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111 of CHRONIC CONDITION MANAGEMENT FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT THE FLINDERS PROGRAM ™

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Presentation on theme: "111 of CHRONIC CONDITION MANAGEMENT FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT THE FLINDERS PROGRAM ™"— Presentation transcript:

1 111 of CHRONIC CONDITION MANAGEMENT FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT THE FLINDERS PROGRAM ™

2 2 Importance Confidence

3 333 Welcome and Introductions Current Role Client Group Interest in Chronic Condition Management Expectations of the Workshop

4 444 The Program Day 1 Background & Evidence The Flinders Program ™ Day 2 Review of Day 1 Additional Resources for Interviews (Stages of Change, Motivational Interviewing) Volunteer Interview Planning for Practice Change

5 555 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

6 666 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

7 777 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 ™

8 8 Professional Development This workshop has been endorsed by The Royal Australian College of General Practitioners (RACGP) & The Royal College of Nursing, Australia (RCNA) according to approved criteria. RACGP 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).

9 999 History of Flinders Program ™ Flinders Program™ developed Coordinated Care Trials SA Health Plus 1997-1999 Sharing Health Care Initiatives C’wealth Dept Health & Aging 2001 - 2004 Partners In Health scale trialed and standardised 2001

10 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.

11 11 Flinders Program ™ in Context WHO identify chronic conditions as major health impact 2002-2003 SA Chronic Disease Strategy 2004 National Chronic Disease Strategy From 2005 National Primary Care Collaboratives From 2004 Australian Better Health Initiative 2006- 2010

12 12 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

13 13 Why Do We Need To Change? Disease burden has changed towards chronic conditions around the world. Health systems have not. Effective interventions exist for most chronic conditions, yet patients/clients do not receive them. Current health systems are designed to provide episodic, acute health care and fail to address self-management, prevention and follow up. Chronic conditions require a different kind of health care (mismatch). WHO Health Care for Chronic Conditions team (CCH) http://whqlibdoc.who.int/hq/2002/WHO_NMC_CCH_02.01.pdf

14 14 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)

15 15 Informed Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model www.improvingchroniccare.org

16 16 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.

17 17 Activity – Brainstorm What are the characteristics of people who self-manage well? What barriers might they experience?

18 18 Definition of a Good Self- Manager The Centre for Advancement in Health (1996) proposes the following definition: “[the person with the chronic disease] engaging in activities that protect and promote health, monitoring and managing of symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes.”

19 19 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”. Definition of a Good Self- Manager

20 20 Principles of Self-Management 1. K now your condition 2.Be actively I nvolved with the GP & health workers to make decisions & navigate the system 3.Follow the C are Plan that is agreed upon with the GP and other health professionals

21 21 4. M onitor symptoms associated with the condition(s) and R espond to, manage and cope with the symptoms 5.Manage the physical, emotional and social I mpact of the condition(s) on your life 6.Live a healthy L ifestyle 7.Readily access S upport S ervices Principles of Self-Management cont.

22 22 Principles of Self-Management K I C MR I L S Knowledge Involvement Care Plan Monitor and Respond Impact Lifestyle Support Services

23 23 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

24 24 Activity – Brainstorm What are the capabilities of those who support others to self-manage well? What barriers might they experience?

25 25 Characteristics of Successful Self-Management Support 1.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)

26 26 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)

27 27 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)

28 28 Group Discussion How does your current management of chronic conditions support clients to self-manage? What would you like to change?

29 29 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 5.35- 3.55 (p<0.001) - Mental Health Summary Score SF12 Reduced hospital admission rates

30 30 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)

31 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 (p<0.001) - Goal Rating 7.26- 5.42 (p<0.001) - Mean HbA1c 8.74 – 8.08 (p<0.001)

32 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 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.

33 33 PIH

34 34 PIH

35 35 Hospital admission

36 36 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 Internal report

37 37 (Warsi et al, Newman et al.) 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

38 38 Flinders Program ™ Applications Distribution: –Australia; New Zealand; USA; Canada; Hong Kong; Scotland; Sweden Population Groups include:- –Indigenous Health; Child Health; Aged Care; Mental Health; Disability; War Veterans; Renal Services; MS Society; General Practice Networks; Rural & Remote. RACGP- GPMP & TCA Care Planning Templates based on the Flinders Program™ principles of self-management –http://www.racgp.org.au/clinical resources/templates

39 39

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

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

42 42

43 43 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

44 44 Introduction

45 45

46 46 CUE & RESPONSE INTERVIEW V10 JUNE 2010

47 47 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

48 48 Cue & Response Interview Cue questions need to explore: Understanding / Knowledge What actually happens What are their Strengths What are the Barriers

49 49 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)

50 50 Funnel Technique Begin with open ended questions Further explore with specific open questions Use closed questions to examine issues in more detail Summarise / Recap

51 51 Funnel Technique

52 52 In Pairs Turn to the person next to you. Use open ended questions to find out 3 things about this person.

