1. 1 CHRONIC CONDITION SELF-MANAGEMENT FLINDERS HUMAN BEHAVIOUR & HEALTH RESEARCH UNIT THE FLINDERS MODEL

2. 2 Positive Policy Environment Community Health Care Organization Prepared Prepared Prepared Prepared Patients and Families Better Outcomes for Chronic Conditions Links WHO’s Health Care for Chronic Conditions team (CCH) http://whqlibdoc.who.int/hq/2002/WHO_NMC_CCH_02.01.pdf

3. 3 Positive Policy Environment  Strengthen Partnerships  Support legislative frameworks  Promote consistent financing  Develop and allocate human resources  Integrate policies  Provide leadership and advocacy Community  Raise Awareness  Encourage better outcomes through leadership and support  Mobilize and coordinate resources  Provide complementary services  Promote continuity and coordination  Encourage quality through leadership and incentives  Organize and equip health care teams  Use information systems  Support self-management and prevention Health Care Organization Prepared Prepared Prepared Prepared Patients and Families Better Outcomes for Chronic Conditions Links

4. 4 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

5. 5 History of Flinders Model Flinders Model 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

6. 6 History of The Flinders Model 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- present

7. 7 Self-Management: Who’s Responsible? Self-management Self-management support

8. 8 Characteristics of Successful Self-Management Support 1. Collaborative Problem Definition (between client and health professionals) 2. 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)

9. 9 Characteristics of Successful Self-Management Support 3. Self-Management Training and Support Services (include instruction on disease management, behavioural support, & address physical & emotional demands of having a chronic condition) 4. Active and Sustained Follow-up (reliable follow-up leads to better outcomes) (Von Korff et al, 1997)

10. 10 Principles of Self-Management K I C MR I L Knowledge Involvement Care Plan Monitor and Respond Impact Lifestyle

11. 11 Researched & Published outcomes

12. 12 Care Plan Agreed Issues Agreed Interventions Shared Responsibilities Review Process The Flinders Model Problems and Goals + Assess Self-Management Psychosocial Support Community / Carer Support Self- Management Medical Management

13. 13 The Final Product : The Care Plan An active document that supports: –Communication –Organisation –Partnership –Motivation –Planning and follow-up –Outcome measurement

14. 14 What is new?

15. 15 Summary of The Flinders Model 6 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

16. 16 Further Information Flinders Human Behaviour Health Research Unit Phone: (08) 8404 2323 Fax: (08) 8404 2101 Email: self-management@fmc.sa.gov.auself-management@fmc.sa.gov.au http://som.flinders.edu.au/FUSA/CCTU/Home.html http://www.improvingchroniccare.org http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pq -ncds http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pq -ncds http://www.who.int/chp/knowledge/publications/icccreport/en/