11 of chronic condition management flinders human behaviour & health research unit the flinders...
TRANSCRIPT
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11
of
CHRONICCONDITION
MANAGEMENT
FLINDERS HUMAN BEHAVIOUR & HEALTH
RESEARCH UNIT
THE FLINDERSPROGRAM™
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Welcome and Introductions
• Current Role • Client Group• Interest in Chronic Condition
Management• Expectations of the Workshop
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The Program
Day 1
• Background & Evidence
• The Flinders Program
Day 2
• Review of Day 1
• Additional Resources for Interviews (Stages of Change, Motivational Interviewing, Problem Solving)
• Volunteer Interview
• Planning for Practice Change
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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
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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
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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
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History of Flinders Program
Flinders Program developed
Coordinated Care TrialsSA Health Plus
1997-1999
Sharing Health Care Initiatives
C’wealth Dept Health & Aging2001 - 2004
Partners In Health scale trialed and
standardised2001
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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.
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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
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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
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Chronic…
What characterises :
Acute…care models ?
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Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformation
SystemsSelf-
Management Support
Health System
Resources and Policies
Community Health Care Organization
Chronic Care Model
www.improvingchroncicare.org
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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.
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Activity – Brainstorm
What are the characteristics
of people who
self-manage well?
What barriers might they experience?
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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.” (p.1)
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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
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6 Principles of Self-Management 1. Know your condition
2. Be actively Involved with the GP & health workers to make decisions & navigate the system
3. Follow the Care Plan that is agreed upon with the GP and other health professionals
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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
6 Principles of Self-Management cont.
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Principles of Self-Management K
I C
MRIL
KnowledgeInvolvementCare PlanMonitor and RespondImpact
Lifestyle
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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
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Activity – Brainstorm
What are the capabilities
of those who support others
to self-manage well?
What barriers might they experience?
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Characteristics of Successful Self-
Management Support1. 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)
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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)
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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
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Brainstorm
• What does client / patient / person centred mean
• What skills are required for effective ‘partnering’
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Patient Centred Capabilities
• 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
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Behaviour Change Capabilities
• Frameworks for behaviour change
• Collaborative problem definition
• Motivational interviewing
• Goal setting & Goal achievement
• Structured problem solving
Battersby & Lawn,2009
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Organisational/System Capabilities
• Multi/Inter disciplinary teams
• Communication systems
• Evidence based practice
• Research
• Partnerships with community
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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?
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Research ProjectsNoarlunga (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
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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)
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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)
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Sharing Health Care Whyalla• Participants - People with complex & chronic
illnessAboriginal people > 35 years of ageNon-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 plansHarvey, 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.
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PIH
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PIH
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Hospital admission
0 1 2 3
time
0.25
0.30
0.35
0.40
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Vietnam VeteransAlcohol 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
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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
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Flinders Program Applications
• Distribution:– Australia; New Zealand; USA; Canada
• 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
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Principles of Self-Management K
I C
MRIL
KnowledgeInvolvementCare PlanMonitor and RespondImpact
Lifestyle
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Care PlanAgreed Issues
Agreed Interventions Shared Responsibilities
Evidence Based PracticeReview Process
The Flinders Program
Problems and Goals+
AssessSelf-Management
PsychosocialSupport
Community / Carer Support
Self-Management
MedicalManagement
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Partners In Health Scale
• Measures self-management capacity• Completed by client independently• Contains 13 questions covering the 6
principles of self-management• Takes 5 – 10 minutes to complete• Can be used to record change over time
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Introduction
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Cue & Response Interview
• A tool for GP / health professionals
• Covers the same 13 questions in the Partners in Health Scale
• Open-ended cue questions enable issues to be explored
• Answers are scored
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Cue & Response Interview
Cue questions need to explore:
• Understanding / Knowledge
• What actually happens
• What are their Strengths
• What are the Barriers
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Open ended questions
Affirmations
Reflective listening
Summaries
(Moyers & Rollnick, 2002)
Key Skills for Communication
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Guiding - Specific 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)
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Funnel Technique• Begin with open ended questions
• Further explore with specific open questions
• Use closed questions to examine issues in more detail
• Summarise / Recap
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Funnel Techniquegeneral open questions
specific open questions
closed questions
answers
accurate problemidentification
Clarifyand
checkback
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In Pairs
Turn to the person next to you.
