A pragmatic randomized controlled trial of the Flinders Program of chronic condition management in community health care services

Barriers and facilitators to the implementation of the Flinders Chronic Condition Management Program in outpatient drug and alcohol settings in Australia

INTRODUCTION

There has been a growing call for drug and/or alcohol dependence to be managed as a chronic condition. The Flinders Chronic Condition Management Program (Flinders Program) was implemented in a drug and alcohol service in Australia in 2019-2022 to explore the feasibility of chronic condition management in outpatient clinics. Implementation involved: adaptation of the Flinders Program; adaptation of clinical procedures; training clinicians and managers; training Flinders Program Accredited Trainers; and system integration. This study aims to explore barriers and enablers to implementation.

METHODS

A qualitative formative evaluation was undertaken. Data included implementation documents (n = 7), responses to open-ended questions in post-training surveys (n = 27), and focus groups and interviews with implementation staff, clinicians, managers and a trainer (n = 16). Data were analysed using the Consolidated Framework for Implementation Research in a 'coding reliability' approach to thematic analysis.

RESULTS

Participants responded positively to the Flinders Program's philosophy, processes, tools and training. However, barriers were identified across three Consolidated Framework for Implementation Research domains: (i) outer setting (client suitability and incompatibility with external policies and incentives); (ii) characteristics of individuals (low self-efficacy); and (iii) inner setting (lack of system and workflow integration).

DISCUSSION AND CONCLUSIONS

Executive support and systems integration are important for the implementation of the Flinders Program in drug and alcohol services. This needs to be achieved within externally mandated key performance indicators for outpatient services. Further research is needed to fully evaluate the potential of a chronic condition management framework in Australian outpatient drug and alcohol services.

Individualized Hospital to Home, Exercise-Nutrition Self-Managed Intervention for Pre-Frail and Frail Hospitalized Older Adults: The INDEPENDENCE Randomized Controlled Pilot Trial

Purpose

Pre-frailty and frailty in older adults are associated with poor health outcomes and increase health-care costs, and further worsening during hospitalization. This study aimed to examine the effect of an individualized hospital to home, exercise-nutrition self-managed intervention for pre-frail and frail hospitalized older adults.

Patients and Methods

Older adults admitted to an acute medical unit of a tertiary hospital in South Australia who were pre-frail or frail were recruited from September 2020 to June 2021, randomized to either control or intervention group and followed up at 3 and 6 months. The outcome variables were program adherence, frailty status by the Edmonton Frail Scale (EFS) score, lower extremity physical function, handgrip strength, nutritional status, cognition, mood, health-related quality of life, risk of functional decline, unplanned readmissions.

Results

Participants were 79.2 ±6.6 years old, 63% female, mostly frail (67%), with EFS of 8.6±1.9. Adherence to the inpatient and home visits/telehealth intervention were high (91±13% and 92±21%, respectively). Intention-to-treat analysis using linear regression models showed that participants in the intervention group had significantly greater reduction in EFS at 3 (-3.0; 95% CI: -4.8 to -3.0) and 6 months (-2.5; 95% CI: -3.8 to -1.0, P<0.001 for both) compared to the control group; particularly the functional performance component. There were also improvements in overall Short Physical Performance Battery score at 3 (4.0; 95% CI: 1.3 to 6.6) and 6 months (3.9; 95% CI: 1.0 to 6.9, P<0.05 for both), mini-mental state examination (2.6; 95% 0.3-4.8, P=0.029) at 3 months and handgrip strength (3.7; 95% CI: 0.2-7.1, P=0.039) and Geriatric Depression Scale, at 6 months (-2.2; 95% CI: -4.1 to -0.30, P=0.026) in the intervention group as compared to control.

Conclusion

This study provided evidence of acceptability to a patient self-managed exercise-nutrition program that may benefit and alleviate pre-frailty and frailty in hospitalised older adults.

Comparison of short and long forms of the Flinders program of chronic disease SELF-management for participants starting SGLT-2 inhibitors for congestive heart failure (SELFMAN-HF): protocol for a prospective, observational study

Introduction

Congestive heart failure (CHF) causes significant morbidity and mortality. It is an epidemic, and costs are escalating. CHF is a chronic disease whose trajectory includes stable phases, periods of decompensation, and finally palliation. Health services and medical therapies must match the various patient needs. Chronic disease self-management (CDSM) programmes that are patient-focused, identify problems and set actionable goals that appear as a logical, cost-friendly method to navigate patient journeys. There have been challenges in standardising and implementing CHF programmes.

Methods and analysis

SELFMAN-HF is a prospective, observational study to evaluate the feasibility and validity of the SCRinHF tool, a one-page self-management and readmission risk prediction tool for CHF, with an established, comprehensive CDSM tool. Eligible patients will have CHF with left ventricular ejection fraction <40% and commenced sodium glucose co-transporter-2 inhibitors (SGLT2-i) within 6 months of recruitment. The primary endpoint is the 80% concordance in readmission risk predicted by the SCRinHF tool. The study will recruit >40 patients and is expected to last 18 months.

