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Success Stories

Ethel’s Story

‘Ethel’ is a fictitious character. Her story and situation has been documented and utilised in our workshops. In this video ‘Ethel’ provides an insight into her family and the challenges she faces in her life.

Peter’s Story 2010

Peter Rose talks to Education & Trainer Officer, Coral Trowbridge about the changes he has made to his life in the last two years through using the Flinders Program. He addresses changes that have impacted on many areas of his life including work, his goals, his social life and the knowledge around his condition.

Peter’s Story 2013

This video was taken in 2013, three years after we first interviewed Peter. Peter has continued to make improvements to his health and life by using the Flinders Program.

Terrence’s Story

This is the story of Terrance who has found success using the Flinders Program after being introduced to the program as a volunteer at the training workshop.


Personal Case Studies

Leanne's Story - 28 years old: Eating disorder


Emaciation, eating disorder. Leanne attended the Closing the Gap workshop in Mildura as a volunteer for Workshop 3.


My weakness means that I can’t look after my horses and ride like I want to. This makes me feel useless.

  • Anorexia
  • Mood irritability
  • Socially withdrawn
  • Weakness
  • Unable to hold a job
  • Financial insecurity
  • Would not engage with GP or health professionals
  • Not compliant with screening tests


I would like to be able to work at a horse riding school five days a week.

Leanne took her care plan from the workshop and achieved her goal through:

  • Attending GP appointments to ask for a referral to a practice nurse
  • Referral to a Dietician
  • Regular pathology screening
  • Volunteering at a riding school for the disabled
  • Attending social functions with her family
  • Maintaining goal weight
  • Says “I am happier now


Leanne now:

  • Has not had a lethargy attack since July 2011
  • Continues to engage with her GP
  • Continues to work with her care team
  • Complies with screening tests
  • Volunteers at a riding school for the disabled
  • Is looking at job re-entry training to work at a local stable
  • Engages with family regularly
  • Is financially Ok now she has received assistance

Ben's Story - 10 years old: Poorly controlled asthma


Poorly controlled asthma


Previous medical history of asthma. Ben presented on the 4/6/12 with asthma. He had run out of Ventolin. Staff noticed he was unwell and commenced treatment. Ben has had three admissions during 2011-2012.

  • Three admissions during 2011-2012
  • Poor medication compliance
  • Poor knowledge and understanding of condition and treatment and poor living conditions


To provide support and education around the knowledge of asthma and the appropriate treatment. Ben’s goal was to be able to play football.


Referral to an Exercise Physiologist to assess Ben’s exercise tolerance and offer a plan to improve it.


Ben now:

  • Ben was discharged from HARP services on 2/10/12
  • No Urgent Care Centre presentations or hospital admissions since this time
  • Effective self-management strategies in place together with improved knowledge of treatment and condition for both client and parents
  • Ben will receive ongoing support from family and school
  • Ben and his mother received education supporting the differences between common/everyday breathlessness due to exertion and signs and symptoms of asthma
  • Planning with Ben and his family (in consultation with the school) to ensure a comfortable, safe location to use the medication at school
  • Asthma action plan and emergency management plan in place

Geoff's Story - 53 years old: Chronic Obstructive Pulmonary Disease (COPD)

He has no fixed address and was referred by police due to homelessness.


Diagnosed with Chronic Obstructive Pulmonary Disease (COPD)


Lifestyle risks – smoking, drinking, homelessness, disconnected from family.

  • Poor knowledge of condition, treatment and medication
  • Non-compliant with medication due to literacy level, shame and inability to access GP
  • Poor monitoring and response to symptoms
  • Lifestyle risks or smoking, drinking, homelessness, disconnect with family


Establish a connection with a local GP through a health professional acting as Advocate.


  • Referral to a housing support worker
  • Referral to a respiratory specialist for assessment
  • Referral to a quit facilitator
  • Referral to a legal aid
  • Referral to a counsellor

Geoff spent a lot of time travelling between three regions. He established a common Care Plan and facilitated introductions with regional service providers. This enabled Geoff to access clinical care and specialist appointments in different regions with advocates that could support health literacy, Care Plans and minimise his feelings of shame.


