self-Management
Support (SMS)

• 5. Collaborative Problem Solving is effective
• 6. Diverse professionals and lay persons can
  deliver effective self-management support if
  tasks are defined and evidence based
• 7. Self-management interventions can be delivered
  by diverse modalities e.g, individual, group,
  telephone, self-instruction
• 8. Interventions should strengthen self-efficacy

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Evidence-Based Principles for Self-Management
Support (SMS)

• 9. Organised follow up improves outcomes
• 10. Case management is effective only if it is
  goal directed and guideline based
• 11. SMS should include community based programs
  that are evidence based
• 12. Multi-faceted interventions are more
  effective than single component interventions

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Better outcomes

• Best outcomes for an individual are achieved by a
  combination of
• evidence based medical management and
• self-management i.e, a partnership
• Self-management is what the patient does
• Self-management support is what the health
  professional, the practice and system provides
• Von Korff M, Gruman J, Schaefer J,
  Curry SJ, Wagner EH (1997), Collaborative
  Management of Chronic Illness, Annals of Internal
  Medicine, 127(12) 1097-1102

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Flinders Model

• Outcomes based
• Generic
• Motivational
• Medical with self-management (Holistic)
• Patient-centred
• Communication
• Coordination

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Partners In Health Scale

• Measures self-management capacity
• Completed by patient (5-10 minutes)
• Contains 12 questions covering the 6 principles
  of self-management
• Can be used as a screening tool
• Can be used to record change over time

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• VIDEO INTRO AND CUE AND RESPONSE

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Cue and Response Interview

• A tool for GP/health professional
• Covers the same 12 questions in Partners in
  Health Scale
• A series of open ended cues allows the questions
  to be explored
• Answers are scored by the GP/health professional
• Checks assumptions
• Motivational

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VIDEO

• CUE AND RESPONSE

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Cue Response Interview

• AREAS FOR DISCUSSION
• When both parties have rated the question on the
  high end of the scale
• When scores differ markedly on any question
• AGREEMENT ON ISSUES
• Establish which identified issues the
  patient/client wishes to address and what
  interventions may be appropriate
• THESE BECOME ISSUES FOR THE SELF-MANAGEMENT PLAN

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VIDEO

• VIDEO CUE AND RESPONSE, COMPARE SCORES
  NEGOTIATION AND COLLABORATION

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Problems and Goals

• Traditionally
• We identify the patients problems (implicit or
  explicit)
• We set the goals
• Clinical goals
• Exercise goals
• Pick from a check list

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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 interventions patients in SA
  Health Plus CCT (1997-99)
• 60 of patients improved their problem rating
  score
• Up to 60 made progress with goals
• Battersby M, Ask A, Markwick M, Collins J.- A
  case Study using the Problems and Goals
  Approach Aus Journal Primary Health 2003 7(3)
  45-48
• Battersby M et al - Health Reform through
  Coordinated careSA HealthPlus. BMJ
  2005330662-6

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VIDEO

• PROBLEM AND GOAL INTRO

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VIDEO

• PROBLEM AND GOAL GOAL SETTING

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Care Plan

• Identified issues from PIH and CR
• Identified issues from PG assessment
• Lists preventative medical, allied health,
  psychological and self management services or
  actions
• Management Aims
• Interventions
• Responsibilities
• 12 month planned appointments / tests etc
• Sign off

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Monitoring and Review

• Monitoring is an important component of this
  process
• Provider-initiated follow up
• Self-monitoring
• Helps to maintain motivation
• Enables modelling of problem solving
• Allows change if circumstances change

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VIDEO

• CARE PLAN INTERVENTIONS AND SHARED
  RESPONSIBILITY

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Unique Features

• Application of Banduras self efficacy research
  on behaviour change systematically to chronic
  conditions
• Takes into account the importance of patient
  centered care, motivational interviewing
  (Miller) and relapse prevention (Marlatt)
• Links chronic conditions with with persons
  priorities and thus addresses physical and mental
  health problems

58
Flinders Stanford

• Generic
• Taught by health professionals and peers to
  patients
• Traditional doctor/patient relationship
• Generic skills goal setting, problem solving,
  symptom management
• Based on cognitive and behavioural principles and
  techniques

• Generic
• 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)
• Based on cognitive and behavioural principles and
  techniques

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Sharing Health Care Demonstration Projects
ACT Division of General Practice
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Sharing Health Care Evaluation Report 2004

• Health outcomes generally improved
• Sustainability is a problem
• Financial disincentives for GPs
• Stanford model effective
• COACH program effective
• Flinders model effective 800 health workers
  trained
• Also worked for indigenous programs