Use open ended questions to find out 3 things about this person.
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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
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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
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Cue & Response Introduction
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Cue and Response
Physical Impact
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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
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Cue & Response Summary Sheet
May be used to record Health Professionals reflections about:
• Issues for Care plan ie score greater than 4 or discrepant over 3
• Interventions for the care plan
• Particular strengths/barriers
• Linking the Cue & Response with Care Plan
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Cue & Response Discussion(discrepancy)
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Self-Management Assessment
Partners in Health
Scale (PIH)
Cue & Response Interview (C&R)
Quick Takes time
Self Assessment Health Professional tool
13 Questions Expanded with open-ended cue questions
Scored by client Scored by interviewer
Collaborative identification of issues
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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:• Comparing your scores with the person’s scores
• Reinforcing person’s areas of good self-management (low scores)
• Items with scores 4 and above go onto the issues section of the care plan
• Discuss scores with 3 or more difference and change scores if needed.
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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?
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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
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Brainstorm
Why is using a scale/numbers useful?
Why is comparing the scores useful?
– For the person?– For the worker?
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Care PlanAgreed Issues
Agreed Interventions Shared Responsibilities
Evidence Based PracticeReview Process
The Flinders Program
Problems and Goals+
AssessSelf-Management
PsychosocialSupport
Community / Carer Support
Self-Management
MedicalManagement
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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
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Battersby M, Ask A, Marwick M, Collins J- A Case Study using the “Problems and Goals Approach”. Aus Journal Primary Health 2003;7(3):45-48Battersby M et al – Health Reform through Coordinated Care: SA Health Plus. BMJ 2005;330:662-6
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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?
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Why do we want to know the problem
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Problem Statements3 parts to a problem statement
• The Problem
• What happens to the client because of the problem?
• How this makes the client feel?
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The 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 a effectively self-managing with minimal disability, they may not have a problem.
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Problem MeasurementProblem 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 3 4 5 6 7 8Not at Very little Somewhat a fair bit A lot
all
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Problem MeasurementProblem 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 3 4 5 6 7 8Not at Very little Somewhat A fair bit a lot
all
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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
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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)
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Goal StatementsRepeated and S.M.A.R.T.
Specific (doing something)
Measurable (observable)
Action based
Realistic (not too reliant on others)
Timeframe (how long / how often)
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Problem & Goals Monitoring Record v9 Sept 2009 Name: ………………………………… Patient ID [ ] [ ] [ ] [ ] [ ] [ ]
DATE
Client / Patient Problem Statement: SCORE
Client / Patient Goal Statement: SCORE
Sub-goals: SCORE
SCORE
SCORE
1. Write the Problem and Goal onto the record.2. The scores for both the Problems and Goals are rated using the scales at the bottom of this page.3. Make sure the date is put at the top of the scoring column that you are using each time you want to record a score.4. When the client tells you their score for their Problem and Goal, write down their score under the date.
