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CCSM Education Training Manual Part 2

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1 CCSM Education Training Manual Part 2
THE FLINDERS PROGRAM™ of CHRONIC CONDITION MANAGEMENT FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT 1 1

2 Intention Importance Confidence

3 Welcome and Introductions
CCSM Education Training Manual Part 2 Welcome and Introductions Current Role Client Group Interest in Chronic Condition Management Expectations of the Workshop 3 3 3

4 CCSM Education Training Manual Part 2
Day 2 Review of Day 1 Additional Resources for Interviews (Stages of Change, Motivational Interviewing) Volunteer Interview Planning for Practice Change The Program Day 1 Background & Evidence The Flinders Program™ 4 4

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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 5 5

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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 6 6

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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™ 7 7

8 Professional Development
This workshop has been endorsed by the Royal Australian College of GPs. RACGP office requirements for GP’s attending the 2-day workshop: When a GP achieves their Certificate of Competence an “Attendance list” is submitted to them by FHBHRU and only then can the GP claim their 40 CPD points.  Acc Trainers need to let FHBHRU E&T Team know when GP’s or any other medical practitioner for that matter attends a workshop. Submitting the Blue personal information forms will satisfy this. Trainers must inform GP participants for their workshops that they can apply for their 40 points after they have been awarded a Certificate of Competence as this will flag they have completed the “Reinforcing Activity” which is an essential component of a Category 1 activity.  At this point, we inform the RACGP QA&CPD program that they have completed all Category 1 activity requirements and we forward an Attendance Record and Activity Report.  GP’s who do not complete all these requirements may be able to apply for points by claiming they have completed a Category 2 activity and the maximum number of points and they would need to complete both days of the workshop to claim these points.  They could claim 12 points for attendance at 1 day of the workshop, that is, 2 points per hour for the 6 hours of contact time on Day 1.    This workshop has been endorsed by Royal College of Nursing, Australia. Attendance attracts 11.5 RCNA Continuing Nurse Education (CNE) points as part of RCNA’s Life Long Learning Program (3LP)” Day One: 6 RCNA CNE points Day Two: 5.5 RCNA CNE points This information must be used, along with the attached logo, on any promotional materials, certificates of attendance etc. 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 QA&CPD 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 RCNA’s Life Long Learning Program (3LP).

9 History of Flinders Program™
CCSM Education Training Manual Part 2 History of Flinders Program™ Trainer to mention latest Flinders program developments in the areas of Prevention Coordinated Care Trials SA Health Plus Flinders Program™ developed Sharing Health Care Initiatives C’wealth Dept Health & Aging Partners In Health scale trialed and standardised 2001 9 9

10 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. 10

11 Flinders Program™ in Context
CCSM Education Training Manual Part 2 Flinders Program™ in Context WHO identify chronic conditions as major health impact SA Chronic Disease Strategy 2004 National Primary Care Collaboratives From 2004 National Chronic Disease Strategy From 2005 Australian Better Health Initiative 11 11

12 National Chronic Disease Strategy (www.coag.gov.au)
CCSM Education Training Manual Part 2 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 12 12

13 CCSM Education Training Manual Part 2
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) 13 13

14 Chronic Condition under an Acute Model
CCSM Education Training Manual Part 2 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) 14 14

15 CCSM Education Training Manual Part 2
Chronic Care Model Community Health System Resources and Policies Health Care Organization Clinical Information Systems Self- Management Support Delivery System Design Decision Support Prepared, Proactive Practice Team Informed Activated Patient Productive Interactions Self-m support is the most important of these elements – if a person is not walking out of the doctor’s or health professional’s office deciding to do something differently then the rest of the CCM is irrelevant. The CCM means that the evidence says that care delivered by a team is more effective than a single practitioner (this leads to discussion on day 2 about implementation ie other health professionals can contribute to the development of the care plan and the follow up. 15 15 Improved Outcomes

16 Self-Management: Who’s Responsible?
CCSM Education Training Manual Part 2 Self-Management: Who’s 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

17 CCSM Education Training Manual Part 2
Activity – Brainstorm What are the characteristics of people who self-manage well? What barriers might they experience? 17 17

18 CCSM Education Training Manual Part 2
Definition of a Good Self-Manager Centre for Advancement in Health (1996). Indexed bibliography on Self-management for People with Chronic Disease. Washington DC: ?. 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

