A Randomised Control Trial of the Flinders Model of Self-Management support for older Australians with complex chronic diseases, and their carers.

INTERVENTION: Participants in the intervention group will receive the Flinders Model of Self‐Management (Flinders Model). The Flinders Model provides a generic set of tools that enable health professionals to undertake a structured assessment of self‐management behaviours, collaborative identification of problems and goal setting leading to the development of individualised self‐management care plans. The Flinders Model is generic and not disease specific. The intervention will comprise a total of three home visits and four follow‐up phone calls conducted over a six month period by health professionals (e.g. nurses, occupational therapists, social workers, psychologists) trained in the Flinders Model. Participants in the intervention group will also receive their usual medical care throughout the trial. CONDITION: Cardiovascular disease (including: ischaemic heart disease, cerebrovascular disease/stroke, peripheral vascular disease, congestive heart failure, hypertension). Diabetes (Type 1 or Type 2). Digestive (including: gastro‐oesophageal reflux disease). Kidney disease Musculoskeletal (including: osteoarthritis, rheumatoid arthritis, other arthritis, osteoporosis, chronic back pain). Non‐end stage cancers. Psychological (including: depression, anxiety, insomnia). Respiratory (including: asthma, chronic obstructive pulmonary disease). PRIMARY OUTCOME: Health Behaviours. ; ; This measure includes questions about exercise behaviours (using the Stanford evaluation tools) and medication adherence (using the Medication Adherence Report Scale or MARS‐5 by Horne & Weinman, 1999). Health Services Utilisation. ; ; This measure is one of the Stanford evaluation tools. Health Status. ; ; This measure includes questions about self‐rated health, health distress, illness intrusiveness, pain, energy, fatigue and depression. ; ; These items are from evaluation tools developed at the Stanford Patient Education Research Centre. Perceived self‐efficacy. ; ; This measure is one of the Stanford evaluation tools. The primary outcome measure for carers is the Caregiver Risk Screen (Guberman, Keefe, Fancey, Nahmiash & Barylak, 2001). SECONDARY OUTCOME: The Health Education Impact Questionnaire (heiQ) for both patients and carers (Osborne, Whitfield & Elsworth, 2007). INCLUSION CRITERIA: Participants will be aged 60 years or older with two or more of the following types of chronic conditions: ‐ Cardiovascular (including: ischaemic heart disease, cerebrovascular disease/stroke, peripheral vascular disease, congestive heart failure, hypertension); ‐ Respiratory (including: asthma, chronic obstructive pulmonary disease); ‐ Musculoskeletal (including: osteoarthritis, rheumatoid arthritis, other arthritis, osteoporosis, chronic back pain); ‐ Psychological (including: depression, anxiety, insomnia); ‐ Digestive (including: gastro‐oesophageal reflux disease); ‐ Kidney disease ‐ Diabetes (Type 1 or Type 2); and ‐ Cancer.