Title: Education Module
1THE FLINDERS PROGRAM
of CHRONIC CONDITION MANAGEMENT
FLINDERS HUMAN BEHAVIOUR HEALTH RESEARCH UNIT
1
1
2 3Welcome and Introductions
- Current Role
- Client Group
- Interest in Chronic Condition Management
- Expectations of the Workshop
-
3
3
4The 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
4
4
5Aims
- 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
5
5
6Learning 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
6
6
7The Flinders Program
- Certificate of Competence
- Part of a Quality Assurance Process
- Submit a minimum of 3 care plans
- Licence to use the Flinders Program
7
7
8Professional 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).
9History 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
9
9
10Valuable 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.
10
11Flinders 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
11
11
12National 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
12
12
13Why 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
13
13
14Chronic 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)
14
14
15Chronic 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
15
15
www.improvingchroniccare.org
Improved Outcomes
16Self-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.
16
16
17Activity Brainstorm
- What are the characteristics
- of people who self-manage well?
What barriers might they experience?
17
17
18Definition 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.
18
18
19Definition 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.
19
19
20Principles 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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20
21Principles 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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21
22Principles of Self-Management
Knowledge
Involvement
Care Plan
Monitor and Respond
Impact
Lifestyle
Support Services
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22
23Self-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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23
24Activity Brainstorm
- What are the capabilities
- of those who support others
- to self-manage well?
- What barriers might they experience?
24
24
25Characteristics 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)
25
25
26Characteristics 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)
26
26
27Core 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
27
(Battersby Lawn, 2009)
28Group Discussion
- How does your current management of chronic
conditions support clients to - self-manage?
- What would you like to change?
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28
29Research 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
29
29
30- 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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30
31- 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)
31
31
32- 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
32
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.
33PIH
33
34PIH
34
35Hospital admission
35
36- 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
36
Internal report
37Benefits 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.)
37
38Flinders 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
38
38
3939
39
40Principles of Self-Management
Knowledge
Involvement
Care Plan
Monitor and Respond
Impact
Lifestyle
Support Services
40
40
41The 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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41
4242
42
43Partners 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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43
44Introduction
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4545
45
46CUE RESPONSE INTERVIEW V10 JUNE 2010
46
46
47Cue 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
47
47
48Cue Response Interview
- Cue questions need to explore
- Understanding / Knowledge
- What actually happens
- What are their Strengths
- What are the Barriers
48
48
49Open 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..
49
49
(Rollnick et al,2008)
50Funnel Technique
- Begin with open ended questions
- Further explore with specific open questions
- Use closed questions to examine issues in more
detail - Summarise / Recap
50
50
51Funnel Technique
51
51
52In Pairs
- Turn to the person next to you.
- Use open ended questions to find out 3 things
about this person.
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52
53Tips 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
53
53
54Tips 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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54
55Cue Response Introduction
55
5656
57Cue and ResponsePhysical Impact
57
58Cue 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
58
58
59Cue 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
59
60(No Transcript)
61Cue Response Discussion(discrepancy)
61
6262
62
63Self-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
63
63
64Activity 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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64
65Group 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?
65
65
66Impact 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
66
66
67Brainstorm
- Why is using a scale/numbers useful?
- Why is comparing the scores useful?
- For the person?
- For the worker?
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67
6868
68
69The 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
69
69
70Problems 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
70
70
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
71Problems 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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71
7272
72
73Problem 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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73
74Problem 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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74
75Problem 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
75
75
76Problem 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
76
76
77Goal 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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77
78Goal 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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78
79Goal 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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79
8080
80
81Sub-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
81
81
82Goal 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
82
82
83Goal 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
83
84- What is the purpose of scoring
- ?
84
84
85Goal Setting
85
86Practical
- Role play
- Group Discussion
86
86
87(No Transcript)
8888
88
89The 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
89
89
90Care Planning
90
90
9191
91
92Flinders Care Plan
- Identifies health care needs / management aims
- Vital for communication
- Informed by evidence based guidelines
- Includes
- Planned Services
- Medication lists
92
92
9393
93
94Flinders 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
94
94
95Identified 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.
95
95
96What 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
96
96
97Steps 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
97
97
98Steps
External resources
Tools
- Symptom Action Plan
- Monitoring Diary
- Handbook
- Checklist
- Best Practice Guidelines
- Next Steps
Coping skills
Courses/Groups
98
98
99Steps
External resources
Tools
- Other health professionals
- Community activities
- Support packages
- Help lines i.e. Quitline
- Libraries
- Internet
Coping skills
Courses/Groups
99
99
100Steps
External resources
- DASSA
- Walking and exercise groups
- Group Programs
- Self-help/ Support groups
- Education classes
Tools
Coping skills
CoursesGroups
100
100
101Steps
External resources
Tools
- Problem Solving
- Stress Management
- Anger Management
- Job re-entry
- Assertiveness training
Courses/Groups
Coping skills
101
101
102Review 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
102
102
103Structured Problem Solving
103
103
104What 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
104
104
(Hawton Kirk, 1989)
105When 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
105
105
106 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
106
106
107Practical
- Using the role play,
- complete the Care Plan
107
107
108The Final Product The Care Plan
- An active document that supports
- Communication
- Organisation
- Partnership
- Motivation
- Planning and follow-up
- Outcome measurement
108
108
109109
109
110...Principles of Self-Management
Knowledge
Involvement
Care Plan
Monitor and Respond
Impact
Lifestyle
Support Services
110
110
111The 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
111
111
112Flinders 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
112
113...Characteristics of Successful Self-Management
Support
- Assessment of Self-Management
- Targeting, Goal Setting Planning
- Collaborative Problem Definition
- Self-management training and support services
- Active and sustained follow-up.