19 CCSM Education Training Manual Part 2
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”. 19 19

20 CCSM Education Training Manual Part 2
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 20 20

21 CCSM Education Training Manual Part 2
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 21 21

22 CCSM Education Training Manual Part 2
Principles of Self-Management K I C MR L S Knowledge Involvement Care Plan Monitor and Respond Impact Lifestyle Support Services 22 22

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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 23 23

24 Activity – Brainstorm What are the capabilities
CCSM Education Training Manual Part 2 Activity – Brainstorm What are the capabilities of those who support others to self-manage well? What barriers might they experience? 24 24 24

25 CCSM Education Training Manual Part 2
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) 25 25

26 CCSM Education Training Manual Part 2
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) 26 26

27 Core Skills for the Health Care Workforce
The 19 Capabilities were defined and confirmed as necessary for the PHC workforce to successfully support pts & carers within the s-m continuum through:- Survey with the national Primary Health Care (PHC) workforce Survey of existing training organisations delivering Chronic condition management and self-management education National consultation with key stakeholders from across PHC education, training, professional accreditation and clinical delivery sector 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 (Battersby & Lawn, 2009) 27

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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? 28 28

29 CCSM Education Training Manual Part 2
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 (p<0.001) - Goal rating (p<0.001) - Mental Health Summary Score SF12 Reduced hospital admission rates 29 29

30 CCSM Education Training Manual Part 2
RGH (Chronic & Complex Lung Disease) Prospective unblinded, RCT, 12 months follow up Resp’y rehab with and without Flinders Program™ Statistically significant improvement - in 6 minute walk (p<0.05) - the impact scale of the SGRQ (p<0.05) Clinical Improvement - in 6 minute walk (>54m) - QOL Score (SGRQ total score) 30 30

31 CCSM Education Training Manual Part 2
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 (p<0.001) - Goal Rating (p<0.001) - Mean HbA1c 8.74 – 8.08 (p<0.001) 31 31

32 Sharing Health Care Whyalla
Participants - People with complex & chronic illness Aboriginal people > 35 years of age Non-Aboriginal people > 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):

33 PIH 33

34 PIH 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 34

35 Hospital admission 35

36 Alcohol Related Chronic Conditions
Vietnam Veterans Alcohol Related Chronic Conditions 9 month RCT n=77 Usual Care vs Usual Care + FP +/- Stanford Statistically significant improvement (intervention n=46) i) Alcohol dependence as per DSM-IV Baseline 61% > 9 months 41% > 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

37 Benefits of self-management programs
CCSM Education Training Manual Part 2 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.) 37

38 Flinders Program™ Applications
CCSM Education Training Manual Part 2 Flinders Program™ Applications The purpose of this slide is to demonstrate the breadth of acceptance and testing of the FP for Chronic Care management. New Zealand first to adopt the Program outside Australia and the others followed in ? For many of these groups there are Research findings to support the validity and flexibility of the FP. 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 resources/templates 38 38 38

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39 39

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Principles of Self-Management K I C MR L S Knowledge Involvement Care Plan Monitor and Respond Impact Lifestyle Support Services 40 40

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The Flinders Program™ Assess Self-Management Problems and Goals + Self- Management Medical Management Community / Carer Support Psychosocial Support Care Plan Agreed Issues Agreed Interventions Shared Responsibilities Evidence Based Practice Review Process 41 41

42 CCSM Education Training Manual Part 2
Picture of PIH 42 42

43 Partners In Health Scale
CCSM Education Training Manual Part 2 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 43 43

44 Introduction 44

45 CCSM Education Training Manual Part 2
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46 CCSM Education Training Manual Part 2
CUE & RESPONSE INTERVIEW V10 JUNE 2010 46 46

47 Cue & Response Interview
CCSM Education Training Manual Part 2 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 47 47

48 Cue & Response Interview
CCSM Education Training Manual Part 2 Cue & Response Interview Cue questions need to explore: Understanding / Knowledge What actually happens What are their Strengths What are the Barriers 48 48

49 Open Questions “What’s most on your mind today about your illness?’
CCSM Education Training Manual Part 2 Open Questions “What’s 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……..” (Rollnick et al,2008) 49 49 49

50 Funnel Technique Begin with open ended questions
CCSM Education Training Manual Part 2 Funnel 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 50

