Flinders Program™ fact sheets

Flinders Program™ fact sheets

This series of 14 Flinders Chronic Condition Management Program™ (Flinders Program) fact sheets are a resource for health practitioners to share with their clients to build their self- management capacity.

Fact sheets

1. Living with a chronic condition

2. What do we mean by health partnership?

3. How to be an active partner

4. Know about your condition

5. Sharing decisions

6. How to be actively involved

7. Care Plan

8. Monitoring and responding to your treatment

9. Symptom Monitoring Action Plan and Symptom Action Plan

10. Visit Checklist

11. Managing the impacts of the condition on your life

12. Adopting a healthy lifestyle

13. Using health and other support services

14. Contacting your general practitioner or care coordinator

© Flinders University 2020


Flinders Program™ fact sheet 1 Living with a chronic condition

Overview

This fact sheet is part of the Flinders Program and provides information about chronic conditions.

What is a chronic condition?

Any illness that lasts for more than six months is a chronic condition. Diabetes, heart disease, chronic obstructive pulmonary disease and arthritis are just some examples but you can probably name many others.

What is the best way to manage a chronic condition?

People with ongoing chronic conditions have different needs to those with acute single episode health problems such as broken limbs or appendicitis.

The most effective way to manage chronic conditions is to have an active partnership with your care coordinator. This partnership includes good medical management and good self- management.

What is self-management?

You self-manage your chronic condition every day when you take your medications, monitor your symptoms or eat healthy food. Managing the effect of your chronic condition on your everyday life is also part of self-management.

What is a Care Plan?

A Care Plan can help identify your needs and goals. It can also summarise your treatment plan by listing such things as specialist visits, pathology tests and x-rays that you should have over a 12 month period.

The use of a Care Plan can help you, in partnership with your health team or care coordinator, improve your health management.

Related fact sheets in the Flinders Program fact sheet series 3. How to be an active partner7. Care Plan


Flinders Program™ fact sheet 2 What do we mean by health partnership?

Overview

This fact sheet is part of the Flinders Program and provides information about health partnerships.

What is a health partnership?

A health partnership is the development of a relationship between the health care team, health practitioner and / or care coordinator, the person with the chronic condition and their family and carers, which encourages the person to take an active role in the management of their chronic condition. Many studies have shown that clients who work in partnership with their health care team, health practitioner and / or care coordinator enjoy better health and are more satisfied with the services they receive.

An example of a good partnership

Bill has been suffering from chronic obstructive pulmonary disease for many years and his condition is becoming more serious. He is having more difficulty with shortness of breath and he is spending a lot of time sitting in his armchair at home. His care coordinator suggests that his shortness of breath symptoms could improve if he was able to walk for about 20 minutes each day. He is concerned that he cannot do this so his care coordinator offers to help him work out a plan and he agrees to start by going for a ten minute walk on alternate days. At first, he will take frequent rests and in a month’s time, he will discuss his progress with his care coordinator and with his/her support he will aim to continue with the walk on alternate days but for a longer period and take shorter rests. He will continue to discuss his progress with his care coordinator over the next few months and modify his walking program until eventually he can walk for 20 minutes without stopping for a rest on most days in the week.

Why does a good partnership improve your health?

Partnerships can improve your health by:

• improving the quality of decisions made about the management of your chronicconditions

• helping and encouraging you to become more actively involved in the treatment of yourchronic conditions. Your role in the treatment plan is as important as that of the carecoordinator.

The client’s role in the partnership

People with chronic health conditions who have developed successful partnerships with their health practitioner and/or care coordinator do the following:

• know about their condition and understand the treatment and treatment options

• follow the treatment (i.e. Care Plan) agreed to with their care coordinator


• are actively involved in decisions made in relation to the treatment and management oftheir chronic condition

• monitor and record their symptoms and take appropriate action to manage and copewith their symptoms

• manage the physical, emotional and social impact of the condition on their life

• adopt lifestyles that promote good health and do not make the symptoms worse

• access health and other support services that fit in with their culture and beliefs.

