The Flinders Model of chronic condition self-management
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The Flinders Model of Chronic Condition Self-Management is a structured process that enables clinicians and clients to collaboratively assess self-management behaviors, set goals, and create personalized care plans. It emphasizes the importance of self-management education, adherence to treatment, and ongoing monitoring, empowering patients to take an active role in managing their health. The model also highlights the need for integration between primary and secondary care while addressing implementation challenges in various healthcare settings.
The Flinders Model of chronic condition self-management
- 1. THE FLINDERS MODEL OF CHRONIC CONDITION SELF-MANAGEMENTPresenter: Nada RatcliffeAIDS ACTION COUNCIL OF THE ACT
- 2. 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
- 3. What does it mean?CollaborationPersonalised Care PlansSelf-management educationAdherence to treatmentsFollow up and monitoring
- 4. 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)
- 5. Self-management is enabling....Make informed choicesGain new perspectivesGain new skillsPractice new health behavioursMaintain or regain emotional stability
- 6. 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
- 7. The 6 principles of Self-ManagementKnowledge 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
- 8. 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
- 9. Desired outcomesIDENTIFICATION OF ISSUESDEVELOPMENT OF INDIVIDUALISED CARE PLANMONITORING AND REVEWING
- 10. The Care Plan.................Identified issues & main problemAgreed goalsAgreed interventionsA sign offReview dates
- 11. ApplicationsEducation module in chronic condition self-management – each state and territory3 Indigenous projects“SHARING HEALTH CARE”
- 12. Targeted GroupsCulturally & Linguistically DiverseAboriginal & Torres Strait IslanderLow socio-economic groups
- 13. workshopsCourses are available for health professionals to understand & use the modelPost graduate study: -Graduate Certificate in Health (Self-management) -Grad. Diploma in Chronic Condition Management
- 14. 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
- 15. 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 othersReduced benzodiazepines – 1 doctor – more disclosure with GPPoor knowledge of condition and treatment addressed One worker visit Has begun next goal of cigarette reduction More social interaction, less paranoid
- 16. Implementation Challenges Integration of chronicconditionself-management into primary care and general practice in particular Integration between hospitals and primary care of chronic care and self-management Implementation ChallengesIntegration of chronicconditionself-management into primary care and general practice in particular
- 17. Integration between hospitals and primary care of chronic care and self-management
- 18. Flinders vs. Stanford Models?What’s the difference ?
- 19. Stanford...............Utilises a group settingTrains & uses peer educatorsStandardised structured sessions
- 20. Flinders...........Underpinned by Cognitive Behavioural Therapy (CBT) Generic approachClient centredBetween the individual & health professional/sOne on one model
- 22. 3 year project“The interprofessional learning in primary health care to encourage active patient self-management of Chronic Disease”
- 23. ACT CHRONIC CONDITIONS ALLIANCEIdentify & 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
- 24. …..OTHER CHALLENGESMedical practitioners & allied health professionals undertake comprehensive training involving both personal commitment to the process & outcomes and a commitment to the significant time requiredPractitioners need to work within an holistic framework
- 25. ContactsFlinders Human Behaviour and Health Research UnitSharon.lawn@fmc.sa.gov.au Malcolm.Battersby@fmc.sa.gov.au Ph (08) 8404 2323 Fax (08) 8404 2101 http://som.flinders.edu.au/FUSA/CCTU/Home.html
Editor's Notes
- #2: This is named the Flinders Model OF Chronic Condition Self-Management – you may have heard of the STANFORD MODEL OF CHRONIC CONDITION SELF-MANAGEMENT that was developed by Stanford University in the United States .....and I shall discuss the differences later in the presentation.
- #3: This is a direct quote from Flinders University Human Behaviour and Health Research Unit. These INDIVIDUALISED CARE PLANS IS INTEGRAL to the self-management of people living with chronic conditions.
- #4: IT IS IMPORTANT TO KEEPS THINGS IN CONTEXT AS I HAVE WHEN RESEARCHING THIS MODEL – THE FHB&HRU WAS SET UP WITHIN THE SCHOOL OF MEDICINE. It’s all well and good to refer to self-management, but what does it mean? For the management of chronic conditions. literature suggests that the following areas need to be considered - list them - especially for “self-management” to be effective
- #5: This statement refers to the client / patient depending on the context. This in theory relates to the person with the chronic condition has greater responsibility in the management of their condition. This definition introduces social and psychological wellbeing into the BIO