51 Funnel Technique 51 51 CCSM Education Training Manual Part 2
How have things been going with the treatment since I last saw you? Discussion about some good things but “having trouble with the tablets” Sounds like some things have been going really well, but you are concerned about the tablets. How have the tablets been a trouble? So how many days a week are you forgetting the evening ones? Reinforce the importance of summaries. 51 51 51

52 In Pairs Turn to the person next to you.
CCSM Education Training Manual Part 2 In Pairs Turn to the person next to you. Use open ended questions to find out 3 things about this person. 52 52 52

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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 53 53

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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 54 54

55 Cue & Response Introduction
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56 56

57 Cue and Response Physical Impact
57

58 Cue & Response Discussion
CCSM Education Training Manual Part 2 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 58 58

59 Cue & Response Summary Sheet
This remains an optional tool but can be emphasised a an effective additional support to the learning process ie provide the HP with a structured way of summarising the discussion phase of the C&R and ensure that all identified issues are transferred to the Care Plan. The form may only be used for the issues that score greater than 4 or are discrepant by 3 or more. 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

61 Cue & Response Discussion (discrepancy)
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62 62 62

63 Self-Management Assessment
CCSM Education Training Manual Part 2 Self-Management Assessment Partners in Health Scale (PIH) Cue & Response Interview (C&R) 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 63 63

64 CCSM Education Training Manual Part 2
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 C&R 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. 64 64

65 CCSM Education Training Manual Part 2
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? 65 65

66 Impact of Cue and Response
CCSM Education Training Manual Part 2 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 client’s own resources 66 66

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Brainstorm Notes to include explanation of Leikardt Scale Why is using a scale/numbers useful? Why is comparing the scores useful? For the person? For the worker? 67 67

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68 68

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The Flinders Program™ Assess Self-Management Problems and Goals + Self- Management Medical Management Community / Carer Support Psychosocial Support Care Plan Agreed Issues Agreed Interventions Shared Responsibilities Evidence Based Practice Review Process 69 69

70 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 ( ) 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 2003;7(3):45-48 Battersby M et al – Health Reform through Coordinated Care: SA Health Plus. BMJ 2005;330:662-6

71 Problems and Goals Approach
CCSM Education Training Manual Part 2 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? 71 71

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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? 73 73

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Problem Statement In coordinated care trials 70% of Problems were not health related. The client’s 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. 74 74

75 CCSM Education Training Manual Part 2
Problem Measurement Problem Statement “Because I’m often short of breath I don’t go out much and I feel frustrated and angry” Rating Scale How much of a problem is this for me? Not at Very little Somewhat a fair bit A lot all 75 75

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Problem Measurement Problem Statement “Since my daughter moved I don’t see my grandchildren and I feel sad and useless” Rating Scale How much of a problem is this for me? Not at Very little Somewhat A fair bit a lot all 76 76

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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 77 77

78 CCSM Education Training Manual Part 2
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 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) 78 78

79 CCSM Education Training Manual Part 2
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) 79 79

80 80 80

81 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 81 81

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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: No % Complete progress success 82 82

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Goal Measurement Goal Statement “I will my grandchildren every week when I go to the library ” Rating Scale My progress towards achieving this goal is: No % Complete progress success 83

84 What is the purpose of scoring
CCSM Education Training Manual Part 2 The trainer here tell a story about a client for whom the problem was barrier to positive health behaviours What is the purpose of scoring ? 84 84 84

85 Goal Setting 85

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Practical Role play Group Discussion 86 86

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The Flinders Program™ Assess Self-Management Problems and Goals + Self- Management Medical Management Community / Carer Support Psychosocial Support Care Plan Agreed Issues Agreed Interventions Shared Responsibilities Evidence Based Practice Review Process 89 89

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Care Planning 90 90

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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 92 92

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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 94 94

95 CCSM Education Training Manual Part 2
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. 95 95

96 What I Want to Achieve Not just the ‘opposite of the issue’.
They are the client’s 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

97 CCSM Education Training Manual Part 2
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 client’s 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

98 Steps Coping skills External resources Tools Symptom Action Plan
Monitoring Diary Handbook Checklist Best Practice Guidelines Next Steps Coping skills Courses /Groups 98 98

99 Steps Coping skills External resources Tools
Other health professionals Community activities Support packages Help lines i.e. Quitline Libraries Internet Coping skills Courses /Groups 99 99

100 Steps Coping skills External resources DASSA Tools
Walking and exercise groups Group Programs Self-help/ Support groups Education classes Tools Coping skills Courses Groups 100 100