The health practitioner and / or care coordinator’s role in the partnership

Care coordinators who make good partners:

• are good listeners and give their client time to fully discuss ways of managing theirproblems

• are prepared to discuss alternative ways of solving a problem

• assist clients to access information and support services they require

• respect the client’s right to choose the course of treatment and encourage the client toshare in decision making.

Benefits in developing a partnership with your health care team

Benefits could include that:

• you will have more control over the management of your conditions

• you may have fewer health crises, i.e. hospital admissions

• you and your carers can enjoy a better quality of life

• you may find the treatment is more successful

• you may be more satisfied with consultations with your care coordinator.

But I want my care coordinator to make all the decisions for me

Not everyone wants to develop an equal partnership with their health care team and / or health practitioners. Some individuals may prefer the care coordinator to make the decisions. Furthermore, they do not feel comfortable with asking their doctor questions. If this is the case you may still find the contents of this fact sheet useful in helping you and your care coordinator to make the right decisions regarding the treatment and management of your conditions.

Related fact sheets in the Flinders Program fact sheet series 3. How to be an active partner5. Sharing decisions

Flinders Program™ fact sheet 3 How to be an active partner


Overview

This fact sheet is part of the Flinders Program and provides an overview of the seven principles of self-management and an easy way of remembering these.

Seven principles of self-management

1. Know about your condition.

2. Seek to be actively involved in decisions made in relation to the treatment andmanagement of your condition.

3. Follow the treatment that you agreed to with your care coordinator (i.e. care plan )

4. Monitor and record your symptoms and respond by taking appropriate action tomanage and cope with your symptoms.

5. Manage the physical, emotional and social impact of the condition on your life.

6. Live a healthy lifestyle.

7. Use the health and other support services available to you.

How to remember the seven principles

An easy way to remember the seven principles of self-management is the acronym KIC MR ILS.

Related fact sheets in the Flinders Program fact sheet series 4. Know about your condition6. How to be actively involved7. Care Plan8. Monitoring and responding to your treatment11. Managing the impacts of the condition on your life12. Adopting a healthy lifestyle13. Using health and other support services


Flinders Program™ fact sheet 4 Know about your condition

Overview

This fact sheet is part of the Flinders Program and provides information on the first principle of self-management: Knowledge

Principle 1. Know about your condition.

To manage your chronic condition you need to have an understanding of the causes, symptoms and treatment of your chronic condition. This will make it easy for you to work with your health practitioner and / or care coordinator to make the right decisions about your health.

Finding out more about your condition

Some good sources of information on chronic conditions are:

• your general practitioner and other health care practitioners

• condition-specific associations (i.e. Asthma Australia, Diabetes Australia, HeartFoundation, Arthritis Australia) for books, pamphlets, courses and other relevantresources

• self-help and support groups (ask your health practitioner, care coordinator or localcommunity health centres and home care services for information about groups)

• information and referral services (see telephone directory, local councils)

• libraries (i.e. books, articles, online resources)

• the internet (Be aware, however, that some of the information offered might beinaccurate and unsubstantiated. If in doubt check with your care coordinator).

Related fact sheets in the Flinders Program fact sheet series 3. How to be an active partner


Flinders Program™ fact sheet 5 Sharing decisions

Overview

This fact sheet is part of the Flinders Program and provides information on sharing decisions about medications, medical tests and lifestyle behaviour changes. This relates to the second principle of self–management: involvement.

Principle 2 Seek to be actively involved in decisions made in relation to the treatment and management of your condition.

Shared decisions about medications Learn the basics

• What is the name of the drug and why do I need it?

• How does it work?

• How long does it take to work?

• How long will I need to take it?

• How much does it cost?

• Is a generic drug available (e.g. same formula, lower cost)?

• Are there non-drug alternatives?

• When to call the general practitioner, pharmacist or other health professional.

Consider the risks and benefits • How much will this drug help?

• What are the side effects and what to do about them?

• Could this drug react with other drugs that I am currently taking?

• Can I start with a prescription for a few days to make sure this medication agreeswith me?

• What to do if I forget to take it?

• What could happen if I do not take the medication?

Let the general practitioner or care coordinator know • Any concerns you have about the drug

• What you expect it will do

• All other medications (including over-the-counter drugs) you are taking

• How you feel about filling the prescription and taking the drug.

