Ten years of research and clinical use in a variety of settings and countries has led to robust reinforcement of the components of the Flinders Program™, the education and training options and adaptations for special populations.
The Flinders Program™ care planning process
From its inception in the SA HealthPlus coordinated care trial (1997-99), and subsequent research and development, the Flinders Program™ care planning process has five functions:
- Generic and holistic chronic condition management: it provides a generic clinical process for assessment and planning for disease specific management. It uses a semi-structured framework, which could be applied to any chronic disease or condition and co-morbid conditions in the same person, that is patient centred and holistic i.e., incorporates the bio (disease) psychosocial aspects of a person into a plan, and is motivational.
- Case management: The Partners in Health scale can be used as a screening tool to determine who requires full care planning and case management. The care plan itself then becomes the case management model by defining the roles of the health professionals and the client, the need for case management or coordination could be determined. (Not all people with chronic conditions need support, education or case management).
- Self-management support: The care planning process enables assessment of the person's self-management knowledge, behaviours and barriers so as to be able to target self-management education and support to the person.
- Systemic and organisational change: the program provides a longitudinal structure, which if followed naturally leads to the development of an integrated care plan for each patient which addresses: self-management issues; evidence based medical care; motivation and maintenance of effort; a care plan for each medical condition which is measurable and monitored and meshes with public or private practice business processes.
- Health professional change: Use of the Flinders ProgramTM can change a health professional's understanding of their practice in delivering patient centred care. The Flinders ProgramTM provides a semi-structured method of ensuring that patients are fully engaged in the delivery of their own care. The quality of the therapeutic alliance is optimised. back to top
B. Components of the Flinders ProgramTM
The Flinders ProgramTM chronic care philosophy and tools present an assessment, planning and motivational process which has been applied to chronic medical or mental conditions and co-morbidities.
1. Specialty areas include:
1.1 Mental health.
1.2 Children, adolescents and their families: chronic conditions such as cystic fibrosis and asthma.
1.3 Indigenous health: chronic care planning in combination with Point of Care testing, has been trialled and incorporated into Aboriginal medical services.
1.4 Disabilities: autism, spina bifida.
Flinders Human Behaviour and Health Research Unit (FHBHRU) offer a number of options for education and training including the following:
2.1 Vocational or professional education
2.1.1 Flinders Chronic Condition Care Planning Process is available as a two day workshop followed by support to achieve a Certificate of Competence in the use of the Flinders Care Planning Tools or on-line: CCM Online. The online program enables participants to work through activities, case studies and work based activities to achieve the same learning outcomes as the Flinders Chronic Condition Management Program™ workshop.
2.1.3 Flinders Chronic Condition Care Planning Process Trainer Accreditation workshop leads to Accredited Trainer status: Health professionals who have a Flinders Program™ Certificate of Competence can complete the Trainer Accreditation workshop and with support achieve Accredited Trainer status.
2.1.4 Flinders Chronic Condition Prevention Program™. The Flinders ProgramTM has been adapted for risk factor modification under the South Australian Department of Health 'Do it For life' program, targeted at disadvantaged people. Lifestyle advisors were trained in the Flinders Program™ approach and processes to assist people with one or more of the 5 SNAPS (smoking, nutrition, alcohol, physical activity, stress) risk factors for chronic conditions. This program was evaluated and informed the use of the adapted Flinders Program™ tools for general use.
2.1.5 Communication and Motivation workshop: A one day Communication and Motivation workshop builds capacity in these essential skills for health professionals working with people with chronic conditions and for people learning the Flinders Program™ care planning process.
2.1.6 Implementation program. Based on feedback ('I have learnt the process but how do I implement this in my practice?'), assistance with embedding the Flinders Program™ in practice can be provided. Targeted at managers as well as practitioners, this training examines services before and after the Flinders Program™ is provided. The aim of this workshop is to understand the incentives, barriers and solutions to embedding Chronic Condition Self-Management care planning process into routine clinical practice. This will include how services have embedded the principles of the Wagner Chronic Care Model. back to top
2.2 Post Graduate education: Flinders University
2.3 Undergraduate/graduate entry: Flinders University
Flinders School of Medicine chronic condition and self-management curriculum.
