Partnering in Primary Healthcare in New Zealand
RCN International Research Conference 2010
Partnering in Primary Healthcare in New Zealand:
Clients’ and Practitioners’ Experience of the Flinders
Programme in the Management of
Long-term Conditions
Dr Dianne Roy RN, PhD, FCNA(NZ) 1
Faith Mahony2
Assoc Prof Margaret Horsburgh2
Dr Janine Bycroft2
Denise Miller2
Unitec New Zealand1
University of Auckland2
Flinders Programme
• Developed by Flinders Human Behaviour & Health Research Unit Flinders University, South Australia
Format:
• Detailed one-to-one assessment, care planning & follow-up
• Use of standardised forms and tools
• Requires health professionals to complete a two-day workshop and
certification process
Advantages:
• Individualised and client-centred (using clients’ goals)
• The programme differentiates between care for LTCs and that
for acute conditions
• Promotes systems change within organisations to enhance
LTC care and supported self-management
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Flinders - Overview
Self
management
Problem
identification
Goal
identification
Medical
management
Multi-disciplinary
support
Community/carer
support
Psychosocial
support
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CARE-PLAN
Agreed Issues
Agreed
Interventions
Shared
Responsibilities
Review Process
The Study
Aim:
• To assess the acceptability and usefulness of the
Flinders Programme when utilised by primary healthcare
nurses with individuals who have long-term conditions
• Ethics approval for the study was obtained from the NZ
Northern Y Regional Ethics Committee.
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Design:
• Mixed methods with qualitative
and quantitative components
• Pre and post feasibility study
Study population:
• 20 general practices and 100
participants
• Intervention: 10 practices with
50 participants
• Control: 10 practices with 50
participants
• Eligibility: Adults with any
significant long-term condition
and not currently enrolled in a
Chronic Condition Management
programme
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Method
100 Participants - Baseline measures
• Control – usual care
• Intervention
• Flinders assessment, care planning, implementation with
primary care nurse
• Follow-up as required and at 3 and 6 months
At 6 months: Repeat outcome measures
Interviews: Nurses and Participants (intervention group)
Web-based Survey: Flinders trained health professionals
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Participant Numbers
Participants
Registered
Completed
Did not
complete
Intervention
48
27
21
Control
52
30
22
Total
100
57
43
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Demographics
Control (n=30
Intervention (n=27)
Average age
59
62
Age range
Gender
25 - 89
25 - 90
Male
53%
41%
Female
47%
59%
Maori
23%
30%
New Zealand European
47%
30%
Pacific
22%
17%
Other
8%
24%
CVD/Stroke/PVD
45%
33%
COPD/Asthma
58%
44%
Gout
21%
30%
Diabetes Mellitus
40%
56%
Arthritis
45%
44%
Other
55%
56%
If with co-morbidities
78%
72%
Age
Ethnicity
Disease
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Qualitative Data
Interviews - intervention group
• 11 clients
• 4 practice nurses
Focus Groups x 2
• Flinders trained practice nurses
• pre intervention (8 participants)
• post intervention (5 participants)
Practice nurse reflection notes x 11
Free-text responses from web-based survey
Data management and Analysis
• digital recordings transcribed verbatim
• thematic – informed by interpretive description (Thorne, 2008)
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Findings
Four theme clusters
• Enablers and benefits
• Challenges
• Paradox of time
• Catalyst for change
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Findings – Enablers and Benefits
Clients:
Nurses:
The process
The process
•
•
•
•
•
Goal setting
Ownership
Written plan
Follow up
Time
Relationship with nurse
• Being listened to
• Partnership
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•
•
•
•
•
Client-centred
Using the whole programme
Nurse autonomy
Right environment
Time
Relationship with client
• Time to listen
• Know client in context
Findings - Challenges
Clients
Nurses
• Motivation
• Resistance to change
• Initial
• Ongoing
• Cost of repeat visits
• Cost to achieve goals
• Time to achieve goals
• Nurse
• Colleagues
• Primary care structure
• Funding
• Models of care
• Client population
• Language barriers
• Transient populations
• Time for initial assessment
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Findings – Paradox of Time
Time both an enabler and a challenge
Time enabled:
•
•
•
•
Assessment and goal setting
Getting to know client
Being listened to
Improved client/nurse relationship
Time as a motivator - a right time for change
Time as a challenge:
• Initial assessment (40-60mins) does not fit usual appointment
schedule
• Time as money
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Flinders as a Catalyst for Change
• Client – Maori woman (60 years) living with asthma
• Prior to Flinders:
I never acted until it was too late… I used to be so bad by
the time I got up to the clinic I would be fighting for breath
they would be saying ‘why do you leave it so late?’ (client)
She was up here quite a few times with her asthma; it was
very difficult to approach her because she would just shut
off. I would talk to her, try to educate her but she wasn’t
listening. (nurse)
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Flinders as a Catalyst for Change
Flinders assessment
• Hearing impairment
• Lack of knowledge of medications
• Misunderstanding of asthma action plan
I couldn’t catch what she was saying. My hearing had been like
that for quite a while. Because I couldn’t hear them and I couldn’t
understand what they were talking about. (client)
With Flinders I was approaching it from her level, trying to
understand why she had recurrent episodes. The thing that was
actually a problem was she was deaf, she couldn’t hear so that
was the turning point of the whole thing. (nurse)
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Flinders as a Catalyst for Change
Goals
•
To be able to get out and about more and do things with
family/whanau.
•
To sort out hearing issues
So I said ‘hey I have to do something’ so I did that for myself, I
noticed my hearing was getting too much of an issue, and now I
know what they are talking about. (client)
We referred her for hearing assessment, but until she had a hearing
aid she needed to know when she wheezing, so I taught her to use
the peak flow and to record and act on the readings because she
couldn’t hear herself wheeze. (nurse)
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Flinders as a Catalyst for Change
• Dramatic reduction in asthma symptoms
I haven’t been back to the doctor since I first started Flinders.
• Knows how to monitor and manage symptoms
I record my peak flow, the picture is so logical, I see the picture and
think ‘wow’. Before I wasn’t recording the graphs, but now I understand
what the picture means. I have 2 inhalers; I have a brown and a blue
one, I didn’t know the difference between them before, but now I do.
• Has a hearing aid and is wearing it
Communication is a lot easier. The two of us kept working together
despite the hearing problem. I kept saying ‘I can’t hear you, you have to
talk up’ but now I say ‘don’t yell, I can hear you’.
• Taken up a hobby previously unable to tolerate...
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The Korowai
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Conclusion
Future challenges
• Restructuring of primary care to better facilitate management
of LTC
• financial
• environmental
• underpinned by chronic care models
• How to screen/identify those who will most benefit from being
included in a full Flinders programme
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Mahia te mahi, mēnā he painga mō te iwi.
Do what needs to be done if there is a benefit in it for the
people.
Dr Dianne Roy droy@unitec.ac.nz
© Unitec New Zealand
Acknowledgments
• All the nurses, practices and clients for their willingness to
participate
• Members of our Advisory Group
• Counties Manukau District Health Board
• Auckland District Health Board
• ProCare Health Auckland
• Prof Malcolm Battersby, Dr Sharon Lawn and team at
FHBHRU
• STAR Fund
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References
Flinders Human Behaviour & Health Research Unit. The
'Flinders Program' of chronic condition self-management.
Retrieved from
http://som.flinders.edu.au/FUSA/CCTU/self_managemen
t.htm
Thorne, S. (2008). Interpretive description. Walnut Creek,
CA: Left Coast Press.
© Unitec New Zealand