Tips for remembering to take medications • Take your medicine at the same time as one of your daily routines, for example, at

meal times• Put a sign on a frequently visited place (e.g. the bathroom mirror)

• Ask someone to remind you

• Set an alarm e.g. on the stove or mobile phone.


Shared Decisions about Medical Tests Before agreeing to do the test, ask your general practitioner or care coordinator:

• What is the name of the test and why do I need it?

• If the test is positive, what will the care coordinator do differently?

• What could happen if I don’t have the test?

• How accurate is the test? How often does it indicate a problem exists when there isnone? How often does it say there is not a problem when there is one?

• Is the test painful? What can go wrong?

• How will I feel afterward?

• How much does the test cost?

Tell your general practitioner or care coordinator: • Your concerns about the test

• Any medications you are taking

• About any other medical conditions

• Your decision to accept the test or not.

Once you agree to a test, ask your care coordinator: • What you can do to reduce the chance of errors?

• What food, exercise, alcohol, or medications to avoid before the test?

• When will the results be available and how will you be informed?

• W hat does my carer need to know?

Shared Decisions about Lifestyle Behaviour Changes The symptoms of chronic conditions can be significantly improved through changes in lifestyle such as regular exercise, healthy eating and quitting smoking. Discuss all lifestyle changes with your health practitioner and / or care coordinator and consider:

• the benefits of making lifestyle changes

• personal strengths and limitations to making lifestyle changes

• who can assist you to make lifestyle changes.

Related fact sheets in the Flinders Program fact sheet series 3. How to be an active partner4. Know about your condition6. How to be actively involved7. Care Plan9. Symptom Monitoring Action Plan and Symptom Action Plan12. Adopting a healthy lifestyle


Flinders Program™ fact sheet 6 How to be actively involved

Overview This fact sheet is part of the Flinders Program and provides information on the second principle of self-management: involvement.

Principle 2 Seek to be actively involved in decisions made in relation to the treatment and management of your condition.

State your position In all communications with your care coordinator, tell them you want to share responsibility in making decisions about your health and be honest and clear about your thoughts about what you need and want.

Become informed Do your own research and ask your care coordinator or other health care providers about:

• your condition and the treatments (see fact sheet 4: Know about your condition).

• diagnostic tests, results and their implications (see fact sheet 5: Sharing decisions)

• what they think is the best lifestyle change and why

• what they think about treatments other than those they recommend and costs, sideeffects and other problems that could arise from treatment.

Exercise your rights As the client, you have the right to:

• bring a companion with you when you see a care coordinator

• receive information about your treatment, medication and the best way to look afteryourself and your particular health condition

• question any advice given to you and be listened to and treated with dignity andconsideration when you have a question or want information

• seek a second opinion or change care coordinator if you are not satisfied

• expect that any information you share with your care coordinator will be confidentialunless otherwise agreed

• make sure that any risks involved in treatment are explained to you before you consentto treatment

• have an interpreter to assist if you have difficulties speaking or understanding English.

Related fact sheets in the Flinders Program fact sheet series 3. How to be an active partner4. Know about your condition5. Sharing decisions


Flinders Program™ fact sheet 7 Care Plan

Overview

This fact sheet is part of the Flinders Program and provides information on the third principle of self-management: Care Plan.

Principle 3 Follow the treatment agreed on your Care Plan

The Care Plan describes the agreed treatment decisions made with your health care team. The Care Plan states the goals you wish to achieve and describes the treatment and services you require and is therefore important in the management of your care.

What is the Care Plan?

As a complete record of the current treatment you are receiving the Care Plan includes:

• your diagnosis and the medications and treatments that have been prescribed for you

• personal information (i.e. allergies, medical history)

• names and contact details of your care coordinator

• your problems and goals (i.e. areas that you would like to work on)

• support services that have and will be used by you.

The benefits of having a personalised Care Plan

The Care Plan clearly describes your treatment plan, which can lead to:

• better understanding by you and your carers of the treatment plan

• improved communication between you and the care coordinator and healthpractitioners involved in your treatment

• better coordination of services that are required by you.