FHBHRU, originally the Coordinated Care Training Unit (CCTU), was established within the School of Medicine at Flinders University, to provide support and training for service coordinators and general practitioners during the SA HealthPlus trial. The SA HealthPlus Trial was one of the larger of the first round Coordinated Care Trials, enrolling 3,100 clients into its intervention arm. The Problem and Goals assessment was used routinely with all SA HealthPlus intervention clients (Battersby, Higgins and Collins et al., 2002).
The Partners in Health scale and the Cue and Response interview were developed in response to the learning from this trial (Battersby, 2005). It became evident that 'self-management' was a key factor in determining a client's need for a 'coordinator' to work with them and their general practitioner. The CCTU undertook an extensive literature review to look at 'self-management'. Key questions included: What do we mean by 'good' self-management? What research has been undertaken? Are there assessment tools available to look at client's self-management ability or status? What would be the use of such tools? back to top
Substantial evidence was found around the characteristics of good self-management and the characteristics of programs that improve people's ability to self-manage. Evidence was also found that structured self-management and behavioural change programs improve health outcomes for people with a range of chronic diseases. While some disease specific assessment tools described, there were no generic assessment tools, or processes, to measure self-management.
In 2009 the research and clinical team at FHBHRU changed the name of the Flinders approach to chronic condition prevention and management (the 'Flinders Model' of self-management) to the Flinders Chronic Condition Management ProgramTM. The reasons for this change were two fold i.e., that the Flinders Program™ care planning process was originally designed as a set of processes and tools that could be used for many aspects of chronic care management with self-management support being but one important element of this process, secondly, that since its development 10 years ago, the process and philosophy has been adapted for many clinical areas and evolved into a series of training and education modalities. back to top
The literature suggests that we need to consider these components in effective management of chronic disease (Wagner et al., 1996):
- Personalised care plans
- Self-management education
- Adherence to treatment
- Follow up and monitoring.
The research also suggests that programs that are successful in improving self-management have the following characteristics:
- Goal Setting
- Planning. back to top
The definition of self-management as developed by the Centre for Advancement of Health (Centre for the Advancement of Health, 1996, p1):
'involves (the person with the chronic disease) engaging in activities that protect and promote health, monitoring and managing the symptoms and signs of illness, managing the impact of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes.'
Kate Lorig (1993) one of the leading researchers in this area adds 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 practise new health behaviours, and to maintain or regain emotional stability.' back to top
The following characteristics could therefore be seen to summarise a 'good' self-manager and are an important part of the Flinders Program™ known as the seven Principles of Self-Management.
The seven Principles of Self-Management refers to the capacity of individuals to:
1. Have knowledge of their condition
2. Follow a treatment plan (care plan) agreed with their health professionals
3. Actively share in decision making with health professionals
4. Monitor and manage signs and symptoms of their condition
5. Manage the impact of the condition on their physical, emotional and social life
6. Adopt lifestyles that promote health
7. Have confidence, access and the ability to use support services.
A simplified version of these principles, using acronym KIC MR ILS is promoted to health professionals to use with clients to help them understand and remember the principles of self-management.
- Know your condition
- Be actively Involved with the GP & health professionals
- Follow the Care Plan that is agreed upon
- Monitor symptoms and Respond to them
- Manage the physical, emotional and social Impact of the condition(s)
- Live a healthy Lifestyle
- Readily access Support Services. back to top
The Flinders Program™ aims to provide a consistent, reproducible approach to assessing the key components of self-management that:
- improves the partnership between the client and health professional(s)
- collaboratively identifies problems and therefore better (i.e. more successfully) targets interventions
- is a motivational process for the client and leads to sustained behaviour change
- allows measurement over time and tracks change
- has a predictive ability, i.e. improvements in self-management behaviour as measured by the Partners in Health scale, related to improved health outcomes.
The Flinders Program™ consists of a set of tools that are completed by both the client and the health care professional/work, working together as a team. The Flinders Program™ Care Planning Tools provide a formal, systematic approach to assessing self-management capacity and care planning. Tools use to assess self-management capacity:
- Partners in Health Scale and
- Cue and Response interview, and
- Problems and Goals Statement
The care planning tool is the:
- Chronic Condition Management Care Plan.