53 53 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

54 54 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

55 55 Cue & Response Introduction

56 56

57 57 Cue and Response Physical Impact

58 58 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

59 59 Cue & Response Summary Sheet May be used to record Health Professionals reflections about: Issues for Care plan ie score 4 or below or discrepant 3 or more Interventions for the care plan Particular strengths/barriers Linking the Cue & Response with Care Plan

60 60

61 61 Cue & Response Discussion (discrepancy)

62 62

63 63 Self-Management Assessment Partners in Health Scale (PIH) Cue & Response Interview (C&R) QuickTakes time Self AssessmentHealth Professional tool 12 QuestionsExpanded with open-ended cue questions Scored by clientScored by interviewer Collaborative identification of issues

64 64 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.

65 65 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?

66 66 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

67 67 Brainstorm Why is using a scale/numbers useful? Why is comparing the scores useful? –For the person? –For the worker?

68 68

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

70 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 (1997-99) 60% of patients improved their problem rating score Up to 60% made progress with goals 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 71 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?

72 72

73 73 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?

74 74 Problem Statement 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.

75 75 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? 0 1 2 34567 8 Not at Very little Somewhat a fair bit A lot all

76 76 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? 0 1 2 34567 8 Not at Very little Somewhat A fair bit a lot all

77 77 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

78 78 Goal Statements Client goals (not Health Professional) Should be written positively + be a personal reward They are long / medium term and involve a degree of challenge (Locke, 1996) Can be clearly and simply evaluated using the 0 - 8 scale Can be maintenance goals for people effectively self- managing Avoid “One off” goals and “I wanna’ be happier, skinnier, prettier, richer” Are not clinical interventions (e.g. referral or blood tests)

79 79 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)

80 80

81 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

82 82 Goal Measurement Goal Statement “I will catch the community bus to the local community centre, twice a week for the afternoon Craft Group” Rating Scale My progress towards achieving this goal is: 0 1 2 3 4 5 6 7 8 No 50% Complete progress success

83 83 Goal Measurement Goal Statement “I will email my grandchildren every week when I go to the library ” Rating Scale My progress towards achieving this goal is: 0 12345678 No 50% Complete progress success

84 84 What is the purpose of scoring ? 84

85 85 Goal Setting

86 86 Practical Role play Group Discussion

87 87

88 88

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

90 90 Care Planning

91 91

92 92 Flinders Care Plan Identifies health care needs / management aims Vital for communication Informed by evidence based guidelines Includes –Planned Services –Medication lists

93 93

94 94 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

95 95 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.

96 96 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 What I Want to Achieve

97 97 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

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

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

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

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

102 102 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

103 103 Structured Problem Solving

104 104 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 (Hawton & Kirk, 1989)

105 105 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

106 106 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

107 107 Practical Using the role play, complete the Care Plan

108 108 The Final Product : The Care Plan An active document that supports: –Communication –Organisation –Partnership –Motivation –Planning and follow-up –Outcome measurement

109 109 What we covered so far…

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

111 111 …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

112 112 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

113 113...Characteristics of Successful Self-Management Support 1. Assessment of Self-Management 2. Targeting, Goal Setting & Planning 3. Collaborative Problem Definition 4. Self-management training and support services 5. Active and sustained follow-up. (Von Korff et al, 1997;Battersby and Lawn,2009)

114 114 Feedback

115 115 End of Day One

116 116

117 117 of CHRONIC CONDITION MANAGEMENT FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT THE FLINDERS PROGRAM ™

118 118 Overview of Day 2 Recap Flinders Program ™ Volunteer Interview Care Plan Review Planning for Practice Change

119 119 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

120 120 Principles of Self-Management K I C MR I L S Knowledge Involvement Care Plan Monitor and Respond Impact Lifestyle Support Services

121 121 ‘Susan’ 121

122 122 Stages of Change “People would rather die than change, and most do” Mark Twain

123 123 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

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

125 125 Volunteer Interview

126 126 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?

127 127 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

128 128 Volunteer Interview 1. Introduce the Flinders Program ™ to the client 2. Client to complete Partners in Health 3. Complete Cue & Response interview 4. Identify the issues and put them on the Care Plan 5. Complete – Problems &Goals interview 6. Complete the Care Plan together – discuss Desired achievements Steps Who’s responsibleand put them on the Care Plan

129 129 Feedback How was the interview for the volunteer? How was the interview for the interviewer?