You and your carers are directly involved in the development of the Care Plan and this can result in:

• becoming more actively involved in the management of your health condition

• feeling more committed to the course of treatment described in the Care Plan

• as well as your carer and care coordinator, easily seeing what improvements haveoccurred and in what areas.


Tips for using your Care Plan

• If you have problems understanding the Care Plan or feel that the treatment is notworking for you, then it is important to discuss your concerns with your carecoordinator.

• Make and attend appointments with services specified in the Care Plan.

• Use the medications given to you according to your general practitioner, pharmacist ornurse’s directions, and the Care Plan.

• Follow the exercise, dietary and / or other treatment advice given to you.

• Notify your care coordinator if you are having trouble following your Care Plan.

• Take your Care Plan with you when attending health appointments.

• Notify your general practitioner or health practitioners if something occurs that mayaffect the treatment described in the Care Plan (e.g. travel).

Your Care Plan should be reviewed when you:

• attend any appointments

• see a new general practitioner or care coordinator

• have your medication adjusted or are referred for tests

• have a change of circumstances (e.g. a change of address or a hospital admission).

Related fact sheets in the Flinders Program fact sheet series 3. How to be an active partner6. How to be actively involved

Flinders Program™ fact sheet 8 Monitoring and responding to your symptoms


Overview

This fact sheet is part of the Flinders Program and provides information on the fourth principle of self-management: Monitor and respond.

Principle 4 Monitor and respond to your symptoms

Monitoring your symptoms and the effects of your treatments by recording measurements and symptoms allows you and your care coordinator to make sure your treatment/s is going to plan.

This may also help you and your health practitioner and / or care coordinator to identify problems early, to avoid them becoming more serious or requiring emergency treatment.

Some people find diaries are an easy way to record and monitor their symptoms.

When recorded measurements and other symptoms show that your condition/s is becoming worse, it is important that you take the right action.

The right action at the right time may stop symptoms from worsening and ultimately, help avoid medical emergencies.

The Symptom Monitoring Action Plan and Symptom Action Plan can help you manage your symptoms.

Related fact sheets in the Flinders Program fact sheet series 3. How to be an active partner5. Sharing decisions9. Symptom Monitoring Action Plan and Symptom Action Plan10. Visit checklist


Flinders Program™ fact sheet 9 Symptom Monitoring Action Plan and Symptom Action Plan

Overview This fact sheet is part of the Flinders Program and provides information on the Symptom Monitoring Action Plan and Symptom Action Plan. See the next page for a sample of the Symptom Monitoring Action Plan and Symptom Action Plan.

Symptom Monitoring Action Plan How will it help? Regular recording by you of your symptoms (e.g. breathlessness) and measures (e.g. peak flows) in the Symptom Monitoring Action Plan may help to identify the signs that indicate when your condition is worsening.

This information can assist you and your general practitioner and / or care coordinator to develop a Symptom Action Plan. This provides you with advice on what to do when the signs indicate that your condition is worsening. The right action taken at the right time can prevent medical emergencies.

If your condition or your treatment changes, you can also use the Symptom Monitoring Action Plan to generate information, which you and your care coordinator can use to determine what modifications need to be made.

When do I use it? You may choose to use the Symptom Monitoring Action Plan every day or you might only use it when your symptoms or measures change, become worse or your treatment stops working as it should.

How do I use it? Complete the Symptom Monitoring Action Plan when your symptoms appear, or when you monitor your measures. At your next appointment, discuss the results with your general practitioner and/or care coordinator.

Symptom Action Plan How will it help? The Symptom Action Plan provides you with clear guidelines about what action to take when your condition and symptoms become worse. The Symptom Action Plan is the plan developed in partnership with you and your care coordinator that helps you manage your condition.

When do I use it? With your help, your general practitioner or care coordinator will complete the Symptom Action Plan. You should carry it with you and refer to it when your symptoms or measures get worse.


Flinders Program™ Symptom Monitoring Action Plan

This table is for regular recording, by you, of symptoms (e.g. breathlessness) and measures (e.g. peak flows) to help identify the signs that may indicate when your illness is getting worse. Use this with your Symptom Action Plan to help you, your doctor and care coordinator, manage your illness.