Ethics and dissemination

This study has been approved by the St Vincent's ethics committee (approval no. LRR 177/21). All participants will complete a written informed consent prior to enrolment in the study. The study results will be disseminated widely via local and international health conferences and peer-reviewed publications.

A randomized controlled trial evaluating the effectiveness of a self-management program for adolescents with a chronic condition: a study protocol

BACKGROUND

Self-management support is increasingly viewed as an integral part of chronic condition management in adolescence. It is well recognized that markers of chronic illness control deteriorate during adolescence. Due to the increasing prevalence of long-term chronic health conditions in childhood and improved survival rates of previously life-limiting conditions in children and adolescents, significant numbers of adolescents are having to manage their chronic condition effectively as they transition to adult health care. Therapy adherence has been identified as a major challenge for young people living with a chronic condition such as cystic fibrosis, diabetes, or asthma requiring long-term pharmacological therapy and/or lifestyle modifications. Most systematic reviews on self-management interventions address adult populations. Very few intervention studies are directed at adolescents with a chronic condition who are transitioning to adult health services. This protocol describes a prospective randomized controlled trial of a standardized self-management intervention program delivered to adolescents aged 15-18 years prior to their transfer to adult care. This study has been designed to provide evidence regarding self-management programs for adolescents and is the first study to use the Flinders Program with this important, under-researched age group.

METHODS

A randomized controlled trial is used to investigate the effectiveness of a modified adolescent-friendly version of an adult self-management program. This program is directed at improving self-management in an adolescent cohort 15-18 years of age with a chronic condition being treated in a specialist pediatric hospital. Participants will be randomized to either usual care or the modified Flinders Program plus usual care. Data collection will include measures of specific illness control, unscheduled hospital admissions, and questionnaires to record self-management competencies, quality of life, self-efficacy, and outcome measures specific to the chronic condition at baseline, 3 months, 6 months, and 12 months after delivery.

DISCUSSION

This study will provide a better understanding of the elements required for effective self-management programs in adolescents with a chronic condition and address some important knowledge gaps in current literature. The study will be carried out in collaboration with the Discipline of Behavioural Health at Flinders University, Adelaide, Australia, in order to inform the development of an adolescent version of the successful and validated Flinders Program™.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN12621000390886). Registered on April 8, 2021.

Effects of sociodemographic and health factors on the self-management of non-communicable diseases among Chilean adults during the Covid-19 pandemic

Individuals with non-communicable diseases (NCDs) are potentially at increased vulnerability during the Covid-19 pandemic and require additional help to reduce risk. Self-management is one effective strategy and this study investigated the effect of sociodemographic and health factors on the self-management of some non-communicable diseases, namely hypertension, type 2 diabetes mellitus and dyslipidemia, among Chilean adults during the Covid-19 pandemic. A cross-sectional telephone survey was carried out on 910 participants with NCDs, from Santiago, Chile. An adapted and validated version of the "Partners in Health" scale was used to measure self-management. Exploratory Factor analysis yielded five dimensions of this scale: Disease Knowledge, Healthcare Team Relationship, General Self-Management and Daily Routines, Drug Access and Intake, and Monitoring and Decision-Making. The average of these dimensions was calculated to create a new variable Self-Management Mean, which was used as a dependent variable together with the five separate dimensions. Independent variables included age, gender, years of schooling, number of diseases, the percentage of Multidimensional Poverty Index in the commune of residence, and self-rated health status. Beta regressions and ANOVA for the Beta regression residuals were utilized for analyses. Beta regression model explained 8.1% of the variance in Self-Management Mean. Age, years of schooling, number of diseases and self-rated health status were statistically associated with Self-Management Mean and dimensions related to daily routines and health decision making, such as Disease Knowledge, General Self-Management and Daily Routines, and Monitoring and Decision-Making. Gender and the percentage of Multidimensional Poverty Index in the commune of residence were insignificant. Strategies for self-management of NCDs during a crisis should consider age, years of schooling, number of diseases, and self-rated health status in their design.

An Integrative Review on the Feasibility and Acceptability of Delivering an Online Training and Mentoring Module to Volunteers Working in Community Organizations

