Self-Management

The ‘Flinders Program ’ of Chronic Condition Self-Management

What is the Flinders Program (formerly The Flinders Model)?

Flinders Human Behaviour & Health Research Unit (FHBHRU) has developed a generic set of tools and processes that enables clinicians and clients to undertake a structured process that allows for assessment of self-management behaviours, collaborative identification of problems and goal setting leading to the development of individualised care plans. These care plans are important cornerstones in enhancing self-management in people with chronic conditions. The tools include the Partners in Health Scale ©, Cue and Response Interview © and Problem and Goals assessment.

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History and development

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.

The Partners in Health (PIH) scale and the Cue and Response interview were developed in response to the learnings from this trial. 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’. 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? 

It was found that there was substantial evidence around characteristics of good self-management and the characteristics of programs that improve people’s ability to self-manage, as well as evidence that structured self-management and behavioural change programs improve health outcomes for people with a range of chronic diseases. While there were some disease specific assessment tools described, there were no generic assessment tools, or processes, to measure self-management.

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What is effective management of chronic disease?

The literature suggests that we need to consider these components in effective management of chronic disease:

The research also suggests that programs that are successful in improving self-management have the following characteristics:

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So what is self-management?

The definition of self-management as developed by the Centre for Advancement of Health (Center for the Advancement of Health) was adopted by SA HealthPlus.

Self-management:
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 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

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The Six Principles of Self-management

The following characteristics could therefore be seen to summarise a “good” self-manager.
They are individuals who:

  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.

These six characteristics could be considered to be the Six Principles of Self-management.

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Aim of the Flinders Program

The aim of the program is to provide a consistent, reproducible approach to assessing the key components of self management that:

Assessment Tools

Leading to

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Assessment Tools

Partners in Health Scale (PIH)

The PIH is a thirteen part questionnaire that is based on the six principles of self management.  The client completes the questionnaire by scoring their response to each question on a nine point scale, zero being the best response and eight being the worst.

The questions cover the following 14 areas:

Cue and Response Interview (C&R)

The ‘Cue and Response’ (C&R) interview is an adjunct to the PIH scale.The C&R process uses a series of open-ended questions or cues to explore the patient’s responses to the PIH 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 clinician 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 PIH scale, to be ‘validated’ by the health professional, it has proved to be a useful clinical tool in its own right.

The PIH scale and C&R interview tools can be used together or individually.

The C&R 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 higher 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. Identification of issues allows relevant strategies and interventions to be discussed and agreed on.

This information is easily incorporated into a care plan, whether it is a care plan supported by the Enhanced Primary Care (EPC) MBS or simply one that involves the health professional and the client.

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 eg managing the impact of the disease on their life, monitoring and managing the symptoms, adopting healthy lifestyles etc.

Preliminary Data

There have been two psychometric investigations of the Partners in Health Scale.  The first study of 46 subjects used the original 11 item version which showed high internal reliability, inter-rater reliability and construct validity using factor analysis.  A second study of the 12 item version with 175 subjects again showed high internal reliability and construct validity was confirmed with four factors emerging:  Knowledge, symptom management, coping and adherence. Further studies of the 14 item version are underway.

Problem and Goals (P&G) Assessment

The Problems and Goals assessment is another tool that can be used as an adjunct to the PIH and C&R process or as a stand-alone assessment. The PIH and C&R 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.

As well as defining the problem from the client’s perspective, this assessment also clearly identifies a goal or goals that the client can work towards.

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Self-management Care Plan

The information is gained from the PIH, C&R, and P&Gs assessments and can be summarised on the self-management care plan which documents the medical investigations, self-management tasks by the patient, self-management education and allied health and community services the person will access over the following 12 months.

The information on a self-management care plan should include:

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Clinical Applications

The Flinders Program is being trialed in a variety of clinical settings and across a range of conditions. The Commonwealth Government, through the “Sharing Health Care” initiative has 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, 3 indigenous projects that have the opportunity of using the education module and the tools as one of the strategies within their project.  A randomised control trial has been completed with Vietnam Veterans and another randomised control trial has been approved to assess the value of this program with people aged 60 years and over.  .

Targeted population groups 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.

In addition four projects funded by Department of Health in South Australia have been completed.  These projects have shown encouraging outcomes both statistically and clinically.  These projects have been in the areas of mental health, diabetes in rural aboriginal populations, chronic lung disease and heart disease. For more details view our relating Projects.

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Do clinicians find this a useful process? Worth the time?

The most common responses by health professionals are that the Flinders Program adds structure to how they are already working with their clients with chronic disease and that it encourages the client to have ownership of the management process and their care plan.

These are comments from a range of health workers using the Flinders Program clinically:

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FHBHRU Publication relating to the Flinders Program

Chronic Condition Self-Management Workshops

FHBHRU conducts courses for health professionals to understand and use the Flinders Model.  

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Postgraduate study in self-management

Postgraduate study in self-management is available through the Graduate Certificate in Health (Self-management) the Graduate Diploma in Chronic Condition Management and the Master of Public Health (Chronic Condition Management)

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Licensing and Use of the Flinders Program

Information concerning the licensing and use of the Flinders Program

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What is the difference between the Flinders Program and the Stanford Model?

The Stanford and Flinders models are complimentary approaches to chronic condition self-management (CCSM). The Stanford Model has been developed by Kate Lorig and associates at Stanford University, USA. It enables people to work in a group setting, to understand the components of self-management and to learn skills and strategies that will help to improve their ability to manage their lives. It has been well researched for over 20 years. It uses peer educators and standardised structured sessions.

Malcolm Battersby and associates at the Flinders Human Behaviour and Health Research Unit (FHB&HRU) have developed 'The Flinders Program'. The program, underpinned by cognitive behavioural therapy (CBT) principles, offers a generic approach to chronic condition self-management that can be applied to a wide range of health conditions. It provides a structured, patient centred framework for collaborative problem definition, goal setting, care planning and review between an individual and the health professional. 

That is, it is a one-on-one model, with interventions /actions in the care plan tailored to the identified needs and priorities of the individual.

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Useful information

FHBHRU publications relating to the Flinders Program (formerly Flinders Model)

Navigating self-management:  a practical approach for Australian health agencies
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.

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Updated: 18 November, 2009