Use of these tools enables the health professional and the client to identify issues, form an individualised care plan and a system monitoring and reviewing progress. These tools are available in word and electronic versions. back to top
Partners in Health scale
The Partners in Health is a questionnaire that is based on the principles of self-management. The client completes the questionnaire by scoring their response to each question on a nine point scale. The questions cover the following areas:
- Knowledge of condition
- Knowledge of treatment
- Ability to take medication
- Ability to share in decisions
- Ability to deal with health professionals
- Ability to attend appointments
- Ability to monitor and record
- Ability to manage symptoms
- Ability to manage the physical impact
- Abiltiy to manage the emotional impact
- Ability to manage the social impact
- Progress towards a healthy lifestyle. back to top
Cue and Response Interview
The Cue and Response interview is an adjunct to the Partners in Health scale. This process uses a series of open-ended questions or cues to explore the patient's responses to the Partners in Health scale in more depth. It enables the barriers to self-management to be explored, and it checks the assumptions that either the clinician or the client may have. The health professional can score the responses and compare their score with the client's scores. Whilst originally developed to enable the patient's perception of their self-management, as recorded on the Partners in Health scale, to be 'validated' by the health professional, it has proved to be a useful clinical tool in its own right to explore self-management.
Some examples of cue questions are to be found in Table 1. The cue questions are not prescriptive and serve as examples of the types of questions that may be asked.
Table 1: Examples of Cue Questions:
|Principle of self-management||Sample Cue and Response interview questions|
|Knowledge of treatment||What can you tell me about your treatment?|
|What other treatment options including alternative therapies do you know about?|
|What does your family/carer understand about your treatment?|
|Sharing in decisions||Does your doctor/health worker listen to you?|
|How involved do you feel in making decisions about your health with your doctor/health worker?|
|Healthy Lifestyle||What are you doing to stay healthy as possible?|
|What things do you do that could make your health worse?|
|What aspects of your lifestyle would you like to change?|
The Partners in Health scale and Cue and Response interview tools can be used together or individually.
The Cue and Response interview is a motivational process for the client and a prompt for behaviour change. It allows the individual the opportunity to look at the impact of their condition on their life, some time to reflect on cause and effect.
Scores rated on the lower end of the scale, by either client or health professional or both, flag issues for further discussion. This allows for clarification of issues and a common set of problems to be identified by client and health professionals. It also allows the clinician to acknowledge areas where the client is managing well. Collaborative problem identification has been found to be a key indicator in successful self-management programs (Wagner et al., 1996). Identification of issues allows discussion and agreement on relevant strategies and interventions.
The Flinders Program™ is supported by the Enhanced Primary Care (EPC) Medical Benefits Scheme (MBS) for GPs.
The process is generic not disease specific. It looks at the components of self-management, that is, how the tasks associated with self-management are being completed. These are common tasks across diseases e.g. managing the impact of the disease on their life, monitoring and managing the symptoms, adopting healthy lifestyles etc (Lorig, Sobel, Stewart et al., 1999). back to top
There have been two psychometric investigations of the Partners in Health scale. The first study of forty-six (46) subjects used the original eleven (11) item version which showed high internal reliability, inter-rater reliability and construct validity using factor analysis (Battersby, Ask, Reece, et al (2003). A second study of the twelve (12) item version with one hundred and sevent five (175) subjects again showed high internal reliability, and construct validity was confirmed with four factors emerging: Knowledge, symptom management, coping and adherence (Petkov, Harvey and Battersby 2010). Further studies of the new version are underway.
Problem and Goals assessment
The Problems and Goals assessment is another tool that can be used as an adjunct to the Partners in Health and Cue and Response process or as a stand-alone assessment. The Partners in Health and Cue and Response enable the clinician and the client to identify a range of issues or problems that are affecting the client. The health worker may well see one of these issues as the main or biggest problem for the client. The client may see the same thing as their biggest problem but they may see something else as having a far greater impact. For example, the clinician might think that the way the client uses their medication is the biggest problem, however the client may think their biggest problem is the demands the family places on them, perhaps they are caring for grandchildren everyday and have little time for themselves.
The information gained from the Partners in Health, Cue and Response (interview and discussion) and Problems and Goals assessments can be summarised on the care plan. This document includes the medical investigations, self-management tasks by the client, self-management education and allied health and community services, the person will access over the following twelve months.