Background: Volunteer programs that support older persons can assist them in accessing healthcare in an efficient and effective manner. Community-based initiatives that train volunteers to support patients with advancing illness is an important advance for public health. As part of implementing an effective community-based volunteer-based program, volunteers need to be sufficiently trained. Online training could be an effective and safe way to provide education for volunteers in both initial training and/or continuing education throughout their involvement as a volunteer. Method: We conducted an integrative review that synthesized literature on online training programs for volunteers who support older adults. The review included both a search of existing research literature in six databases, and an online search of online training programs currently being delivered in Canada. The purpose of this review was to examine the feasibility and acceptability of community-based organizations adopting an online training format for their volunteers. Results: The database search identified 13,626 records, these went through abstract and full text screen resulting in a final 15 records. This was supplemented by 2 records identified from hand searching the references, for a total of 17 articles. In addition to identifying Volunteers Roles and Responsibilities; Elements of Training; and Evaluation of Feasibility and Acceptability; a thematic analysis of the 17 records identified the categories: (1) Feasibility Promoting Factors; (2) Barriers to Feasibility; (3) Acceptability Promoting Factors; and (4) Barriers to Acceptability. Six programs were also identified in the online search of online training programs. These programs informed our understanding of delivery of existing online volunteer training programs. Discussion: Findings suggested that feasibility and acceptability of online training were promoted by (a) topic relevant training for volunteers; (b) high engagement of volunteers to prevent attrition; (c) mentorship or leadership component. Challenges to online training included a high workload; time elapsed between training and its application; and client attitude toward volunteers. Future research on online volunteer training should consider how online delivery can be most effectively paced to support volunteers in completing training and the technical skills needed to complete the training and whether teaching these skills can be integrated into programs.

Generic Self-Reported Questionnaires Measuring Self-Management: A Scoping Review

This study aimed to (1) identify generic questionnaires that measure self-management in people with chronic conditions, (2) describe their characteristics, (3) describe their development and theoretical foundations, and (4) identify categories of self-management strategies they assessed. This scoping review was based on the methodological framework developed by Arksey and O'Malley and completed by Levac et al. A thematic analysis was used to examine self-management strategies assessed by the questionnaires published between 1976 and 2019. A total of 21 articles on 10 generic, self-reported questionnaires were identified. The questionnaires were developed using various theoretical foundations. The Patient Assessment of Self-Management Tasks and Partners in Health scale questionnaires possessed characteristics that made them suitable for use in clinical and research settings and for evaluating all categories of self-management strategies. This study provides clinicians and researchers with an overview of generic, self-reported questionnaires and highlights some of their practical characteristics.

Empowerment-oriented strategies to identify behavior change in patients with chronic diseases: An integrative review of the literature

BACKGROUND

Chronic diseases in the Americas account for about 80 % (5.2 million) of all deaths. Instruments are needed to enhance knowledge, skills, behavior change and self-care attitudes drawing on patient autonomy.

OBJECTIVE

To identify empowerment-oriented strategies focused on behavioral change in patients with chronic diseases.

PATIENT INVOLVEMENT

None.

METHODS

This is an integrative review of articles published from any period until June 2020 by journals indexed in the following databases: National Library of Medicine National Institutes of Health (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Biblioteca Virtual em Saúde (BVS).

RESULTS

Out of 1,287 articles, 25 met our selection criteria. Reported health interventions were based on self-management and behavior change, shared decisions and a personalized collaborative process, peer support and self-confidence, as well as strategies involving educational media and health literacy.

DISCUSSION

Over 80 % of health interventions were patient-centered and focused on patient knowledge and skill development towards personal goal setting, including effective problem-solving strategy development. Behavior change is not only an outcome of education, but also implicates revisiting values, attitudes, and experiences. Knowledge is important to facilitate decision-making leading to positive outcomes in chronic disease management.

PRACTICAL VALUE

Empowerment-oriented strategies are important tools for providing trust and motivation to people with chronic diseases. Healthcare professionals should support and encourage patient empowerment as a strategy for behavior change and able to offer qualified care for shared decision making. Thus, patients will be able to participate more actively in their own health condition management and to make decisions to promote self-care.

Chronic disease self-management competency and care satisfaction between users of public and private primary care in Singapore

Introduction: Primary healthcare providers play a crucial role in educating their patients on chronic disease self-management (CDSM). This study aims to evaluate CDSM competency and satisfaction in patients receiving their healthcare from public or private healthcare providers. Methods: A cross-sectional household study was conducted in a public housing estate using a standardised questionnaire to interview Singaporeans and permanent residents aged 40 years and above, who were diagnosed with at least 1 of these chronic diseases: hyperlipidaemia, hypertension or diabetes mellitus. CDSM competency was evaluated with the Partners In Health (PIH) scale and a knowledgebased questionnaire. Satisfaction was evaluated using a satisfaction scale. Results: In general, the 420 respondents demonstrated good CDSM competency, with 314 followed up at polyclinics and 106 by general practitioners (GPs). There was no significant difference between patients of polyclinics and GPs in CDSM competency scores (mean PIH score 72.9 vs 75.1, P=0.563), hypertension knowledge scores (90.9 vs 85.4, P=0.16) and diabetes knowledge scores (84.3 vs 79.5, P=0.417), except for hyperlipidaemia knowledge scores (78.6 vs 84.7, P=0.043). However, respondents followed up by GPs had higher satisfaction rates than did those followed up at polyclinics (odds ratio 3.6, confidence interval 2.28–5.78). Favourable personality of the doctors and ideal consultation duration led to higher satisfaction in the GP setting. A longer waiting time led to lower satisfaction in the polyclinic group. Conclusion: Polyclinics and GPs provide quality primary care as evidenced by high and comparable levels of CDSM competency. Redistribution of patients from public to private clinics may result in improvements in healthcare service quality. Keywords: Care satisfaction, chronic disease self-management, primary care, Singapore