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Flinders model

• Aim Enhance and maintain effect of
  self-management interventions through
  reinforcement of behaviour change
• Eyre Aboriginal diabetes HbA1c 12 months
• Noarlunga mental health SF-12 12 months
• Southn respiratory RCT - 6 min walk -12 mths

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Other Research

• Aboriginal diabetes
• Noarlunga mental health
• Respiratory (COPD) RCT
• NHMRC Centre for Clinical Research Excellence in
  Aboriginal Health
• Many research projects, PhDs using PIH
• Vietnam veterans alcohol and PTSD RCT
• Arthritis joint replacement waiting list RCT
• Stroke RCT
• Lehigh Valley Hospital, Pennsylvania, diabetes RCT

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TRAINING
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Training

• 2 day workshop in the Flinders model
• Certificate of Competence and licence
• Follow-up Support from Accredited Trainer and
  FHBHRU
• 2 day workshop for trainer of Flinders model

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Sharing Health Care (DOHA)

• Training in 2 day education program for
  clinicians and 2 day trainer education
• Over 2000 clinicians trained in all Aus states
  and territories including Aboriginal Health
  Workers

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EDUCATION
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CCSM education for Medical Students

• In 2003, a pilot CCSM curriculum in the graduate
  medical course at Flinders University
• This has concluded its third year
• Content
• Yr 1
• 2 PBLs to introduce the topic
• 1 lecture to define CCSM
• Assessment by exam question

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Year 2 Medical Course

• Yr 2
• 2 x 3 hour seminars to teach collaborative care
  planning and the development of a self management
  care plan
• Assignment to do one care plan for presentation
  at the second seminar
• Assessment by OSCE station

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2nd Yr OSCE pass level 12/24 with 28 (30)
students failing and 2 (2.2) students
exceptional
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CCSM education for Medical Students

• Committee of Deans Audit of Medical school
  curricula funded by Cwealth Dept of Health
• 10 Medical Schools visited and curricula surveyed
• ANZAME set of core competencies for CCSM presented

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Training of undergraduate Allied health
Professionals

• Dept of Health project 1. FHBHRU scoping
  requirements for under grad training in CCSM for
  allied health professionals
• Dept of Health project 2. FHBHRU developing a
  curriculum framework for all undergraduate health
  professionals in Australia

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Post Graduate Education

• Graduate Certificate and Graduate Diploma in CCSM
  at Flinders University
• Government scholarships
• Department of Health tender for training needs
  for all primary care clinicians in Australia

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Australian Better Health Initiative

• Council of Australian Governments announced joint
  Commonwealth and State initiative to address
  prevention and management of chronic disease
• 500 million over 4 years
• Prevention
• Early detection
• Integration and coordination
• Self-management

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Implementation Challenges

• Integration of chronic condition self-management
  into primary care and general practice in
  particular
• Integration between hospitals and primary care of
  chronic care and self-management

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Implementation of chronic care WHO 2002

• Support a paradigm shift from acute to chronic
  care
• Manage the political environment
• Build integration shared information,
  coordinated financing
• Align health with other policy areas eg housing,
  transport, education
• Use teams
• Centre care on the patient and family
• Support patients in their communities
• Emphasise prevention

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Successful chronic care (Wagner et al 96)

• Evidence based planned care and guidelines what
  needs to be done at what intervals by whom
• Practice redesign define roles of the team
• Patient education
• Clinical expertise continuing education
• Information registries, care plans

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Collaboratives

• How to translate research into practice (beyond
  the project)
• Up to 25 teams meet on 4 occasions over 12
  months,
• 1-2 day learning sessions
• The Collaborative has clearly stated 12 month,
  clinical and process outcome goals
• Teams aim to implement the 6 elements of the CCM

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Collaboratives

• The core process for the teams is the
• Plan Do Study Act (PDSA) cycle
• The Team include non clinicians, innovators
• There are 2 learning streams
• Evidence based clinical management eg asthma
• Practice change
• Set short term 8 day PDSA cycles
• Have faculty follow up/support

79
Collaboratives Success Elements

• Teams that met weekly
• Successful teams averaged 45 changes
• Successful teams had a high number of early
  change cycles
• A culture of teamwork and growth
• Not dependent on baseline features of CCM
• Not dependent on wealth of the organisation

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Collaboratives Success Elements

• Teams with a higher proportion of doctors
• Teams with a team champion
• High organisational commitment to quality
  improvement
• Contact with other teams during the collaborative
• Emphasis on collaborative decision making with
  patients

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Which Elements of the CCM?