The information on a self-management care plan should include:
- The identified issues / including the main problem
- Agreed goals - What I want to achieve
- Agreed interventions - Steps to get there
- A sign off by both the client and health professional
- Review dates. back to top
The Flinders ProgramTM is being trialed in a variety of clinical settings and across a range of conditions. The Commonwealth Government, through the 'Sharing Health Care' initiative funded the development of an education module in chronic disease self-management that includes the use of the Flinders tools. There were eight "Sharing Health Care" projects, one in each State and Territory, and, in addition, three indigenous projects had the opportunity of using the education module and the tools as one of the strategies within their project (Francis, Feyer and Smith 2007). A randomised control trial completed with Vietnam Veterans with alcohol problems showed positive outcomes. Two randomised control trials have commenced to assess the value of this program in people aged sixty (60) years and over, and to test patient competencies in self-managment are now in analysis and reporting stages.
Other studies have targeted population groups, which include the culturally and linguistically diverse, Aboriginal and low socio-economic. These are not randomised controlled trials but demonstration projects, however they will allow for further studies into the validation and use of the tools and the clinical impact of the Flinders ProgramTM when combined with other interventions such as the Stanford course.
The most common responses by health professionals are that the Flinders ProgramTM adds structure to how they are working with their clients with chronic disease and that it encourages the client to have ownership of the management process and their care plan. The biggest challenge that health professionals face using the Flinders Program™, is finding the additional time that the approach entails. These are comments about using the Flinders ProgramTM clinically:
- "challenged my assumptions about chronicity " (mental health worker)
- "made me focus on the client and goal setting that led to achievable outcomes" (nurse)
- "it does require a commitment to do it as you need to set aside time" but "I feel we are working more as a team"(GP)
- "allows patients to bring up [other] issues" (health worker)
- "relatively quick and simple system for care planning" (GP)
- "the process has changed my focus to what I don’t know about the patient rather than what I think I know" (GP)
- "it’s helped me to understand the effect my illness has had on me" (client)
"it’s pretty in-your-face in that it challenges your own current practice. Such challenges are essential in health care" (health worker).
Contact us for information concerning the licensing and use of the Flinders ProgramTM
Battersby M, Higgins P, Collins J, Reece M, Holmwood C, and Daniel B (2002). Partners in Health: the development of self-management for SA HealthPlus participants in The Australian Coordinated Care Trials: Recollections of an Evaluation , Publications Production Unit (Public Affairs, Parliamentary and Access Branch) Commonwealth Department of Health and Ageing, Canberra, Australia, pp. 201-211.
Battersby M, Ask A, Reece M, and Collins J (2003). "The partners in health scale: The developemnt and psychometric properties of a generic assessment scale for chronic conditions self-management". Australian Journal of Primary Health 9(2&3): 41-52.
Battersby MW (2005). Health reform through coordinated care: SA HealthPlus, British Medical Journal, 330, 662-665.
Center for the Advancement of Health and Center for Health Studies Group Health Cooperative of Puget Sound (1996). An indexed bibliography on self-management for people with chronic disease, Center for the Advancement of Health.
Lorig K (1993). Self-management of Chronic Illness: a model for the future (self care and older adults), Generations, 17, 11-14.
Lorig K, Sobel D, Stewart A, Brown B, Bandura A, Ritter P, Gonzalez V, Laurent D and Holman H (1999). Evidence Suggesting that a Chronic Disease Self-Management Program Can Improve Health Status While Reducing Hospitalization: A Randomized Trial, Medical Care, 37, 5-14.
Francis F, Feyer A, Smith B (2007). "Implementing chronic disease self-management in community settings: lessons from Australian demonstration projects." Australian Health Review 31 (4): 499-509.
Petkov J, Harvey P and Battersby M (2010). The internal consistency and construct validity of the Partners in Health scale: validation of a patient rated chronic condition self-management measure. Quality of Life Research 19(7): 1079-1085.
- FHBHRU publications relating to the Flinders ProgramTM
Navigating self-management: a practical approach for Australian health agencies (download: Navigating Self Management.pdf (PDF 5MB) )
Authors: Jill Kelly, Naomi Kubina
Contributing authors: Roy Batterham, Dr Margarite Vale, Janette Gale
Editor: Fiona Symington
Introduction by Professor Malcolm Battersby
In Navigating Change, Jill Kelly and Naomi Kubina draw upon their considerable experience of working with health professionals and managers to offer a practical guide to self-management. Their approach is straight forward, practical and based on their experience of implementing self-management in a variety of health agencies.