Effectiveness of combined exercise and nutrition interventions in prefrail or frail older hospitalised patients: a systematic review and meta-analysis

OBJECTIVES

To determine the effectiveness of combined exercise-nutrition interventions in prefrail/frail hospitalised older adults on frailty, frailty-related indicators, quality of life (QoL), falls and its cost-effectiveness.

DESIGN

Randomised controlled trials (RCTs) of combined exercise-nutrition interventions on hospitalised prefrail/frail older adults ≥65 years were collated from MEDLINE, Emcare, CINAHL, Ageline, Scopus, Cochrane and PEDro on 10 October 2019. The methodological quality was appraised, and data were summarised descriptively or by meta-analysis using a fixed effects model. The standardised mean difference (SMD) or difference of means (MD) with 95% CIs was calculated.

RESULTS

Twenty articles from 11 RCTs experimenting exercise-nutrition interventions on hospitalised older adults were included. Seven articles were suitable for the meta-analyses. One study had low risk of bias and found improvements in physical performance and frailty-related biomarkers. Exercise interventions were mostly supervised by a physiotherapist, focusing on strength, ranging 2-5 times/week, of 20-90 min duration. Most nutrition interventions involved counselling and supplementation but had dietitian supervision in only three studies. The meta-analyses suggest that participants who received exercise-nutrition intervention had greater reduction in frailty scores (n=3, SMD 0.25; 95% CI 0.03 to 0.46; p=0.02) and improvement in short physical performance battery (SPPB) scores (n=3, MD 0.48; 95% CI 0.12 to 0.84; p=0.008) compared with standard care. Only the chair-stand test (n=3) out of the three SPPB components was significantly improved (MD 0.26; 95% CI 0.09 to 0.43; p=0.003). Patients were more independent in activities of daily living in intervention groups, but high heterogeneity was observed (I²=96%, p<0.001). The pooled effect for handgrip (n=3)±knee extension muscle strength (n=4) was not statistically significant. Nutritional status, cognition, biomarkers, QoL, falls and cost-effectiveness were summarised descriptively due to insufficient data.

CONCLUSIONS

There is evidence, albeit weak, showing that exercise-nutrition interventions are effective to improve frailty and frailty-related indicators in hospitalised older adults.

Psychometric validation of the Partners in Health scale as a self-management tool in patients with liver cirrhosis

BACKGROUND AND AIM

Liver cirrhosis is a chronic disease complicated by recurrent hospital admissions. Self-management skills could facilitate optimal disease management. At present there is no validated instrument for measuring self-management in these patients. Hence, we evaluated the internal reliability and construct validity of the Partners in Health (PIH) scale, a chronic condition self-management tool in cirrhotic patients.

METHODS

In this prospective cohort study, the PIH scale was administered to 133 consenting patients within a Chronic Liver Failure Program of a tertiary hospital from February 2017 to May 2018. A Bayesian confirmatory factor analysis was used to evaluate a priori four-factor structure. Omega coefficients and 95% credible intervals (CrI) were used to assess internal reliability. Known-group validity was assessed in patients receiving active case management (n = 60) versus those without (n = 73).

RESULTS

The mean (± standard deviation (SD)) age of the participants was 62 (±11) years. Model fit for the hypothesised model was adequate (posterior predictive P-value = 0.073) and all hypothesised factor loadings were substantial (>0.6) and significant (P < 0.001). Omega coefficients (95% CrI) for the PIH subscales of Knowledge, Partnership, Management and Coping were 0.88 (0.82-0.91), 0.68 (0.57-0.76), 0.92 (0.89-0.94) and 0.89 (0.85-0.92) respectively. The mean (±SD) overall PIH score was higher in patients receiving case management compared to those without case management (81 ± 12 vs 73 ± 17, P < 0.001).

CONCLUSION

The dimensionality, known-group validity and reliability of the PIH scale for measuring self-management in patients with liver cirrhosis were confirmed. Its clinical predictive value requires further assessment.

The French adaptation and validation of the Partners in Health (PIH) scale among patients with chronic conditions seen in primary care

Objective

Measuring self-management helps identify the degree of participation of people in the management of their chronic conditions and guides clinicians in determining person-centred priorities for providing support. The Partners in Health scale, a self-report generic questionnaire, was developed to capture the self-management of patients with chronic conditions. This study aimed to translate the Partners in Health scale into French and to examine its psychometric properties in French-speaking people with chronic conditions followed in primary care.

