the flinders model of chronic condition self-management
TRANSCRIPT
THE FLINDERS MODEL OF CHRONIC CONDITION SELF-MANAGEMENT
Presenter: Nada RatcliffeAIDS ACTION COUNCIL OF THE ACT
The ‘Flinders’ ModelWhat is it?
“A generic set of tools & processes that enables clinicians & clients to undertake a structured process.....for assessment of self managing behaviours , collaborative identification of problems and goal setting the development of individualised care plans”
(Flinders Human Behaviour & Health Research Unit, 2006)
2
What does it mean?Collaboration
Personalised Care Plans
Self-management education
Adherence to treatments
Follow up and monitoring
What is self-management?
Involves engaging in activities that protect & promote health, monitoring & managing the symptoms & signs of illness, managing the impact of illness on functioning emotions & interpersonal relationships & adhering to treatment regimes
• (Centre for Advancement of Health)
Self-management is enabling....Make informed choices
Gain new perspectives
Gain new skills
Practice new health behaviours
Maintain or regain emotional stability
Patients are already the primary source of care
“People with chronic conditions are the principal care-givers
Health care professionals should be consultants supporting them in this role
Each day, patients decide what they are
going to eat, whether they will exercise and to what extent they will consume prescribed medicines.”
Bodenheimer et al, JAMA 2002
The 6 principles of Self-Management
Knowledge of one’s conditionFollow a care planActively share in decision-makingMonitor and manage signs & signs &
symptomsManage impact on physical, emotional &
social lifeAdopt lifestyles that promote health
AIM OF THE FLINDERS MODELImprove relationship between client and
health professionalsCollaboratively identify problemsTarget interventionsMay lead to ongoing behaviour changesBe motivationalAllows for measurement over timeHas a predictive ability
Desired outcomes
IDENTIFICATION OF ISSUES
DEVELOPMENT OF INDIVIDUALISED CARE PLAN
MONITORING AND REVEWING
The Care Plan.................Identified issues & main problem
Agreed goals
Agreed interventions
A sign off
Review dates
Applications
Education module in chronic condition self-management – each state and territory
3 Indigenous projects
“SHARING HEALTH CARE”
Targeted Groups
Culturally & Linguistically Diverse
Aboriginal & Torres Strait Islander
Low socio-economic groups
workshops
Courses are available for health professionals to understand & use the model
Post graduate study:-Graduate Certificate in Health (Self-management)-Grad. Diploma in Chronic Condition Management
Case study45 year old single man, living alone. Client of
mental health service for 20 years - paranoid schizophrenia. History of violence (2 worker home visits), cigarette smoker, benzodiazepine dependent – doctor shopper, treatment order
Problems with planning, concentration, memory and problem solving, persistent paranoia
Goals: Better body image/decrease weight, decrease benzo’s, better financial state, better care of self and dog
Outcomes..........Cleaning contract for 5 weeks to feel better about house so
could do weights and to be able to invite friends into house – boost self esteem and challenge view of being dangerous to others
Reduced benzodiazepines – 1 doctor – more disclosure with
GP Poor knowledge of condition and treatment addressed
One worker visit
Has begun next goal of cigarette reduction
More social interaction, less paranoid
Implementation Challenges
Integration of chronic condition self-management into primary care and general practice in particular Integration between hospitals and primary care of chronic care and self-management Implementation Challenges
Integration of chronic condition self-management into primary care and general practice in particular
Integration between hospitals and primary care of chronic care and self-management
Flinders vs. Stanford Models?
What’s the difference ?
Stanford...............
Utilises a group setting
Trains & uses peer educators
Standardised structured sessions
Flinders...........Underpinned by Cognitive Behavioural
Therapy (CBT)
Generic approach
Client centred
Between the individual & health professional/s
One on one model
Local initiatives.............UNSW Centre
for Clinical Governance
ACTDGP
ANU College of Medicine &
Health Services
Australian National
University
3 year project
“The interprofessional learning in primary health care to encourage active patient self-management of
Chronic Disease”
ACT CHRONIC CONDITIONS ALLIANCE
Identify & present issues of concernPromote information exchangeTo lobby for relevant health servicesBridge the gap between govt and ngo’sCollaboration in the development of health
servicesBe a communication channel for
organisations to engage with chronic conditions groups & services
…..OTHER CHALLENGESMedical practitioners & allied health
professionals undertake comprehensive training
involving both personal commitment to the process & outcomes and a commitment to the significant time required
Practitioners need to work within an holistic framework
Contacts
Flinders Human Behaviour and Health Research Unit
Ph (08) 8404 2323 Fax (08) 8404 2101
http://som.flinders.edu.au/FUSA/CCTU/Home.html
thankyou
Any questions.........................?