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The Flinders Chronic Condition Management Program Information Paper


The Flinders Chronic Condition Management Program (henceforth referred to as The Flinders Program) is a generic set of tools and processes enabling health professionals to support their clients to more effectively self-manage their chronic condition(s). The Flinders Program is a self-management partnership based on cognitive behaviour therapy, problem solving and motivational interviewing techniques. Clients actively participate in making decisions about their physical, emotional and social well-being. Health practitioners work individually with clients using the Program tools to assess self-management behaviours, barriers, psychosocial issues and preferences, and produce an individualised Care Plan that includes problem and goal statements, interventions, steps and responsibilities that align with the client’s values, priorities and beliefs.

The Program is based on extensive research identifying the importance of self-management and self-management support in chronic condition management (see Effective Management of Chronic Conditions). The need for health professionals and their clients to work together in the management of chronic conditions is supported by professional organisations in Australia (e.g., RACGP) and internationally (e.g., Royal College of Physicians).

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Flinders Program Information Paper

The Flinders Program tools and processes provide a framework for practitioners and clients to:

  • Undertake a structured assessment of self-management

  • Collaborate in identifying problems and goals, leading to

  • Development of an individualised care plan

The process is generic rather than disease-specific. It looks at the components of self-management; that is, how the tasks associated with self-management are being completed. These are common tasks across diseases, e.g., managing the impact of the disease on their life, monitoring and managing the symptoms, adopting healthy lifestyles, etc.

The Flinders Human Behaviour & Health Research Unit (FHBHRU) at Flinders University was originally established to provide support and training for service coordinators and general practitioners during the SA HealthPlus Trial, 1997-1998. This trial was one of the larger of the first round of Coordinated Care Trials, enrolling 3,100 clients into its interventions arm.

The Flinders Program tools and processes were developed in response to the outcomes from this trial, and further trialled and refined during the Sharing Healthcare Initiative 2000-2004, funded by the Australian Government. The Program continued to develop over the following decade of research and clinical use. The processes and tools have been tested and evaluated with a number of different patient populations both within Australia and internationally1-16.Flinders Program Evidence Summary’ for more information about the evidence base for the Flinders Program.

The Flinders Program consists of a set of tools that are completed by both the client and the health care professional/worker, working together as a team. The Flinders Program Care Planning Tools provide a formal, systematic approach to assessing self-management capacity and care planning.

The Flinders Program Care Planning Tools are as follows:

  • Partners in Health Scale (to assess the client’s self-management knowledge and capacity)
  • Cue and Response interview (a series of open-ended questions or cues to explore the patient’s responses to the Partners in Health Scale in more depth)
  • Problem and Goals Statement (used to define the problem(s) affecting the client, and identify a goal/goals that the client can work towards)
  • Chronic Condition Management Care Plan (based on the information gained from the Partners in Health, Cue and Response interview, and Problem and Goals assessment)

Use of these tools enables the health professional and the client to identify issues and form an individualised Care Plan, and provides a system for monitoring and reviewing progress. The reliability and validity of the tools has been established15.16.

For more information see ‘The Flinders Program Tools‘.

The Flinders Program has been applied to the management of chronic medical or mental conditions and co-morbidities in a variety of clinical settings and countries.

Clinical settings include, for example: General Practice networks, rural and remote health, respiratory care, cardiac care, aged care, mental health, disability, renal dialysis.

Population groups include, for example: Aboriginals and Torres Strait Islanders, children, adolescents, veterans, carers.

Patient groups include, for example: multiple sclerosis, autism, cystic fibrosis.

The Discipline of Behavioural Health offer a number of options for education and training. Vocational or professional education can be modified depending on the needs of the group. See here for more information.

The Flinders Program is used in primary health services to support the delivery of integrated, patient-centred care for people with chronic conditions. Successful implementation of program requires an understanding of the characteristics of health care at organisational, system and individual levels.

The Implementation online courses provide more information about the skills needed across different levels to implement the Flinders Program as a consumer-directed, collaborative approach to care, and provides a structured process to develop an action plan for implementing the Flinders Program within your service. 

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 conditions and that it encourages the client to have involvement and ownership of their care plan.