Date Time Symptom or measure

Measurement Comment

E.g. What were you doing before symptoms started? How didyou respond? Did the symptoms/ measures become worse,improve or stay the same?

Mild/Mod/Severe

And/or Level/Reading

Duration

18/01/2010 12.30pm Wheeze Mild / peak flow 300 30 minutes Out gardening - Ventolin / Atrovent Nebuliser - symptoms improved


Flinders Program™ Symptom Action Plan

Client

DOB / /

Doctor / care coordinator

Admissions during past 2 years

Reason for admission

Social. Home environment e.g. falls

Medication. Not taking medication as prescribed, e.g. cost, forgetfulness, side effects. Mix-up e.g. confusion, collapse

Other

Date completed: / /

Date to be reviewed: / /

My primary condition:

I measure and manage my symptoms in the following way: When /If

then I

When /If

then I

When /If

then I

If unsure contact:

Your doctor or care coordinator: (phone number)

Emergency dept of your local hospital (phone number)



Flinders Program™ fact sheet 10 Visit Checklist

Overview

This fact sheet is part of the Flinders Program and provides information on the Visit Checklist. See the next page for a sample of the Visit Checklist.

What is it?

The Visit Checklist is a guide to help you make the most of the time that you spend with your general practitioner and / or care coordinator.

How will the Visit Checklist help?

It is common during visits to the general practitioner and / or care coordinator, for people to forget questions, or that time runs out before they have a chance to ask some important questions.

The Visit Checklist helps you and your care workers deal with your main concerns.

It also gives you a written record of what was said during the visit, to help you remember what you have to do once you get home.

How do I use the Visit Checklist?

We suggest that you complete a new form before making an appointment with your general practitioner and / or care coordinator.

W hen attending appointments, take the completed form with you and give to the general practitioner and / or care coordinator at the beginning of the appointment.

After the visit, follow through with any recommendations and then file the form in your personal records. If you have difficulties filing in the form, ask someone to help you.

Related fact sheets in the Flinders Program fact sheet series 14. Contacting your general practitioner or care coordinator


Visit Checklist This form is a guide to help you make the most of the time that you spend with your doctor, care coordinator and other health care providers. You can use this form to record information and questions about your condition, medications, tests, other treatment and Care Plan appointments.

Name: Date of Visit: _ / / Time of visit:

Reason for seeing the Doctor / care coordinator Things to do after seeing the Doctor / care (i.e. description of the problem and symptoms) coordinator

Medical Tests

Things to ask the Doctor / care coordinator

1.

Appointments

2.

3. Changes to Treatment

Prescription Renewal – List Medications Below:

Other (e.g. exercise)


Flinders Program™ fact sheet 11 Managing the impacts of the condition on your life

Overview

This fact sheet is part of the Flinders Program and provides information on the fifth principle of self-management: impact.

Principle 5 Manage the physical, emotional and social impact of the condition on your life.

Having a chronic condition may impact on the practical day to day aspects of living. It can also affect how you feel emotionally and how you socialise.

It may be more difficult to continue with some of the activities that you have always enjoyed. In saying this, it is important to listen to what your body is saying to you and to seek treatment and advice accordingly.

Tiredness too, can be a symptom of stress, or overwork or maybe the result of the body getting over an illness. By keeping your body as healthy as possible, you can help reduce symptoms such as shortness of breath and conditions such as anxiety, depression and other mental disorders.

Feeling worried and anxious can be part of everyday life. However it is not normal when anxiety becomes overwhelming and interferes with daily life. Learning and practising skills such as relaxation can help you to manage your condition.

Related fact sheets in the Flinders Program fact sheet series 3. How to be an active partner5. Sharing decisions7. Care Plan9. Symptom Monitoring Action Plan and Symptom Action Plan

Flinders Program™ fact sheet 12 Adopting a healthy lifestyle

Overview

This fact sheet is part of the Flinders Program and provides information on the sixth principle of self-management: healthy lifestyle.

Principle 6. Adopt a lifestyle that promotes health and improves symptoms.

Significant improvements in chronic conditions can be achieved through changes in lifestyle. Lifestyle changes such as healthy eating, quitting smoking and regular exercise can improve the health of people living with chronic conditions.