Methods

The Partners in Health scale was translated into French using Hawkins and Osborne’s method (2012). Content validity was evaluated through cognitive interviews (Think Aloud Method). Internal consistency was measured at baseline with Cronbach’s alpha. Test-retest reliability was evaluated at baseline and two weeks later using the intraclass correlation coefficient. Concurrent validity was measured at baseline with the Self-efficacy for Managing Chronic Disease (SEM-CD) and the Patient Activation Measure (PAM), using Spearman correlations.

Results

Cognitive interviews were conducted with 10 participants. During these interviews, most items were clearly understood and accepted as formulated; only a few terms were modified. To evaluate the psychometric properties of the French-language version of the Partners in Health scale, 168 participants (male = 34.5%; mean age = 58 years; mean number of chronic conditions = 4.1) completed the questionnaire at baseline and 47 of them completed the questionnaire two weeks later by telephone. Cronbach’s alpha for internal consistency was 0.85 (95% confidence interval: 0.81–0.88). The intraclass correlation coefficient for test-retest reliability was 0.77 (95% confidence interval: 0.58–0.87). Concurrent validity with spearman’s coefficient correlation of Self-efficacy for Managing Chronic Disease and Patient Activation Measure was 0.68 and 0.61 respectively.

Conclusion

The French-language version of the Partners in Health scale is a reliable and valid questionnaire for the measure of self-management in persons with chronic conditions seen in primary care.

Trained volunteers to support chronically ill, multimorbid elderly between hospital and domesticity - a systematic review of one-on-one-intervention types, effects, and underlying training concepts

BACKGROUND

New approaches are needed to address the challenges of demographic change, staff shortages, and societal change in the care of the elderly. While volunteering has barely been established as a pillar of the welfare state in several countries, legislators and nonprofit or community-based organizations in some countries favor the increased integration of volunteers, as they can rely on many dedicated people. When caring for the multimorbid elderly, the transition from hospital to domesticity involves certain risks. Currently, no systematic knowledge exists on whether and how elderly benefit from volunteer support after a hospital stay. Objectives of this systematic review were to (1) identify evaluated approaches with trained volunteers supporting chronically ill, multimorbid elderly one-on-one at the interface between hospital and domesticity; (2) investigate the patient-related effectiveness of the approaches; (3) present the characteristics of the supporting volunteers; and (4) present the underlying teaching and training concepts for the volunteers.

METHODS

A systematic search of the following online databases was conducted in April 2017: the Cochrane Library, Medline (PubMed), CINAHL, and PsycINFO (Ebscohost). We included (cluster/quasi-) randomized controlled trials, controlled clinical trials and single-group pre-post design. An institutional search was conducted on eight national institutions from research and practice in Germany. Screening was conducted by one researcher, risk of bias was assessed. Study authors were contacted for study and training details.

RESULTS

We identified a total of twelve studies, eight of which evaluated treatment following hospital stay: psychosocial-coordinative support (n = 2), physical-cognitive activation (n = 4), and assistance with medication intake (n = 2). We saw short-term effects with small and medium effect sizes. Most volunteers were women aged between 45 and 61 years. Their training lasted 12-26 h and took place prior to first patient contact. During the intervention, volunteers could rely on permanent supporting structures.

CONCLUSIONS

Few studies exist that have evaluated one-on-one-volunteer support following hospitalization, and the effects are inconsistent. As such, further, well-designed studies are needed. The suitability and transferability of the interventions in country-specific settings should be examined in feasibility studies. Furthermore, an international discussion on the appropriate theoretical backgrounds of volunteer training is needed.

A Realist Evaluation of Local Networks Designed to Achieve More Integrated Care

INTRODUCTION

Not surprisingly given their multi-component nature, initiatives to improve integrated care often evolve to find the best way to bring about change. This paper provides an example of how an evaluation evolved alongside such an initiative designed to better integrate care across primary, community and hospital services in South Auckland, New Zealand.

THEORY AND METHODS

Using the explanatory power of a realist evaluative approach, theories of new ways of working that might be prompted by the initiative were explored in: (i) interviews with stakeholders in 2012 and 2015, (ii) online surveys of general practices and local care organisations, and (iii) a purposive sample of ten general practices.

RESULTS

The results highlighted the institutional contexts that led to difficulties in implementing population health initiatives. They also revealed that changes in work practices focussed mostly on activities that improved the coordination of care for individuals at risk of hospital admissions.

DISCUSSION

Multi-component complex interventions can vary in their delivery and be vulnerable to one or more components not being implemented as originally intended. In the case of this intervention, the move towards strengthening local relationships arose when contractual arrangements stalled. Realist evaluative approaches offer a logic that helps unpick the complexity of the relationships and politics in play, and uncover the assumptions made by those developing, implementing and assessing health service changes.

CONCLUSION

Given the multi-component and evolving nature of initiatives seeking to better integrate care, the realist evaluative emphasis on surfacing early the theories to explain how change is expected to occur helps overcome the challenge of evaluating "a moving target".