101 Steps Coping skills External resources Tools Problem Solving
Stress Management Anger Management Job re-entry Assertiveness training Courses /Groups Coping skills 101 101

102 CCSM Education Training Manual Part 2
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 102 102

103 Structured Problem Solving
CCSM Education Training Manual Part 2 Structured Problem Solving 103 103 103

104 What is Structured Problem Solving?
CCSM Education Training Manual Part 2 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 104 104 (Hawton & Kirk, 1989) 104

105 CCSM Education Training Manual Part 2
When would you use it? To teach problem solving rather than you solving it for them (collaborative not directive) When the person hasn’t been able to achieve a goal from the care plan When barriers to self-management have been identified 105 105 105

106 Steps to Problem Solving
CCSM Education Training Manual Part 2 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 106 106 106

107 CCSM Education Training Manual Part 2
Practical Using the role play, complete the Care Plan 107 107

108 The Final Product : The Care Plan
CCSM Education Training Manual Part 2 The Final Product : The Care Plan An active document that supports: Communication Organisation Partnership Motivation Planning and follow-up Outcome measurement 108 108

109 CCSM Education Training Manual Part 2
What we covered so far… 109 109

110 CCSM Education Training Manual Part 2
...Principles of Self-Management K I C MR L S Knowledge Involvement Care Plan Monitor and Respond Impact Lifestyle Support Services 110 110

111 …The Flinders Program™
CCSM Education Training Manual Part 2 …The Flinders Program™ Principles of Self-Management PIH Scale C&R Interview P&G Assessment Care Plan Systematically supports the patient to achieve self-management Provides a process for implementing planned care for chronic conditions 111 111 111

112 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 112

113 CCSM Education Training Manual Part 2
...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, 1997;Battersby and Lawn,2009)

114 Feedback 114

115 CCSM Education Training Manual Part 2
End of Day One 115 115

116

117 FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT
CCSM Education Training Manual Part 2 THE FLINDERS PROGRAM™ of CHRONIC CONDITION MANAGEMENT FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT 117 117 117

118 CCSM Education Training Manual Part 2
Overview of Day 2 Recap Flinders Program™ Volunteer Interview Care Plan Review Planning for Practice Change 118 118

119 Summary of The Flinders Program™
CCSM Education Training Manual Part 2 Summary of The Flinders Program™ Principles of Self-Management PIH Scale C&R Interview P&G Assessment Care Plan Systematically supports the patient to achieve self-management Provides a process for implementing planned care for chronic conditions 119 119

120 Principles of Self-Management
CCSM Education Training Manual Part 2 Principles of Self-Management K I C MR L S Knowledge Involvement Care Plan Monitor and Respond Impact Lifestyle Support Services 120 120 120

121 ‘Susan’ 121 121

122 CCSM Education Training Manual Part 2
Stages of Change “People would rather die than change, and most do” Mark Twain 122 122

123 CCSM Education Training Manual Part 2
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 123 123

124 Stages of Change ENTER: Particular behaviour problem (e.g. drinking, smoking, over-eating) EXIT: Long-term abstinence or moderation Lapse Maintenance Pre-contemplation Action Contemplation Determination to change 124 (Prochaska & DiClemente, 1986)

125 CCSM Education Training Manual Part 2
Volunteer Interview 125 125

126 CCSM Education Training Manual Part 2
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? 126 126

127 CCSM Education Training Manual Part 2
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 127 127

128 CCSM Education Training Manual Part 2
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 Who’s responsible and put them on the Care Plan 128 128

129 CCSM Education Training Manual Part 2
Feedback How was the interview for the volunteer? How was the interview for the interviewer? 129 129

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Thanks to the volunteers for participating 130 130

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131 131

132 What were the difficulties?
CCSM Education Training Manual Part 2 Feedback What went well? What were the difficulties? 132 132 132

133 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. 133 133

134 Time to reflect and critique your care plan done with the volunteer
CCSM Education Training Manual Part 2 Review of Care Plan Time to reflect and critique your care plan done with the volunteer 134 134 134

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135 135 135

136 Motivational Interviewing
CCSM Education Training Manual Part 2 Motivational 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

137 CCSM Education Training Manual Part 2
Five Key Principles Express empathy Develop discrepancy Avoid argumentation Roll with resistance Support self-efficacy 137 137 (Moyers & Rollnick, 2002)

