Are patient competencies in managing chronic conditions improved using the Flinders self-management approach?

INTERVENTION: Flinders Program for Chronic Care Management The Flinders Program provides a generic set of tools and processes that enables health workers and patients to undertake a structured process that provides assessment of self‐management behaviours, collaborative identification of problems and goal‐setting, leading to the development of individualised longitudinal (12 month) care plans. For the trial, the Flinders Program will be delivered as an initial care planning session between the client and a health professional who has been trained in using the Program. The health professional will provide follow up 2‐4 weekly for up to 6 months to monitor progress, provide feedback and motivation, and problem solving training to assist the client to achieve their goals and enhance their self‐management. Participants in this group also receive usual care for the duration of the Flinders Program and until the end of the trial. CONDITION: chronic obstructive pulmonary disease (COPD) congestive cardiac failure diabetes ischaemic heart disease transient ischaemic attacks PRIMARY OUTCOME: Self‐management competencies as measured by the Partners in Health Scale score SECONDARY OUTCOME: Energy/fatigue as measured by the Energy/Fatigue scale (Stanford Patient Education Research Centre) Health distress as measured by the Health Distress scale (Stanford Patient Education Research Centre) Health‐related quality‐of‐life as measured by the SF‐12 (v2) score Self‐efficacy for managing chronic disease as measured by the Self‐Efficacy for Managing Chronic Disease 6‐Item Scale (Stanford Patient Education Research Centre) INCLUSION CRITERIA: People aged 45 years and over with one or more chronic conditions