Concurrent validity of the Partners in Health scale against general self-rated health in chronic conditions: A short report

The Partners in Health scale is a structurally valid measure of chronic condition self-management behaviours. This report describes a study that further evaluated construct validity of Partners in Health scale by assessing its relationship with a single-item measure of general self-rated health. The concurrent validity of the scale was demonstrated by a statistically significant association with general self-rated health in a population representative sample of people with chronic conditions.

The Chronic Care Model and Chronic Condition Self-Management: An Introduction for Audiologists

Hearing health care is biomedically focused, device-centered, and clinician-led. There is emerging evidence that these characteristics-all of which are hallmarks of a health care system designed to address acute, rather than chronic, conditions-may contribute to low rates of help-seeking and hearing rehabilitation uptake among adults with hearing loss. In this review, we introduce audiologists to the Chronic Care Model, an organizational framework that describes best-practice clinical care for chronic conditions, and suggest that it may be a viable model for hearing health care to adopt. We further introduce the concept of chronic condition self-management, a key component of chronic care that refers to the knowledge and skills patients use to manage the effects of a chronic condition on all aspects of daily life. Drawing on the chronic condition evidence base, we demonstrate a link between the provision of effective self-management support and improved clinical outcomes and discuss validated methods with which clinicians can support the acquisition and application of self-management skills in their patients. We examine the extent to which elements of chronic condition self-management have been integrated into clinical practice in audiology and suggest directions for further research in this area.

A self-management support program for older Australians with multiple chronic conditions: a randomised controlled trial

OBJECTIVE

To determine whether a clinician-led chronic disease self-management support (CDSMS) program improves the overall self-rated health level of older Australians with multiple chronic health conditions.

DESIGN

Randomised controlled trial: participants were allocated to a clinician-led CDSMS group (including client-centred goal setting and the development of individualised care plans) or to a control group in which they received positive attention only.

SETTING AND PARTICIPANTS

Patients aged 60 years or more with at least two chronic conditions, recruited between September 2009 and June 2010 from five general practices in Adelaide.

MAIN OUTCOME MEASURES

The primary outcome was self-rated health. Secondary outcome measures related to health status (fatigue, pain, health distress, energy, depression, illness intrusiveness), health behaviour (exercise, medication adherence), and health service utilisation.

RESULTS

254 participants were randomised to the CDSMS and control groups, of whom 231 (117 control and 114 CDSMS participants) completed the 6-month programs and provided complete outcomes data (91%). An intention-to-treat analysis found that CDSMS participants were more likely than control participants to report improved self-rated health at 6 months (odds ratio, 2.50; 95% confidence interval, 1.13-5.50; P = 0.023). Between-group differences for secondary outcomes were not statistically significant.

CONCLUSION

CDSMS may benefit some older people with multiple chronic conditions to a greater extent than positive attention and health education.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12609000726257.

E-learning for self-management support: introducing blended learning for graduate students - a cohort study

BACKGROUND

E-learning allows delivery of education in many diverse settings and researchers have demonstrated it can be as effective as learning conducted in traditional face-to-face settings. However, there are particular practices and skills needed in the area of providing patient self-management support (SMS), that may not be achievable online. The aim of this study was to compare three approaches in the training of university students regarding the preparation of a Chronic Condition Self-Management Care Plan: 1) traditional face-to-face delivery of SMS training, 2) an e-learning approach and 3) a blended approach (combining e-learning and face-to-face teaching).

METHODS

Graduate entry physiotherapy students and medical students at Flinders University were recruited. Depending on the cohort, students were either exposed to traditional face-to-face training, e-learning or a blended model. Outcomes were compared between the three groups. We measured adherence to care plan processes in the preparation of an assessment piece using the Flinders Program Chronic Care Self Management tools. A total of 183 care plans were included (102 traditional, 52 blended, 29 e-learning,). All students submitted the Flinders Program Chronic Care Plan for university assessment and these were later assessed for quality by researchers. The submission was also assigned a consumer engagement score and a global competence score as these are integral to successful delivery of SMS and represent the patient perspective.

RESULTS

The blended group performed significantly better than the traditional group in quality use of the Flinders Program tools: Problem and Goals (P < 0.0001). They also performed significantly better in the total care plan score (P < 0.0001) and engagement score (P < 0.0001). There was no significant difference between the groups for the Partners in Health tool.

CONCLUSIONS

In this pilot study, the blended learning model was a more effective method for teaching self-management skills than the traditional group, as assessed in the development of a chronic condition self-management care plan. We anticipate that future research with identical groups of students would yield similar results but in the meantime, academics can have confidence that blended learning is at least as effective as traditional learning methods.