113
113
(Von Korff et al, 1997Battersby and Lawn,2009)
114Feedback
114
115End of Day One
115
115
116(No Transcript)
117THE FLINDERS PROGRAM
of CHRONIC CONDITION MANAGEMENT
FLINDERS HUMAN BEHAVIOUR HEALTH RESEARCH UNIT
117
117
118Overview of Day 2
- Recap Flinders Program
- Volunteer Interview
- Care Plan Review
- Planning for Practice Change
118
118
119Summary 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
119
119
120Principles of Self-Management
Knowledge
Involvement
Care Plan
Monitor and Respond
Impact
Lifestyle
Support Services
120
120
121Susan
121
121
122Stages of Change
- People would rather die than change, and most
do - Mark Twain
122
122
123Stages 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
123
123
124ENTER Particular behaviour problem (e.g.
drinking, smoking, over-eating)
Stages of Change
EXIT Long-term abstinence or moderation
Lapse
Maintenance
Pre-contemplation
Action
Contemplation
124
Determination to change
(Prochaska DiClemente, 1986)
125Volunteer Interview
125
125
126Volunteer 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?
126
126
127Tips 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
127
127
128Volunteer 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
128
128
129Feedback
How was the interview for the volunteer? How was
the interview for the interviewer?
129
129
130Thanks to the volunteers
for participating
130
130
131131
131
132Feedback
What went well? What were the difficulties?
132
132
133Care 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.
133
133
134Review of Care Plan
Time to reflect and critique your care plan done
with the volunteer
134
134
135135
135
136Motivational Interviewing
- is a person-centred, directive method for
enhancing intrinsic motivation to change by
exploring and resolving ambivalence (and
procrastination)
(Moyers Rollnick, 2002)
136
136
137Five Key Principles
- Express empathy
- Develop discrepancy
- Avoid argumentation
- Roll with resistance
- Support self-efficacy
137
137
(Moyers Rollnick, 2002)
138Undertaking the Interview
- Examine the good things about the target
behaviour - Examine the less good things and compare the two
- Systematically explore how much of a concern the
negatives are - Ask the client How does this concern you?
138
138
139And.
- Highlight any discrepancies
- Get the client to rate both importance and
confidence on a scale of 1 to 10 - Summarise
- Look to the future. Is the good / not so good
balance going to change?
139
139
140How does the Flinders Program motivate people
to change?
140
140
141Motivational 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
141
141
142 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
142
142
143- Change is more likely if people make decisions
themselves instead of in response to external
pressure - (shared Care Plan)
143
143
144Core 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
144
(Battersby Lawn, 2009)
145Patient 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
145
145
146Behaviour 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
146
Battersby Lawn,2009
147Organisational/System Capabilities
- Multi/Inter disciplinary teams
- Communication systems
- Evidence based practice
- Research
- Partnerships with community
147
148System Change
- Health Care System (National/State)
- Organisation Health Care Model (Local)
- Individual Health Practitioner
148
148
1491. 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
149
149
150Chronic 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
150
150
www.improvingchroncicare.org
Improved Outcomes
1512. Organisation - Health Care Model
151
151
152Planning 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?
152
152
153Experience 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)
154Tips for embedding change
- Change needs Champions! Facilitating change
within complex system. - Fit in the context of the Wagner Model
- Tailored to individual team and individuals
within teams. - Need clear role definition
- Collaborative motivational approach
155- 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.
156Example processes.
skills audit
team formation
service audit
training
Change Facilitator
goal setting
client journey mapping
process mapping
improvement cycles
157Assessment 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
157
157
Bonomi, AE., Wagner E., et al (2002)
158Example
158
158
(Bonomi et al, 2002)
159KIC 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 -
159
159
160The 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
160
160
161Using 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
161
161
162A 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
162
162
163 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
163
163
1643. 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?
164
164
165The 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
165
165
166The Flinders Program training possibilities
- Trainer Accreditation
- 2 day workshop post w/shop activities
- Licensed as an Accredited Trainer
- Follow-up and ongoing support
166
166
167The 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
167
168The Flinders Program training possibilities
- Communication and Motivation skills enhancing
self-management support. - 1 day workshop supplements all workshops.
168
168
169The Flinders Program training possibilities
- Online
- Grad Cert In Health (Self-Management)
- Grad Dip in Chronic Condition Management
- Masters of Public Health (Self-Management)
169
169
170Further Information
- Flinders Human Behaviour Health Research Unit
- Phone (08) 8404 2323
- Fax (08) 8404 2101
- 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/
170
171Personal 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 -
171
171
172 173- What is the most useful thing you have gained
from this workshop?
174- Please complete your evaluation forms
- Thank You
174
174
175175
175