How much of a problem is this for me:
0 1 2 3 4 5 6 7 8 Not at Very somewhat a fair a lot all little bit
My progress towards achieving this goal:
0 1 2 3 4 5 6 7 8 complete 75% 50% 25% no success success
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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 86
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Goal MeasurementGoal Statement
“I will catch the community bus to the local community centre, twice a week for the afternoon Craft Group”
Rating ScaleMy progress towards achieving this goal is:
0 1 2 3 4 5 6 7 8Complete 50% No success success
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Goal MeasurementGoal Statement
“I will email my grandchildren every week when I go to the library ”
Rating ScaleMy progress towards achieving this goal is:
0 1 2 3 4 5 6 7 8Complete 50% No success success
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Why do we
score
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Goal Setting
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Practical
• Role play
• Group Discussion
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Care PlanAgreed Issues
Agreed Interventions Shared Responsibilities
Evidence Based PracticeReview Process
The Flinders Program
Problems and Goals+
AssessSelf-Management
PsychosocialSupport
Community / Carer Support
Self-Management
MedicalManagement
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Care Planning
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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
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Flinders Care PlanContains• Problem & Goal Statements at head of care plan
with scores• Issues from the Cue & Response Interview &
Problems and Goals• ‘Management Aims’• Agreed ‘Interventions/Actions’• Review dates
• Sign off
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Identified Issues
• Ensure all ‘Issues’ negotiated in the Cue and Response Discussion are listed on Care Plan– score of 4 or above 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.
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• Not just the ‘opposite of the issue’.
• They are the client’s aims – – ‘What benefit will a change bring to me?’ – ‘What do I want to achieve in relation to this issue?’
• It will be individualised and specific to the issue
• Can be more than one aim per issue101
Management Aims
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InterventionsInterventions• What are the possible solutions to the identified issues?• Which of these does the person chose to utilise.• Small manageable steps to achieve the aim.
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
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Interventions• Symptom Action Plan• Monitoring Diary• Handbook• Checklist• Best Practice
Guidelines• Next Steps
Tools External resources
Courses/Groups
Coping skills
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Interventions• Other health
professionals• Community activities• Support packages• Help lines i.e. Quitline• Libraries• Internet
Tools External resources
Courses/Groups
Coping skills
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Interventions
• DASSA• Walking and exercise
groups • Group Programs• Self-help/ Support
groups• Education classes
Tools External resources
CoursesGroups
Coping skills
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Interventions
• Problem Solving
• Stress Management
• Anger Management
• Job re-entry
• Assertiveness training
Tools External resources
Courses/Groups
Coping skills
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Review and Monitoring• Specify date when each intervention 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
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Structured Problem Solving
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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)
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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
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Steps of Problem Solving
• Define the problem• Generate and list solutions• Evaluate each alternative solution• Choose the best solution• Plan the implementation• Review progress and evaluate
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Practical
Using the role play,
complete the Care Plan
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The Final Product : The Care Plan
An active document that supports:– Communication – Organisation– Partnership– Motivation– Planning and follow-up– Outcome measurement
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What we covered so far…
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Principles of Self-Management K
I C
MRIL
KnowledgeInvolvementCare PlanMonitor and RespondImpact
Lifestyle
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What we covered so far…• 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
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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
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Characteristics of Successful Self-
Management Support1. 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
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Core Skills for the Primary Health Care Workforce
19 Capabilities for Supporting Prevention and Chronic Condition Self-Management
• 3 Sub group– Patient Centred– Behaviour Change– Organisational/System
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Feedback
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End of Day One
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Overview of Day 2
• Additional Resources for Interviewing (Stages of Change, Motivational Interviewing)
• Volunteer Interview• Care Plan Review• Planning for Practice Change• Follow up
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Summary of The Flinders Program
• 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
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Principles of Self-Management K
I C
MRIL
KnowledgeInvolvementCare PlanMonitor and RespondImpact
Lifestyle
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‘Susan’
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Stages of Change
“People would rather die, than change
and most do”
Mark Twain
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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
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Stages of ChangeEXIT: Long-
term abstinence or moderation
ENTER: Particular behaviour problem (e.g. drinking, smoking, over-eating)
(Prochaska & DiClemente, 1986)
Lapse
Maintenance Pre-contemplation
Action Contemplation
Determination to
change
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Open ended questions
Affirmations
Reflective listening
Summaries
(Moyers & Rollnick, 2002)
Key Skills for Communication
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Volunteer Interview
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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?