• Not enough sites to test this but
• Meta analysis of 112 published studies found that
  each element produced improved outcomes but no
  single element was found to be either essential
  or superfluous.

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Indian Health Service

• National Diabetes Program
• National standards, service accreditation
• Self-management education modules
• Diabetes educators
• National registry data base
• 5 year improvement in HbA1c

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Indiana Outcome targets

• Diabetes and cardiac At 12 months
• 80 of all diabetic patients to have a HbA1c test
  in the last 12 months
• 30 of all diabetic patients to have HbA1c lt7 by
  12 months
• 60 of all cardiac patients to have
  self-management goals documented

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Registry

• A data base provided to all clinics for each
  doctors patients involved in the collaborative
• Provides all pathology results from the last 12
  months
• Evidence based recommended services for each
  condition diabetes, heart disease eg podiatry,
  HbA1c, ophthalmology etc
• Recall and reminder system for clinic staff and
  patient
• Provides above information on each patient and
  able to provide report for all clinic patients
  with same characteristics eg diabetes with HbA1c
  gt10

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Indiana

• Registry (cont)
• Able to collect names of patients to organise
  group education, eg disease specific, lifestyle
  etc
• Able to provide aggregated data on all patients
  involved in the collaborative

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Call Centre

• Care coordinators using a software program linked
  to the medicaide data base with each patients
  health status and care planning self-management
  goals
• Care coordinators have health related
  qualification, not necessarily a clinician
• Chosen for their telephone ability not clinical
  competence

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Call Centre

• Initial assessments conducted by phone
• 15 allocated to case managers but still
  registered with the call centre
• Care coordinators followed stepwise algorithm for
  each planned call. a form of coaching based on
  the medical and self-management goals and risk
  factors

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Call Centre

• Screening questions eg depression with subsequent
  questions to determine severity and risk.
• Provide education materials and local programs
• Summary emailed to GP with agreed follow up
  actions
• Check back technique for patient satisfaction and
  understanding
• Back up of case manager/GP if required

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Indiana Chronic Disease program

• Target group Medicaide patients low income
  individuals and families (4500 people)
• The Model
• Call centre
• Case managers
• A registry
• The Collaborative

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Case Managers

• Community health nurses
• Patients pre selected based on the most complex
  10 with high service use
• Home visits full assessment of medical, social
  and psychological needs
• Time limited 6 months
• Communication with GP

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Results

• 60-80 improvement in all measures at 12 months

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International Implementation

• New Zealand
• Care Plus government initiative administered
  through Primary Health Organisations
• Target is people with chronic conditions or
  terminal illness
• Aim effective management, improve
  understanding, support and lifestyle changes
• Mania PHO, Whangerei Practice nurses
  implementing chronic care using Flinders process
  has turned the rhetoric into reality
• Practice nurse role has now been enhanced
  brings holistic approach to the practice and
  their role is increasingly recognised
• Singapore

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International

• Singapore
• Polyclinics government funded community centres
  have established the role of care managers
  mainly nurses to assess and provide case
  management and education to chronic care
  patients, referred by clinic GP or specialists
• Hospitals have in-patient case managers whose
  role is to select complex patients who re-admit,
  provide assessment and care planning and
  community follow up
• Hospitals have outpatient chronic care planning
  clinics, cardiac clinic, respiratory clinic with
  nurses whose role it is to assess, care plan and
  link chronic care patients with GPs and community
  services

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Flinders Model

• Outcomes based
• Generic
• Motivational
• Medical with self-management (Holistic)
• Patient-centred
• Communication
• Coordination

95
The Flinders Model A Systemic Approach
Patient

• Do PIH
• Do CR interview
• Do PG interview
• Negotiate Care Plan

• Carry Plan
• Carry out Action
• Statements
• Prevention/Risk Factor
• Reduction
• Work on PG

Care Plan is negotiated and signed off
Practice Nurse or Allied Health Worker
General Practitioner

• EBM Care Plan
• Negotiate Health
• Action Statements
• Follow up and Monitor

• Provide PIH
• Do CR interview
• Do PG interview
• Prepare Care Plan

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Flinders Model

• Provides a focus for change, ie gives you
  somewhere to start, early wins, staged
  implementation
• Provides outcome measurement as part of routine
  care which enables
• system
• individual
• population outcomes to be measured
• Is a forcing function for
• patient centred care,
• chronic care,
• self-management support and behaviour change

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Summary

• Self-management support is based on an
  operational definition of self-management
• Outcome measurement is integral to the clinical
  process
• PIH, CR and PG enables measurement of patient
  self-management and competency assessment of
  clinicians/students.