130 130 Thanks to the volunteers for participating

131 131

132 132 Feedback What went well? What were the difficulties?

133 133 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

134 134 Review of Care Plan Time to reflect and critique your care plan done with the volunteer

135 135

136 136 Motivational Interviewing “ is a person-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence ” (and procrastination) (Moyers & Rollnick, 2002)

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

138 138 1. Examine the good things about the target behaviour 2. Examine the less good things and compare the two 3. Systematically explore how much of a concern the negatives are 4. Ask the client: ‘ How does this concern you? ’ Undertaking the Interview

139 139 And…. 5.Highlight any discrepancies 6.Get the client to rate both importance and confidence on a scale of 1 to 10 7.Summarise 8.Look to the future. Is the good / not so good balance going to change?

140 140 How does the Flinders Program ™ motivate people to change?

141 141 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

142 142 … 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

143 143 Change is more likely if people make decisions themselves instead of in response to external pressure (shared Care Plan)

144 144 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)

145 145 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

146 146 Behaviour Change Capabilities (underpin the Flinders Program ™ ) Knowledge of evidence based models of behaviour change Motivational interviewing Collaborative problem definition Goal setting and goal achievement Structured problem solving and action planning Battersby & Lawn,2009

147 147 Organisational/System Capabilities Multi/Inter disciplinary teams Communication systems Evidence based practice Research Partnerships with community

148 148 1.Health Care System (National/State) 2.Organisation – Health Care Model (Local) 3.Individual Health Practitioner System Change

149 149 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

150 150 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model www.improvingchroncicare.org

151 151 2. Organisation - Health Care Model

152 152 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?

153 153 Experience of Change Traditional view 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)

154 154 Tips for embedding change: 1.Change needs Champions! Facilitating change within complex system. 2.Fit in the context of the Wagner Model 3.Tailored to individual team and individuals within teams. 4.Need clear role definition 5.Collaborative motivational approach

155 155 6.Peer learning and modelling is important 7.Facilitation and support within the team 8.Training and competency development is one component 9.Linking of long term aims with shorter action plans. Not a linear process. No magic formula. 10.Structured approach with a variety of tools and processes.

156 156 Example processes. team formation skills audit service audit process mapping client journey mapping goal setting improvement cycles training Change Facilitator

157 157 Assessment of Chronic Illness Care: (ACIC) “A practical quality improvement tool to help organisations identify the strengths & weaknesses of their delivery of care for chronic illness in the areas of: Organisation of Care Community Linkages Self-Management Support Decision Support Delivery System Design Clinical Information Systems” Bonomi, AE., Wagner E., et al (2002)

158 158 (Bonomi et al, 2002) Example

159 159 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

160 160 The PDSA Cycle (www.ihi.org) Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete analysis of the data Compare data to predictions Summarise what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data

161 161 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

162 162 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 Schoolhttp://sgrhs.unisa.edu.au/CDSM/ Navigating self management: a practical approach for Australian health agencies (www.goodlifeclub.info) written by Jill Kelly and Naomi Kubinawww.goodlifeclub.info

163 163 Chronic Disease Items for Care Planning MORE INFORMATION http://www.health.gov.auhttp://www.health.gov.au/epc Info on Allied Health Items http://www.medicareaustralia.gov.au/providers/incentiv es_allowances/medicare_initiatives/allied_health.shtml

164 164 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?

165 165 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

166 166 The Flinders Program ™ – training possibilities Trainer Accreditation  2 day workshop + post w/shop activities  Licensed as an Accredited Trainer  Follow-up and ongoing support

167 167 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

168 168 The Flinders Program ™ – training possibilities Communication and Motivation skills: enhancing self-management support.  1 day workshop – supplements all workshops.

169 169 The Flinders Program ™ – training possibilities Online  Grad Cert In Health (Self-Management)  Grad Dip in Chronic Condition Management  Masters of Public Health (Self-Management)

170 170 Further Information Flinders Human Behaviour Health Research Unit Phone: (08) 8404 2323 Fax: (08) 8404 2101 Email: self.management@flinders.edu.auself.management@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/icccreport/

171 171 Personal Plan Use the PDSA Worksheet for Testing Change to Plan the first step for incremental change to one of the 3 aspects of self management support you would like to change alternatively Complete the Worksheet for the intention of gaining your Certificate of Competence 171

172 172 Importance Confidence

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

174 174 Please complete your evaluation forms Thank You

175 175


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