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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
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Volunteer Interview1. 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 – discussAims
Interventions
Who’s responsible and put them on the Care Plan
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Feedback
How was the interview for the
volunteer?
How was the interview for the
interviewer?
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Thanks to the volunteers
for participatin
g
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Feedback
What went well?
What were the difficulties?
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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.139
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Review of Care Plan
Time to reflect and critique
your care plan done with the
volunteer
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Motivational Interviewing
“is a person-centred, directive method for enhancing intrinsic motivation to change
by exploring and resolving ambivalence” (and procrastination)
(Moyers & Rollnick, 2002)
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• Express empathy • Develop discrepancy • Avoid argumentation• Roll with resistance • Support self-efficacy
(Moyers & Rollnick, 2002)
Five Key Principles
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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
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And….
5. Look to the future. Is the good / not so good balance going to change?
6. Highlight any discrepancies
7. Get the client to rate both importance and confidence on a scale of 1 to 10
8. Summarise
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How does the Flinders Program
motivate people to change?
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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
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Motivational Elements of the Flinders Program
• Client generated P&G statements that are linked to behaviour change
• Collaborative development of the Care Plan with agreed issues and interventions
• Increasing self-confidence in achieving small gains (P&G, Care Plan interventions)
• Shared responsibility / accountability• A sign off on the Care Plan• Monitoring and review
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Change is more likely if people make decisions
themselves instead of in response to external
pressure(shared Care Plan)
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Behaviour Change Capabilities (underpinning 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
planningBattersby & Lawn,2009
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1. Health Care System (National/State)
2. Organisation – Health Care Model (Local)
3. Individual Health Practitioner
System Change
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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
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Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community Health Care Organization
Chronic Care Model
www.improvingchroncicare.org
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2. Organisation - Health Care Model
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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?
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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)
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Part 1: Organisation of the Health Care Delivery System
Chronic illness management programs can be more effective if the overall system in which care is provided is oriented & led in a manner that allows for a focus on chronic illness care.
__________________________________________________________________________________
Components Little Support Basic Support Good Support Full Support
___________________________________________________________________________________
Overall….. …does not exist …reflected in ..reflected by ..part of the
Organisational vision statement senior leadershipsystem long
Leadership in term plan
Chronic Illness Care
Score: 0 1 2 3 4 5 6 7 8 9 10 11
(Bonomi et al, 2002)
Example
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KIC MR IL AuditKnowledge 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
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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
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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
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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
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Chronic Disease Items for Care Planning
MORE INFORMATION
http://www.health.gov.au/epc
Info on Allied Health Items
http://www.medicareaustralia.gov.au/providers/incentives_allowances/medicare_initiatives/
allied_health.shtml
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3. Individual Health Practitioner Change
• What am I going to do in the next week?– Enablers– Barriers
• Whom have I met here that I can contact for support?
• How do I plan to get my Certificate of Competence in 3 months time?
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KIC MR IL AuditKnowledge of Condition
• Does the program (my service) 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
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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
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The Flinders Program –training possibilities
• Trainer Accreditation
2 day workshop + post w/shop activities
Licensed as an Accredited Trainer
Follow-up and ongoing support
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The Flinders Program –training possibilities
• Flinders Program for Prevention of Chronic Conditions- Living Well
2 day workshop + post w/shop activities1 day bridging workshop + post w/shop activities
Follow-up and ongoing support
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The Flinders Program –training possibilities
• Communication and Motivation skills: enhancing self-management support.
1 day workshop – supplements all workshops.
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The Flinders Program –training possibilities
OnlineGrad Cert In Health (Self-Management)Grad Dip in Chronic Condition ManagementMasters of Public Health (Self-Management)
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Further InformationFlinders Human Behaviour Health Research Unit
Phone: (08) 8404 2323
Fax: (08) 8404 2101
Email: [email protected]
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/
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Personal Plan• Use the PDSA Worksheet for Testing Change to
Plan a 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 Competence172
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Please complete your evaluation forms
Thank You
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