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• Evaluation of Flinders Self-management Care
  Planning

100
Sharing Health Care Evaluation Report 2004

• Health outcomes generally improved
• Sustainability is a problem
• Financial disincentives for GPs
• Stanford model effective
• COACH program effective
• Flinders model effective 500 health workers
  trained
• Also worked for indigenous programs

101
Sharing Health Care Whyalla

• Rural remote communities
• 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)

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Participation in the project will lead to

• increased access to appropriate use of health
  services
• improved patient self-management knowledge
  skill
• improved communication more effective
  collaboration between service providers, patients
  carers
• improved health related quality of life for
  patients

103
SHC SA Strategies

• PIH, assessment goal setting
• Formal 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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PIH
105
PIH
106
PIH
107
PIH
108
PIH
109
PIH conclusions

• Both patient and provider PIH scores have
  improved from baseline to 18 months
• These improvements indicate that patient
  self-management skills and abilities have
  improved during the intervention
• Patients tend to score their improvements more
  cautiously than do providers

110
Health Service Outcomes
GP visits
111
Hospital admission
 
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Health Outcomes (Stanford 2000)
 
Random effects - unstructured covariance model
for change over time (Stanford 2000)
NB similar results from the national (PWC)
analysis for general health, distress, coping,
social functioning, self efficacy visits to
hospital
 
113
Sharing Health Care National Evaluation

• 8 projects in non-controlled pre-post design
  showed
• Improved health outcomes,
• Improved quality of life and
• Reduced use of health services
• for people with a wide range of chronic
  conditions.

114
Eyre Peninsula Aboriginal Diabetes-
demonstration project

• Aim Develop a CCSM program that is based on
  staff training, is culturally sensitive and
  flexible, to promote self management principles
  through goal setting, encourage lifestyle changes
  and improve access to preventative services
• 12 months
• Sustainability through the care planning item
  numbers
• Community development approach
• Elders committee

115
Eyre CCSM

• Improved scores on PIH self management at 12
  months
• Problem improved 6.22 5.28 (p lt0.01)
• Goal improved 7.26 5.42 (p lt0.001)
• Improved HbA1c 8.74 -8.09 (plt 0.01 )
• BP 139/84 -136/83
• No change in SF-12 (difficulty with questions)

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Noarlunga Mental Health

• Aim To explore the use of the Flinders tools,
  peer educators and Stanford course in a mental
  health populations with both mental and physical
  illness
• Reduce risk behaviours and improve health
  outcomes
• 12 months
• Noarlunga Mental Health services, Southern
  Division of General Practice, Flinders Mental
  Health, Southern Region Consumer Advisory Group
• Lawn, Pols, Battersby et al Int J of Soc Psych
  2006

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Results

• 21 attended 6 week Lorig generic course
• Improved PIH self management (all scales
  significant)
• Improved Problem 5.19 3.16 (plt0.001)
• Goal Achievement 5.35 3.55 (plt0.001)
• SF-12 improved mental summary score

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Case Study

• 45 year old single man, living alone. Client of
  mental health service for 20 years with paranoid
  schizophrenia. History of violence ( 2 worker
  home visits), cigarette smoker, benzodiazepine
  dependent doctor shopper, treatment order
• Problems with planning, concentration, memory and
  problem solving, persistent paranoia
• Goals Better body image/decrease weight,
  decrease benzos, better financial state, better
  care of self and dog

119
Outcomes

• Cleaning contract for 5 weeks to feel better
  about house so could do weights and to be able to
  invite friends into house boost self esteem and
  challenge view of being dangerous to others
• Reduced benzodiazepines one doctor more
  disclosure with GP
• Poor knowledge of condition and treatment
  addressed
• One worker visit
• Has begun next goal of cigarette reduction
• More social interaction, less paranoid

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VIDEO

• DOES IT MAKE A DIFFERENCE - KELLY

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Sharing Health Care Recommendations

• Flexible approaches with tailoring of
  interventions to meet client need in terms of
  content and mode of delivery
• Ability to identify and respond to client need
  through the use of appropriate planning tools at
  the start of the program, reinforced by ongoing
  coaching and follow-up and
• Ability to provide appropriate and structured
  support to clients, finding the balance between
  over-dependence on the support on offer and being
  isolated from the program.

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Only in Japan
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Contact details

• Flinders Human Behaviour and Health Research Unit
• Sharon.lawn_at_fmc.sa.gov.au
• Malcolm.Battersby_at_fmc.sa.gov.au
• Ph [phone] Fax [phone]
• http//som.flinders.edu.au/FUSA/CCTU/Home.html
• http//www.improvingchroniccare.org

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THANK YOU