Table 1 Summary of the Flinders Program tools [17]

1) The Partners in Health Scale (PIH):

A patient Likert-rated validated questionnaire informed by the WHO and Australian National Chronic Disease Strategy principles of self-management [59, 60] It enables measurement of perceived change over time where 0 = less favourable and 8 = more favourable self-management capacity. Self-management rated capacities include: knowledge of condition and treatments; quality of relationships with healthcare providers; actions taken to monitor and respond to signs and symptoms; access to services and supports; physical, social and emotional impacts, and lifestyle factors.

2) The Cue and Response Interview (C&R):

An adjunct to the PIH using open-ended questions or cues to explore the patient’s responses to the PIH in more depth, with the patient and worker comparing their Likert-ratings to identify agreed good self-management, agreed issues that need to be addressed, and any discrepancies in views that can then be discussed as part of formulation of a self-management care plan. It enables the strengths and barriers to self-management to be explored, and checks assumptions that either the worker or patient may have, as part of a motivational process.

3) The Problems and Goals (P&G) Assessment

Defines a problem statement from the patient’s perspective (the problem, its impact and how it makes them feel) and identifies specific, measurable, achievable, realistic and timely (SMART) goals that they can work towards. It is Likert-rated, allowing measurement of progress over time where 0 = not a problem and 8 = a significant problem; and goal statements: 0 = no progress towards achievement and 8 = achieved.

4) Self-Management Care Plan:

Includes self-management issues, aims, steps to achieve them, who is responsible and date for review.