Geoff now:

  • Accesses specialist appointments
  • Monitors his symptoms and follows the action plan
  • Maintains regular visits to his GP
  • Has found temporary relief housing
  • Has worked between three Chronic Care Coordination teams
  • Is compliant with his medication
  • Has ceased smoking
  • Has a high knowledge of his treatment, condition and medication

Grace's Story - 10 years old: Severe asthma


Severe asthma from two years of age.  Grace attended the Closing the Gap workshop in Mildura as a volunteer for Workshop 3.


Shortness of breath when exercising

  • Scared that she would die if she ran or played sport
  • Frequent days of absence from school due to asthma attacks
  • Bullying from peers because she couldn’t play sport
  • Non-compliant with medication due to bullying
  • No friends


Grace wanted to be able to run and play sport three times a week

Grace took her Care Plan from the workshop and achieved her goal through:

  • Attending GP appointments to ask for a referral to a respiratory education program
  • Started the Hospital Admission Risk Program


Grace now:

  • Has not had an asthma attack since July 2011
  • Continues to engage with her GP
  • Her mother has a greater understanding of her condition and treatment
  • Has changed schools
  • Is compliant with her medication (because she says she is not ashamed any more)
  • Has started to grow again
  • Has friends
  • Is not scared anymore and is in control of her condition
  • Has achieved her goal and plays soccer, tennis, and participates in the swimming team

Heather's Story - 48 years old: Morbid obesity, Asthma, Septicaemia


Morbid obesity, asthma, septicaemia

A referral was received because Heather was severely unwell with septicaemia. She is a carer for her two disabled daughters and has transport issues to access services.

At my first point of contact with Heather, I completed the partners in health scale over the phone and it wasn’t until I asked if the services she received fit with her cultural values that Heather disclosed she was of Aboriginal decent.

Heather became unwell with septicaemia from a leg wound caused by a knock on the coffee table. She required emergency transport to the hospital. Unfortunately due to her weight, transport had to be ordered from Melbourne. Extra services were called in to assist with the transfer but were still unable to lift her into the ambulance. Heather had to be transported in the back of a lower van with medical assistance.

Heather explained that she didn’t identify as an Aboriginal because it was “just easier” but her mother was of Aboriginal decent and her sister was looking into finding out more about her family.

Heather was admitted to our program on the 16/01/2012


Because of my legs (Arthritis) I cannot get in the car. This means that I’m unable to see my grand-daughter. I feel angry and sad.

Medical problems

  • Weight 140kg
  • Sleep Apnoea
  • Asthma
  • Hypertension
  • Diabetes
  • Poor functional activity level/ sedentary-spends all day in bed or a chair
  • Arthritis
  • CCF
  • Self-management deficits in all 12 questions
  • Does not access a regular GP
  • Non-compliant with medications or on occasions does her own self medicating…..
    Example: won’t take Lasix because it is too hard for her to walk to the toilet
  • Does not BSL test regularly


I will see my grand-daughter on access visits three times a week


  • Referral to a dietician
  • Referral to an OT
  • Referral to an exercise physiotherapist
  • Referral to a social worker to support EPOA and DHS liaison



  • Has had no further admissions to hospital or urgent care
  • Has a regular GP
  • Maintains regular appointments
  • Weight loss to date is 10kg
  • Is compliant with her medication
  • Has achieved her goal of access visits to her granddaughter which requires Heather to get in the car and go up an 8 step flight of stairs
  • Monitors and manages her symptoms

Work with Heather is continuing regarding ongoing weight loss, increasing exercise tolerance and access to peer support groups to achieve her next goal of being able to attend her 10 year old daughter’s parent teacher interview.

Jack's Story - 81 years old: Recent AMI (Acute Myocardial Infarction)


Recent AMI (Acute Myocardial Infarction)

A referral was received because Jack was not compliant with cardiac rehab or GP appointments. He had frequent presentations to the urgent care department with asymptomatic chest pain.

On my first visit to see Jack, I completed the partners in health scale and it wasn’t until I asked whether the services he received fit in with his cultural values that Jack disclosed that he was of Aboriginal decent. Jack explained that he was from the Tasmanian people. The last memory he had was of having to go into the bush to spend Christmas with his grandfather who was in his words “scary because he was very dark skinned.” Jack explained that he was sent to a mainstream school because of his fair skin and that he had no idea who his father was.

Jack’s interview led straight to the Problem and Goal statement.