How to adopt a healthy lifestyle

Ask your health practitioner and/or care coordinator to advise and discuss:

• what lifestyle changes may improve your state of health

• what benefits you are likely to experience

• where you can go to get assistance in making lifestyle changes

Other sources of assistance

You can also seek information and assistance from:

• condition-specific associations (e.g. Asthma Australia, Diabetes Australia, HeartFoundation, Arthritis Australia)

• community health centres

• self-help and support groups (e.g. Alcoholics Anonymous)

• the internet (Keep in mind that some information on the internet might be inaccurateand unsubstantiated. If in doubt, check with your health practitioner and/or carecoordinator.)

• libraries

• bookshops.

Related fact sheets in the Flinders Program fact sheet series 3. How to be an active partner5. Sharing decisions7. Care Plan


Flinders Program™ fact sheet 13 Using health and other support services

Overview


This fact sheet is part of the Flinders Program and provides information on the seventh principle of self-management: support services.

Principle 7. Use the health and other support services available to you.

A broad understanding of available resources, supports, services and activities that are in your community can help you manage your chronic condition. You need to know what the services involve, how to access them and have the confidence to use these services.

How to access support services

Ask your health practitioner and/or care coordinator to discuss:

• what support services may assist you to improve your health and general well-being

• what benefits you are likely to experience

• how you can use support services that fit with your culture and beliefs.

Other sources of assistance

You can also seek information and assistance from:

• condition-specific associations (e.g. Asthma Australia, Diabetes Australia, HeartFoundation, Arthritis Australia)

• community health centres

• self-help and support groups (e.g. Alcoholics Anonymous)

• the internet (Keep in mind that some information on the internet might be inaccurateand unsubstantiated. If in doubt, check with your health practitioner and/or carecoordinator.)

• libraries

• bookshops.


12. Adopting a healthy lifestyle


Flinders Program™ fact sheet 14 Contacting your general practitioner or care coordinator

Overview

This fact sheet is part of the Flinders Program and provides information about contacting your general practitioner or care coordinator and how to get the most from visits.

A key to developing a good relationship is to prepare before you make phone calls or attend appointments. This way, your general practitioner and / or care coordinator will have more time to address your concerns and you will be more likely to get the kind of care you expect.

Phoning your general practitioner or care coordinator

When calling for advice, have the following to hand:

• a one sentence description of your problem and why you are calling (fact sheet 10: VisitChecklist can help you with this)

• your calendar, in case you need to schedule an appointment.

Getting the most from your visit to your general practitioner or care coordinator

What to take

Make sure you take to every appointment:

• the Visit Checklist that you have prepared

• your Symptom Monitoring Action Plan and other records you have made in relation to yourhealth and lifestyle

You may also find it helpful to take another person, i.e. your carer with you.

What to say

You will get more out of the appointment if you:

• state clearly what your problem is (your Visit Checklist can help you with this)

• make sure that you understand what the general practitioner has said. If you are unsure,ask him / her to explain again.

• talk about how you feel, don’t just say what you think your general practitioner wants tohear

• tell your general practitioner about any medication or other treatments you are using

• state what you are seeking from the general practitioner and / or care coordinator.

Ask your general practitioner or care coordinator to book an interpreter if you have difficulties

speaking or understanding English.


What to do

During the appointment:

• write down or ask your general practitioner and/or care coordinator to write down anyrecommendations

• ask for direction to places where more information is available

• ensure that you understand the reasons for the recommendations and what physical,social and emotional effects the changes may have on your life

Referral to a specialist

Before you go to see a specialist:

• know the diagnosis or suspected diagnosis

• learn about the basic treatment options

• know what your general practitioner would like the specialist to do (i.e. take over the case,conduct tests, confirm a diagnosis)

• make sure that any test results or records on your case have been sent to the specialist.

Discharge from Hospital

Before leaving hospital ask hospital staff if they:

• have your general practitioner’s current contact details

• will be sending details of your hospital treatment to your general practitioner.

Related fact sheets in the Flinders Program fact sheet series 9. Symptom Monitoring Action Plan and Symptom Action Plan10. Visit Checklist

Flinders Program™ fact sheets

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