Improving cardiovascular health and quality of life in people with severe mental illness: study protocol for a randomised controlled trial

Background

The estimated 300,000 adults in Australia with severe mental illness (SMI) have markedly reduced life expectancy compared to the general population, mainly due to physical health comorbidities. Cardiovascular disease (CVD) is the commonest cause of early death and people with SMI have high rates of most modifiable risk factors, with associated quality of life (QoL) reduction. High blood pressure, smoking, dyslipidaemia, diabetes and obesity are major modifiable CVD risk factors. Poor delivery of recommended monitoring and risk reduction is a national and international problem. Therefore, effective preventive interventions to safeguard and support physical health are urgently needed in this population.

Methods

This trial used a rigorous process, including extensive piloting, to develop an intervention that delivers recommended physical health care to reduce CVD risk and improve QoL for people with SMI. Components of this intervention are integrated using the Flinders Program of chronic condition management (CCM) which is a comprehensive psychosocial care planning approach that places the patient at the centre of their care, and focuses on building their self-management capacity within a collaborative approach, therefore providing a recovery-oriented framework. The primary project aim is to evaluate the effectiveness and health economics of the CCM intervention. The main outcome measures examine CVD risk and quality of life. The second aim is to identify essential components, enablers and barriers at patient, clinical and organisational levels for national, sustained implementation of recommended physical health care delivery to people with SMI. Participants will be recruited from a community-based public psychiatric service.

Discussion

This study constitutes the first large-scale trial, worldwide, using the Flinders Program with this population. By combining a standardised yet flexible motivational process with a targeted set of evidence-based interventions, the chief aim is to reduce CVD risk by 20%. If achieved, this will be a ground-breaking outcome, and the program will be subsequently translated nationwide and abroad. The trial will be of great interest to people with mental illness, family carers, mental health services, governments and primary care providers because the Flinders Program can be delivered in diverse settings by any clinical discipline and supervised peers.

Trial registration

Australian and New Zealand Clinical Trials Registry, ACTRN12617000474358. Registered on 31 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2748-7) contains supplementary material, which is available to authorized users.

Chronic condition self-management support for Aboriginal people: Adapting tools and training

PROBLEM

Chronic conditions are major health problems for Australian Aboriginal people. Self-management programs can improve health outcomes. However, few health workers are skilled in self-management support and existing programs are not always appropriate in Australian Aboriginal contexts.

DESIGN

The goal was to increase the capacity of the Australian health workforce to support Australian Aboriginal people to self-manage their chronic conditions by adapting the Flinders Program of chronic condition self-management support for Australian Aboriginal clients and develop and deliver training for health professionals to implement the program.

STRATEGIES FOR CHANGE

Feedback from health professionals highlighted that the Flinders Program assessment and care planning tools needed to be adapted to suit Australian Aboriginal contexts. Through consultation with Australian Aboriginal Elders and other experts, the tools were condensed into an illustrated booklet called 'My Health Story'. Associated training courses and resources focusing on cultural safety and effective engagement were developed.

EFFECTS OF CHANGE

A total of 825 health professionals  across Australia was trained and 61 people qualified as accredited trainers in the program, ensuring sustainability.

LESSONS LEARNT

The capacity and skills of the Australian health workforce to engage with and support Australian Aboriginal people to self-manage their chronic health problems significantly increased as a result of this project. The adapted tools and training were popular and appreciated by the health care organisations, health professionals and clients involved. The adapted tools have widespread appeal for cultures that do not have Western models of health care and where there are health literacy challenges. My Health Story has already been used internationally.

Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital Avoidance Risk Program using the Flinders Chronic Condition Management Program

Objective The study aimed to determine the impact of the Flinders Chronic Condition Management Program for chronic condition self-management care planning and how to improve its use with Bendigo Health’s Hospital Admission Risk Program (HARP). Methods A retrospective analysis of hospital admission data collected by Bendigo Health from July 2012 to September 2013 was undertaken. Length of stay during admission and total contacts post-discharge by hospital staff for 253 patients with 644 admissions were considered as outcome variables. For statistical modelling we used the generalised linear model. Results The combination of the HARP and Flinders Program was able to achieve significant reductions in hospital admissions and non-significant reduction in emergency department presentations and length of stay. The generalised linear model predicted that vulnerable patient groups such as those with heart disease (P = 0.037) and complex needs (P < 0.001) received more post-discharge contacts by HARP staff than those suffering from diabetes, renal conditions and psychosocial needs when they lived alone. Similarly, respiratory (P < 0.001), heart disease (P = 0.015) and complex needs (P = 0.050) patients had more contacts, with an increased number of episodes than those suffering from diabetes, renal conditions and psychosocial needs. Conclusion The Flinders Program appeared to have significant positive impacts on HARP patients that could be more effective if high-risk groups, such as respiratory patients with no carers and respiratory and heart disease patients aged 0–65, had received more targeted care. What is known about the topic? Chronic conditions are common causes of premature death and disability in Australia. Besides mental and physical impacts at the individual level, chronic conditions are strongly linked to high costs and health service utilisation. Hospital avoidance programs such as HARP can better manage chronic conditions through a greater focus on coordination and integration of care across primary care and hospital systems. In support of HARP, self-management interventions such as the Flinders Program aim to help individuals better manage their medical treatment and cope with the impact of the condition on their physical and mental wellbeing and thus reduce health services utilisation. What does this paper add? This paper sheds light on which patients might be more or less likely to benefit from the combination of the HARP and Flinders Program, with regard to their impact on reductions in hospital admissions, emergency department presentations and length of stay. This study also sheds light on how the Flinders Program could be better targeted towards and implemented among high-need and high-cost patients to lessen chronic disease burden on Australia’s health system. What are the implications for practitioners? Programs targeting vulnerable populations and applying evidence-based chronic condition management and self-management support achieve significant reductions in potentially avoidable hospitalisation and emergency department presentation rates, though sex, type of chronic condition and living situation appear to matter. Benefits might also accrue from the combination of contextual factors (such as the Flinders Program, supportive service management, clinical champions in the team) that work synergistically.