138 CCSM Education Training Manual Part 2
Undertaking 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

139 CCSM Education Training Manual Part 2
And…. 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

140 How does the Flinders Program™ motivate people to change?
CCSM Education Training Manual Part 2 How does the Flinders Program™ motivate people to change? 140 140

141 Motivational Elements of the Flinders Program™
CCSM Education Training Manual Part 2 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 (C&R) Encouraging clients to explore barriers to change 141 141

142 … Motivational Elements
CCSM Education Training Manual Part 2 … Motivational Elements Client generated P&G 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 (P&G, Care Plan steps) Shared responsibility / accountability A sign off on the Care Plan Monitoring and review 142 142

143 CCSM Education Training Manual Part 2
Change is more likely if people make decisions themselves instead of in response to external pressure (shared Care Plan) 143 143

144 Core Skills for the Health Care Workforce
The 19 Capabilities were defined and confirmed as necessary for the PHC workforce to successfully support pts & carers within the s-m continuum through:- Survey with the national Primary Health Care (PHC) workforce Survey of existing training organisations delivering Chronic condition management and self-management education National consultation with key stakeholders from across PHC education, training, professional accreditation and clinical delivery sector 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 (Battersby & Lawn, 2009) 144

145 Patient Centred Capabilities (underpin the Flinders Program™)
CCSM Education Training Manual Part 2 Patient Centred Capabilities (underpin the Flinders Program™) Ability to negotiate - see the issues from the patient’s point of view Share decisions Collectively solve problems Establish goals Implement action Clarify roles and responsibilities Evaluate progress Pt centred care has been the promoted in all health professions but hasn’t been operationalised. How do you know when you are providing PCC? Fl M provides a transparent, observable and measurable way of providing PCC. It makes it concrete. 145 145 145

146 Behaviour Change Capabilities (underpin the Flinders Program™)
Demonstrates that the FP is consistent with the evidence base for self management support. Frameworks to understand human behaviour and how to support sustained change. MI- a method utilising cognitive change skills Defining and working with clients on their main problems/issues/concerns Deciding what the client wants, planning how to get there and then supporting the individual to work towards it Systematic way to assist individuals to learn skill of finding solutions to problems. 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

147 Organisational/System Capabilities
Intention: To demonstrate that the FP upholds these agreed capabilities within its processes. Establishing working relationships with others of differing professions- in productive, collaborative and co-ordinated way. Proactive use of clinical data to screen, monitor and provide self management support to clients Health professionals are aware of the evidence and strength of evidence that guides on their practice- consulting with clients to decide on best options for the individual Build on the evidence base in this field through research Being aware of the community resources and services the client can draw upon to support their self management Multi/Inter disciplinary teams Communication systems Evidence based practice Research Partnerships with community 147

148 CCSM Education Training Manual Part 2
System Change Health Care System (National/State) Organisation – Health Care Model (Local) Individual Health Practitioner 148 148

149 1. Health Care System Change
CCSM Education Training Manual Part 2 The Medicare chronic disease dental scheme was introduced in November The scheme allows chronically ill people who are being managed by their GP under an Enhanced Primary Care (EPC) plan access to Medicare rebates for dental services. Additional information about Chronic Disease Management Items (Items 721 to 732) can be found at 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 149 149 149

150 Clinical Information Systems Self- Management Support
CCSM Education Training Manual Part 2 Chronic Care Model Community Health System Resources and Policies Health Care Organization Clinical Information Systems Self- Management Support Delivery System Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Self-m support is the most important of these elements – if a person is not walking out of the doctor’s or health professional’s office deciding to do something differently then the rest of the CCM is irrelevant. The CCM means that the evidence says that care delivered by a team is more effective than a single practitioner (this leads to discussion on day 2 about implementation ie other health professionals can contribute to the development of the care plan and the follow up. 150 150 Improved Outcomes 150

151 2. Organisation - Health Care Model
CCSM Education Training Manual Part 2 2. Organisation - Health Care Model 151 151 151

152 Planning for Organisational Change
CCSM Education Training Manual Part 2 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? 152 152 152

153 Experience of Change Traditional view Dynamic view Linear Non-linear
Disruptive Cause & effect Incremental An event Calamitous Controllable Abnormal Dynamic view Non-linear Revolutionary & incremental Continuous About learning Turbulent Uncontrollable/Unpredictable Creative Full of opportunity Normal (Lawn,2008;McMillan,2004)