The following comments are from health workers using the Flinders Program in clinical practice:

Challenged my assumptions about chronicity (mental health worker)

Made me focus on the client and goal setting that led to achievable outcomes (nurse)

It does require a commitment to do it as you need to set aside time but I feel we are working more as a team (GP)

Allows patients to bring up [other] issues (health worker)

Relatively quick and simple system for care planning (GP)

The process has changed my focus to what I don’t know about the patient rather than what I think I know (GP)

It’s helped me to understand the effect my illness has had on me (client)

It’s pretty in-your-face in that it challenges your own current practice. Such challenges are essential in health care (health worker)

  1. Battersby, M., Harris, M., Smith, D., Reed, R. & Woodman, R. (2015) A pragmatic randomized controlled trial of the Flinders Program of chronic condition management in community health care services. Patient Education & Counseling 98, 1367-1375.
  2. Battersby, M.W., Beattie, J., Pols, R.G., Smith, D.P., Condon, J. & Blunden, S. (2013) A randomised controlled trial of the Flinders Program™ of chronic condition management in Vietnam veterans with co-morbid alcohol misuse, and psychiatric and medical conditions. Australian & New Zealand Journal of Psychiatry 47(5), 451-462.
  3. Crotty, M., Prendergast, J., Battersby, M., Rowett, D., Graves, S., Leach, G. & Giles, G. (2009) Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomized controlled list. Osteoarthritis & Cartilage 17 , 1428-1433.
  4. Lawn, S., Pols, R. G. & Battersby, M. (2009) Working effectively with patients with comorbid mental illness and substance abuse: a case study using a structured motivational behavioural approach.” BMJ Case Reports doi: 10.1136/bcr.08.2008.0674.
  5. Battersby, M.W., Ah Kit, J., Prideaux, C., Harvey, P.W., Collins, J.P. & Mills, P.D. (2008) Implementing the Flinders Model of self-management support with Aboriginal people who have diabetes: findings from a pilot study. Australian Journal of Primary Health 14(1), 66-74.
  6. Pols R.G. & Battersby M.W. (2008) Coordinated care in the management of patients with unexplained physical symptoms: depression is a key issue. Medical Journal of Australia Supplement 188(12), 133-7.
  7. Harvey, P. W., Petkov, J., Misan, G., Warren, K., Fuller, J., Battersby, M., Cayetano, N. & Holmes, P. (2008 ) Self-management support and training for patients with chronic and complex conditions improves health related behaviour and health outcomes. Australian Health Review 32(2), 330- 338.
  8. Battersby, M., Harvey, P., Mills, P.D., Kalucy, E., Pols, R.G., Frith, P.A., McDonald, P., Esterman, A., Tsourtos, G., Donato, R., Pearce, R. & McGowan, C. (2007) SA HealthPlus: a controlled trial of a statewide application of a generic model of chronic illness care. Milbank Quarterly 85 (1), 37-67.
  9. Lawn, S., Battersby, M., Pols, R.G., Lawrence, J., Parry, T. & Urukalo, M. (2007) The mental health expert patient: findings from a pilot study of a generic chronic condition self-management programme for people with mental illness. International Journal of Social Psychiatry 53(1), 63-74.
  10. Francis, F., Feyer. A & Smith, B. (2007) Implementing chronic disease self-management in community settings: lessons from Australian demonstration projects. Australian Health Review 31(4), 499-509.
  11. Regan-Smith, M., Hirschmann, K. & Iobst, W. (2006) Teaching residents chronic disease management using the Flinders model. Journal of Cancer Education 21(2), 60-62.
  12. Battersby M.W. & SA Health Plus Team (2005) Health reform through coordinated care: SA HealthPlus? British Medical Journal 330(7492), 662-665.
  13. Battersby, M., Ask, A., Reece, M., Markwick, M. & Collins, J. (2003) The partners in health scale: the development and psychometric properties of a generic assessment scale for chronic condition self-management? Australian Journal of Primary Health 9(2&3), 41-52.
  14. Battersby, M., Ask, A., Reece, M., Markwick, M. & Collins, J. (2001) A Case Study Using the “Problems and Goals Approach” in a Coordinated Care Trial: SA HealthPlus. Australian Journal of Primary Health 7(3), 45-8.
  15. Petkov, J., Harvey, P. & Battersby, M. (2010) The internal consistency and construct validity of the Partners in Health scale: validation of a patient rated chronic condition self-management measure. Quality of Life Research 19(7), 1079-1085.
  16. Battersby, M., Ask, A., Reece, M. & Collins, J. (2003) The partners in health scale: the development and psychometric properties of a generic assessment scale for chronic conditions self-management. Australian Journal of Primary Health 9(2&3), 41-52.
  17. Fotu, M. & Tafu, T. (2009) The Popao model: A Pacific Recovery and Strength Concept in Mental Health. Pacific Health Dialog 15(1), 164-170.