My health means I am going to die. This means I won’t be here to care for my family and I won’t be able to tell them about their heritage.” (Until this time only Jack’s wife knew of his heritage)

  • Angina
  • Depression DASS scale of 19 indicating moderate depression, 19 indicating severe anxiety and 24 moderate stress
  • Financial insecurity
  • Would not engage with GP or health professionals
  • Not compliant with screening tests (didn’t have time)
  • Illiterate
  • Wife had early dementia (carer strain)
  • Didn’t know father’s identity
  • Lost culture
  • Didn’t trust Aboriginal co-ops
  • Not compliant with medication


I would like to be able to set my family up.

Even though this was not an action goal it was very important to Jack and he had the following objectives to achieve:

  • Reconnect to country
  • Retrieve original birth certificate
  • Set family up so that they are financially secure
  • Record early memories of living in Tasmania and Aboriginal Heritage

Jack’s care plan included:

  • Home based cardiac education
  • Referral to GP
  • Referral to carer’s support to access respite for his wife
  • Link his wife into ongoing group activities
  • Support Jack to set up a furniture removals business for his family to run
  • Link with Tasmania Aboriginal liaison worker and support to fly over and reconnect to country
  • Referral to social work to support voice recorded IT program so Jack could record his memories for his family
  • Regular pathology screening
  • Referral to legal support and Births, deaths and marriages for access to birth certificate
  • Set up Webster pack


Jack now:

  • Had no further admissions to hospital or urgent care
  • Reconnected to country
  • Manages his angina medication
  • Is medication compliant
  • His carer strain has reduced
  • Has set up a very successful business to support 5 children and 12 grandchildren (it was important to Jack that all of his family worked for their money)
  • Has recorded early memories for his family
  • Has included regular exercise into his routine
  • Attended monthly appointments with a GP Nurse who uses a client checklist to support Jack’s consult with the GP and ensure scripts are accessed

Unfortunately we were unable to access Jack’s true Birth certificate due to an act passed in Tasmania by the Governor General.

Jack has just recently passed away. Unfortunately his early cardiac event had left him in a palliative state. I thought though that this case study might show the depth the Flinders program provides in delivering timely care and support.

Jim's Story - 72 years old: Extensive medical history


Extensive medical history-Type 2 diabetic, asthma, COPD (Chronic Obstructive Pulmonary Disease), Chronic renal failure, CCF, IHD, Cardiomyopathy, Hypertension, AMI, Mitral regurgitation, L) ventricular hypertrophy, LVF, Eczema.


  • Not compliant with medications
  • Financial insecurity
  • Insomnia (occasional sleeps in a chair)
  • Poor self-management strategies
  • Poor living conditions, social isolation
  • Frequent hospital admissions and frequent Urgent Care Centre presentations
  • Heavy reliance on health services


To utilise the appropriate health services that will assist Jim to self-manage his health more effectively, reduce his reliance on existing health services and reduce the number of hospital admissions. Jim also requires assistance to gain more financial security and improve his living conditions as well as re-connect with his local community.

Jim was admitted to the HARP (Hospital Admission Risk Program) on the 20/2/12. The HARP worker engaged with Jim by maintaining regular phone calls and home visits.


Jim’s HARP worker was able to put many services and systems in place prior to discharge. These included: community nursing, HACC services, financial advisor, counselling, social work, occupational therapy, regular GP follow up, Men’s Group, CAP’s package.


Jim now:

  • Has had no presentations to UCC in 2012
  • Remains at home, living independently and self-managing effectively with extensive care coordination
  • Occupational Therapy were able to provide a bed for Jim
  • Jim received assistance to apply for a winter heating subsidy and was referred to financial planning services for management of future finances.
  • Jim’s last admission was on 20/2/12


Paul's Story - 46 years old: Type 1 diabetes


Type 1 diabetes since childhood.

Paul is proud of being fit and healthy. He exercises religiously and eats accordingly, maintaining commendable blood sugar levels.


Despite his best efforts Paul still has hypo-glycemic episodes every now and then and neither he nor his GP understand why.


To reduce or ideally eradicate the hypo-glycemic episodes.

Paul is a patient at a local medical centre where his GP and nurse agreed to be part of a small 12 month long “proof of concept” pilot. This was conducted last year using the Flinders Tools in conjunction with their usual GPMP. He had been their patient for ten years but the Partners in Health and Cue & Response Scale gave the nurse the ideal opportunity to formally document Paul’s story to date.