154 Tips for embedding change:
Points to cover in presentation Champion- Defender; Supporter; Campaigner; Driver- the Leadership necessary for success No magic formula. Not a linear process, change within complex system, requiring action on a number of levels, some inevitable ‘backtracking’ and reworking. In the context of the Wagner Model Need a structured approach with a variety of tools and approaches. Structured assessment with outcomes incorporated (Processes might include – formation of team, skills audit, process mapping, client journey mapping, service audit, improvement processes (might include training). Need to meet the team wherever they are on their journey and travel with them. Tailored to individual team and individuals within teams. Linking of long term aims that are aligned evidence base with shorter action plans and regular review of progress. 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. Training and competency development is one part of the picture.(is there an optimal point in the process for training - what does the room think) Peer learning and modelling important – facilitators personal experiences and knowledge of others experiences can be used – variety of examples to draw on and people to use as resources required. Role definition important – eg coach cannot performance manage team members, remains the role of supervisors / managers. Avoid the ‘expert trap’, collaborative approach, motivational approach, the coach does not know the solution or plan before you start, but knows the processes to help find them. Relinquish perception of control over the teams actions - facilitate and support. Successes owned by team.

156 client journey mapping
Example processes. skills audit team formation service audit training Change Facilitator goal setting client journey mapping Change Facilitator can initiate and coordinate the process Act as a bridge Motivate and prompt change Extend the teams horizons Effect team building improvement cycles process mapping

157 Assessment of Chronic Illness Care: (ACIC)
CCSM Education Training Manual Part 2 Assessment of Chronic Illness Care: (ACIC) Service Audit example Others KICMRIL Audit and PCRS “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) 157

158 Example 158 158 CCSM Education Training Manual Part 2
(Bonomi et al, 2002) 158

159 KIC MR IL Audit Knowledge of Condition
CCSM Education Training Manual Part 2 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 159 159 159

160 The PDSA Cycle (www.ihi.org)
CCSM Education Training Manual Part 2 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 IMPROVEMENT CYCLES. Four parts of the cycle: Plan: Decide what change you will make, who will do it, and when it will be done. Formulate an hypothesis about what you think will happen when you try the change. What do you expect will happen? Identify data that you can collect (either quantitative or qualitative) that will allow you to evaluate the result of the test. Do: Carry out the change. Study: Make sure that you leave time for reflection about your test. Use the data and the experience of those carrying out the test to discuss what happened. Did you get the results you expected? If not, why not? Did anything unexpected happen during the test? Act: Given what you learned during the test, what will your next test be? Will you make refinements to the change? Abandon it? Keep the change and try it on a larger scale? 160 160 160

161 Using PDSA Cycles to Facilitate Change
CCSM Education Training Manual Part 2 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 Move on to discussing how the team would plan and implement some quality improvement in the areas identified. Move to the PDSA slide and discuss the tool. Use a PDSA worksheet to plan the first PDSA cycle for the team. Discuss the needs of the group to sustain the process. 161 161 161

162 A Couple of Great Resources
CCSM Education Training Manual Part 2 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.info) written by Jill Kelly and Naomi Kubina 162 162 162

163 Chronic Disease Items for Care Planning Info on Allied Health Items
CCSM Education Training Manual Part 2 Chronic Disease Items for Care Planning MORE INFORMATION Info on Allied Health Items 163 163 163

164 3. Individual Health Practitioner Change
CCSM Education Training Manual Part 2 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? 164 164

165 CCSM Education Training Manual Part 2
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 165 165

166 The Flinders Program™ – training possibilities
CCSM Education Training Manual Part 2 The 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

167 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 167

168 The Flinders Program™ – training possibilities
CCSM Education Training Manual Part 2 The Flinders Program™ – training possibilities Communication and Motivation skills: enhancing self-management support. 1 day workshop – supplements all workshops. 168 168

169 The Flinders Program™ – training possibilities
CCSM Education Training Manual Part 2 The 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

170 Further Information Flinders Human Behaviour Health Research Unit
CCSM Education Training Manual Part 2 Further Information Flinders Human Behaviour Health Research Unit Phone: (08) Fax: (08)   170 170

171 Personal Plan Optional activity depending on time and on relevance to the group working with. 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 Importance Confidence

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

174 CCSM Education Training Manual Part 2
Please complete your evaluation forms Thank You 174 174

175 CCSM Education Training Manual Part 2
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