What are self-management care plans?

Self-management care plans are documents developed and agreed ideally in collaboration with the patient, a carer and other health professionals. (It should be noted that sometimes patients do not wish a carer to be involved in this; covered later in the module.) The self-management care plan is a critical component of self-management support and clarifies the personal goals and aspirations of the patient, along with a plan of action of how this will be achieved. The Consumer and Carer survey determined that only 40% of the respondents had a self-management care plan.

Reflective exercise

On the notepad provided, jot down your thoughts to the following question.

Author’s Answers

Self-management care plan templates

A number of self-management care plan templates have been provided for your use.

          Medicare GP Mental Health Care Plan M3 P1.pdf
          Flinders Care Plan M3 P1.pdf
          RACGP sample care plan M3 P1.pdf

The Flinders care plan is based on an assessment of a person’s self-management knowledge, skills and barriers so that issues and patient determined problems and goals can be identified collaboratively. The training on-line or face to face provides education in how to use the assessment tools and the associated materials that assist the patient with their self-management.

The self-management care plan process

The Flinders Program

One process that can be used is the Flinders program.^{(1, 2, 3)}

Stage 1:    Conduct a collaborative interview with the patient, carer (where available), and other health professionals.

• Identify current level of knowledge

• Assess the capability of the patient and carer for self-management

• Identify patient needs

• Determine goals, prioritise and identify realistic targets, within a realistic framework and with intended outcomes

• Identify and discuss treatments, interventions and supports

• Document the self-management care plan, agree on the self-management care plan and set review dates

• Sign off on the self-management care plan and provide the patient (and relevant others) with a copy of the plan

Stage 2:     Follow-up interviews

• Determined by the patient, carer and psychiatrist

• On a regular basis, for a determined period of time, often one year or wherever necessary e.g. after an episode of relapse

The self-management care plan process⁽⁴⁾

Dim lights Download

 An explanation of the Flinders self-management care plan process is offered in this video vignette. Please note that this example includes only the psychiatrist and patient. A carer or support worker could also be in attendance.

The 5 As Model

The second process that can be used to develop a personal action plan is the 5 As model (assess, advise, agree, assist and arrange). A personal action plan can be established using the behaviour change model.⁽⁵⁾ An example of action plans can be seen by clicking on the PDF.⁽⁶⁾   Action plan.pdf and Action plan 2.pdf

References

1. Battersby M, Lawn S. Capabilities for supporting prevention and chronic condition self-management: A resource for educators of primary health care professionals. Flinders University, Adelaide: Australian Government Department of Health & Ageing, 2009.
2. McColl Institute, Group Health Cooperative, Self-Management Support. Empower and prepare patients to manage their health and health care. Available from http://www.improvingchroniccare.org/index.php?p=Models&s=98
3. Royal Australian College of General Practitioners Chronic Condition Self-Management Guideline for General Practitioners Working with Chronic Conditions. Available from http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/SharingHealthCare/20020703gp.pdf
4. Flinders Human Behaviour & Health Research Unit Self-Management Program. The Flinders Model DVD.
5. Glasgow RE, Emont S, Miller DC. Assessing delivery of the five ‘As’ for patient-centered counselling. Health Promotion International 2006;21(3):245–55.
6. Available from http://www.improvingchroniccare.org/index.php?p=CCM_Tools&s=237