A preliminary investigation of the Partners in Health scale measurement properties in patients with end stage renal disease

End-stage renal disease (ESRD) is becoming more prevalent in Australia. As a result, strategies to improve quality of life when living with ESRD are becoming increasingly important. The Flinders Program has been developed to help support and increase the self-management capacity of people living with chronic disease. The Partners in Health (PIH) scale is a self-management capacity assessment tool, which is an integral element of the Flinders Program. The primary aim of this study was to investigate the preliminary measurement properties of the PIH scale within the ESRD population. Forty participants took part in the study, which involved survey assessments at baseline and follow up and a semi-structured interview. Results indicated that the PIH scale had good internal reliability (α=0.85), moderate test-retest reliability (r=0.33) and face validity in ESRD patients. Areas for improving the instrument or data collection process were identified through qualitative interviews, and implications are discussed specific to ESRD patients.

Construct Validity of the Dutch Version of the 12-Item Partners in Health Scale: Measuring Patient Self-Management Behaviour and Knowledge in Patients with Chronic Obstructive Pulmonary Disease

Objective

The 12-item Partners in Health scale (PIH) was developed in Australia to measure self-management behaviour and knowledge in patients with chronic diseases, and has undergone several changes. Our aim was to assess the construct validity and reliability of the latest PIH version in Dutch COPD patients.

Methods

The 12 items of the PIH, scored on a self-rated 9-point Likert scale, are used to calculate total and subscale scores (knowledge; coping; recognition and management of symptoms; and adherence to treatment). We used forward-backward translation of the latest version of the Australian PIH to define a Dutch PIH (PIH(Du)). Mokken Scale Analysis and common Factor Analysis were performed on data from a Dutch COPD sample to investigate the psychometric properties of the Dutch PIH; and to determine whether the four-subscale solution previously found for the original Australian PIH could be replicated for the Dutch PIH.

Results

Two subscales were found for the Dutch PIH data (n = 118); 1) knowledge and coping; 2) recognition and management of symptoms, adherence to treatment. The correlation between the two Dutch subscales was 0.43. The lower-bound of the reliability of the total scale equalled 0.84. Factor analysis indicated that the first two factors explained a larger percentage of common variance (39.4% and 19.9%) than could be expected when using random data (17.5% and 15.1%).

Conclusion

We recommend using two PIH subscale scores when assessing self-management in Dutch COPD patients. Our results did not support the four-subscale structure as previously reported for the original Australian PIH.

Measuring chronic condition self-management in an Australian community: factor structure of the revised Partners in Health (PIH) scale

PURPOSE

To evaluate the factor structure of the revised Partners in Health (PIH) scale for measuring chronic condition self-management in a representative sample from the Australian community.

METHODS

A series of consultations between clinical groups underpinned the revision of the PIH. The factors in the revised instrument were proposed to be: knowledge of illness and treatment, patient-health professional partnership, recognition and management of symptoms and coping with chronic illness. Participants (N = 904) reporting having a chronic illness completed the revised 12-item scale. Two a priori models, the 4-factor and bi-factor models were then evaluated using Bayesian confirmatory factor analysis (BCFA). Final model selection was established on model complexity, posterior predictive p values and deviance information criterion.

RESULTS

Both 4-factor and bi-factor BCFA models with small informative priors for cross-loadings provided an acceptable fit with the data. The 4-factor model was shown to provide a better and more parsimonious fit with the observed data in terms of substantive theory. McDonald's omega coefficients indicated that the reliability of subscale raw scores was mostly in the acceptable range.

CONCLUSION

The findings showed that the PIH scale is a relevant and structurally valid instrument for measuring chronic condition self-management in an Australian community. The PIH scale may help health professionals to introduce the concept of self-management to their patients and provide assessment of areas of self-management. A limitation is the narrow range of validated PIH measurement properties to date. Further research is needed to evaluate other important properties such as test-retest reliability, responsiveness over time and content validity.