As they were brainstorming possible causes for his hypo-glycemic problem, Paul volunteered that he had had a gastrectomy (his stomach volume was reduced by 75%). This took place fifteen years ago, five years prior to joining the medical centre. No-one had asked him about it and he didn’t think it was important and so never mentioned it.


Paul now:

  • Has not experienced a hypo-glycemic episode in six months since this review
  • Feels he is now really in charge of continuing his good health
  • Has developed a new eating plan consisting of the same foods but he eats six small meals per day instead of the usual three, to accommodate his reduced capacity

Using the Flinders Tools allowed the nurse to complete Paul’s partially documented history. Most practices have not yet recorded an extensive medical and personal history and these tools are perfect for completing both.



Suggestions and feedback on your success using the Flinders Program are more than welcome!

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TML has greatly appreciated the support of the Flinders team. They have assisted TML to establish a Community of Practice for our ‘Closing the Gap’ Care Coordination network which has included sharing resources to assist with the implementation of the Flinders Program for Chronic Condition Management and the Flinders Tools.

The Flinders team have supported the implementation of this framework strategically as well as operationally by providing mentoring support to the workforce and management team. The relationship with the Flinders team has been an extremely positive and productive one in terms of improving our capacity to deliver quality, integrated chronic condition management services.

Debra Burden
Debra BurdenManager Aboriginal Health - TAS Medicare local

The workshop was so great! I am really interested in making care plan and everything is so good! I and my friend hope that when we go back to Vietnam we can run the workshop like this! 

To be honest, my friend and I thought that this is the first workshop we really enjoy in Australia! Although we have language barriers, everyone are so friendly, especially David, Coral and Vee are so nice try to explain carefully with us! That’s so good!

Thanks for your support! 

Thi ThanhThuy Dang
Thi ThanhThuy Dang
I had been working with Lower Murray Medicare Local in Mildura for 3 years as the Indigenous project officer when Flinders University sent an email asking if there was any interest for training to be set up here in the Mallee. I replied to the email to find out what was being offered, not
knowing that it would soon take me on a really exciting journey with our Aboriginal community.

To start with the program came to town and I went with one of my workers to get volunteers to take part. We had more volunteers than we had trainers. I was then asked to train myself up which was the next move on my journey.

As the CTG indigenous project officer for LMML I run health information into the community e.g. Women’s health, pre diabetes, healthy eating to name a few. We transport Aboriginal community members to appointments and do chemist pick-ups for community members who can’t get their own medication. All of this is being done by two workers but we still felt we were missing something. Raylene and Malcolm (FCTGP) had the faith in my ability to come on board to train up to train the trainer. I signed up two weeks ago and in this time I’ve completed ten Flinders Care Plans, assisting new clients and some who have been on our books from the beginning. Working through these care plans has unearthed lots of different issues. We can now refer clients and assist them to better their health and to understand their own health.

One Care Plan I completed, the person I sat with was an older person having had several heart operations. He was very unaware of his health issues and did not understand them. His words were “my ticker stopped working properly.” When asked if he understood his medication, he said “No, I take it coz I’m told to.” As we sat talking I asked him if he understood the early warning signs. He said “I get pain in my chest but I just take a pain killer to stop the pain and it’s hurting now.” This is something that came out of all ten Care Plans; the lack of understanding around their own health, the good and the bad.

As a new comer to this program and having been a case worker in past, I find the Flinders Care Plan one of the easiest to use with the community. It is put in a way that all people seem to understand and they feel comfortable having done a Care Plan for their health. It uncovers the over-riding issues that prevent clients from having good health. I’m proud to be using this with our clients we care for in our area of Mildura and surrounding areas to encourage better understanding and better outcomes for our Aboriginal community.

Wendy Owen
Wendy OwenRegional Implementation Coordinator - VIC

We have been doing a lot of Care Plans weekly. They have been an extremely useful tool for us. It provides a bridge for the medical and psych; we are able to assist patients who cannot get into the family therapist right away. If they have issues; we are able to speak with them in confidence, and it is such a helpful piece of the puzzle that we have been able to really utilize to what I believe to be its’ fullest extent.

We honestly have a fun time using Flinders. Any time that we have a problem in the office; we always say “Don’t worry; we can Flinder that!”. Mostly, we have learned that we have to set our goals very slow and small. Our patients can achieve those things most important to themselves. Once they do that it seems as if they can tackle more. We like it very much and find it very helpful.

Kimberley Otto
Kimberley OttoDoctor of Nursing (DNP) - USA