The Flinders Program care planning tools include both tools used to assess self-management capacity and a care planning tool.
Tools used to assess self-management capacity are:
- Partners in Health Scale
- Cue and Response interview
- Problem and Goals Statement
The care planning tool is the:
- Chronic Condition Management Care Plan
Use of these tools enables the health professional and the client to identify issues, form an individualised Care Plan and provide a system for monitoring and reviewing progress.
The Partners in Health Scale is a validated questionnaire based on the principles of self-management. The client completes the questionnaire by scoring their response to each of the twelve questions on a nine point scale (zero being the lowest response, reflecting low self-management capacity, and eight being the highest, reflecting good self-management capacity). The questions cover the following areas:
- Knowledge of the condition
- Knowledge of treatment
- Ability to take medication
- Ability to share in decisions
- Ability to deal with health professionals
- Ability to attend appointments
- Ability to monitor and record
- Ability to manage symptoms
- Ability to manage the physical impact
- Ability to manage the emotional impact
- Ability to manage the social impact
- Progress towards a healthy lifestyle
The questionnaire takes 5-10 minutes to complete and can be used to record change over time.
The Cue and Response interview is an adjunct to the Partners in Health scale. The Cue and Response process uses a series of open-ended questions (cues) to explore the client’s responses to the Partners in Health Scale in more depth. It enables the barriers to self-management to be explored, and it checks the assumptions that either the health professional or the client may have. The health professional can score the responses and compare their score with the client’s scores. While originally developed to enable the client’s perception of their self-management (as recorded on the Partners in Health scale) to be ‘validated’ by the health professional, it has proved to be a useful clinical tool in its own right to explore self-management.
Some examples of cue questions are listed in the table below. The cue questions are not prescriptive and serve as examples of the types of questions that may be asked.
Principle of self-management
Sample questions in the Cue and Response interview
|Knowledge of treatment||
|Sharing in decisions||
The Partners in Health scale and Cue and Response interview tools can be used together or individually.
The Cue and Response interview is a motivational process for the client and a prompt for behaviour change. It allows the individual the opportunity to look at the effect of their condition on their life.
Scores rated on the lower end of the scale by the client, the health professional or both, flag issues for further discussion. Scores rated on the higher end of the scale allow the health professional to acknowledge areas where the client is managing well. Discussion of lower scores, or scores where there is a discrepancy in rating between client and health professional, allows for clarification of issues and identification of a common set of problems. Collaborative problem identification is a key indicator in successful self-management programs (Wagner et al., 1996). Identification of issues allows relevant strategies and interventions to be discussed and agreed on.
The Problems and Goals assessment is another tool that can be used as an adjunct to the Partners in Health and Cue and Response or as a stand-alone assessment. The Partners in Health and Cue and Response enable the health professional and the client to identify a range of issues or problems that are affecting the client. The health professional may well see one of these issues as the main or biggest problem for the client. The client may see the same thing as their biggest problem, but they may see something else as having a far greater impact. For example, the health professional might think that the way the client uses their medication is the biggest problem; however the client may think their biggest problem is the demands the family places on them – perhaps they are caring for grandchildren every day and have little time for themselves.
As well as defining the problem from the client’s perspective, this assessment also clearly identifies a goal or goals that the client can work towards.
The client’s problem statement is based on three open-ended questions:
- What do you see as your main problem?
- What happens because of the problem?
- How does this problem make you feel?
The problem statement should include the Problem, Impact and Feelings and can be clearly and simply evaluated using a scale from 0 (not at all) to 8 (a lot) measuring ‘How much of a problem is this for me?’
‘Lack of support from my family means I am overwhelmed by the household jobs and I don’t go out and feel depressed’.
The Goal Statement is the client’s goal and should be written positively and be a personal reward. Goals should be long/medium term and involve a degree of challenge (Locke & Latham 2006), and can be clearly and simply evaluated using a 0 (no success) to 8 (complete success) measuring ‘My progress towards achieving this goal’.
The goal should be a SMART goal:
S – Specific (clearly defined)
M – Measurable (observable)
A – Action based (behavioural)
R – Realistic (not too reliant on others)
T – Timely (how long/how often?)
‘I will go out to the community club one afternoon a week for 2 hours’.
The information gained from the Partners in Health, Cue and Response (interview and discussion) and Problem and Goals assessments can be summarised on the care plan. The care plan documents the medical investigations, self-management tasks, self-management education and allied health and community services the person will access over the following twelve months.
The information on a Care Plan should include:
- The identified issues / including the main problem
- Agreed goals – What I want to achieve
- Agreed interventions – Steps to get there
- A sign off by both the patient and health professional
- Review dates
Locke, E.A., & Latham, G.P. (2006) New directions in goal-setting theory. Current Directions In Psychological Science, 15, 265-268.
Wagner, E., Austin, B., & Von Korff, M. (1996) Organizing Care for Patients with Chronic Illness, The Milbank Quarterly, 74, 511- 542.