10)Motivational Wawancara

prosesA dilakukan dengan seseorang untuk mendukung perubahan perilaku mereka. Urutan di Motivational
Wawancara melibatkan mendorong orang untuk berbicara, menghasilkan pernyataan diri motivasi, menghadapi
perlawanan, mengembangkan kesiapan untuk berubah dan bernegosiasi rencana, mengembangkan tekad dan
tindakan. The 5 principles underlying the process are expressing empathy, developing discrepancy, avoiding
arguing, rolling with resistance and supporting self-efficacy. Motivational Interviewing embodies cognitive
change skills (Miller & Rollnick, 1991).
(11) Collaborative problem definition
Having an open dialogue with the patient about what they see as their main problem, what happens because of
the problem, and how the problem makes them feel (Von Korff, et al. 1997).
(12) Goal setting and action planning
The process of deciding on what one wants, planning how to get it, and then working towards the objective of
achieving it, usually by ensuring that it is SMART (specific, measurable, achievable, realistic, and timely). In
the health context, goal setting can be done by the patient alone or with the support of others to help formulate
the goal and help the patient to remain motivated to achieve it, ie involving collaborative goal setting, problem-
solving and other goal attainment skills (Locke & Latham, 1990).
(13) Structured problem solving
The ability to systematically assist a patient to learn the skill of problem solving, ie identify and analyse
practical issues arising in a situation and to determine options for a practical solution, making effective use of
time and resources available (Katon, et al., 2008).
14 Supporting Prevention and Chronic Condition Self-Management
Organisational/ Systems Skills
Definition
(14) Working in multi-disciplinary teams / Interprofessional learning and practice
The ability to establish working relations with others of a different profession or discipline, to interact
effectively, and to promote productive cooperation, collaboration and coordination. It involves understanding
and respecting the role and function of all members, and integrating care by recognising and actively engaging
service providers across systems, sectors and agencies, not just within organisations. It involves communication
skills together with the timeliness of those communications. 'Inter-professional education occurs when two or
more professions learn with, from and about each other to improve collaboration and the quality of care' (Jessop,
2007; Braithwaite & Travaglia, 2005).
(15) Information, assessment and communication management systems
A systematic approach to proactive use of clinical data to screen, monitor and provide self-management support
to patients. This may include use of electronic (or other) recall and reminder systems to enable health service
providers to become pro-active in providing support to patients and alerting them to the need for a review of
their health condition(s). These information system management skills also include use of systems for sharing of
health records and coordination of communication and support between PHC service providers within the
patient's community (Wagner, Austin & Von Korff, 1996b).
(16) Organisational change techniques
Change in the structure of service delivery in order to impact on the way work is delivered to the population
served. Various techniques are used within health care settings, each based on theories of organisational
structure, culture and models of change, group behaviour and values. The Plan, Do, Study, Act (PDSA) cycle is
one mechanism for mobilising staff for incremental organisational change (Johnson & Paton, 2007).
(17) Use of evidence based knowledge
An explicit approach to health care practice in which the health professional is aware of the evidence that bears
on their practice, and the strength of that evidence. This includes the risks and benefits of any intervention
including self-management support. This approach to decision making involves the health professional using the
best evidence available, in consultation with the patient, to decide upon the option which suits that patient best
(Muir Gray, 1997). Most evidence-based guidelines are disease specific. However, co-morbidity is common
among people with chronic conditions. Therefore, it is important for evidence-based knowledge and practice to
acknowledge this complexity.
Supporting Prevention and Chronic Condition Self-Management 15
(18) Conducting practice based research / quality improvement framework
Undertaking practical research or evaluation in the field that can be used to inform everyday practice and
improve the delivery of service to patients. Measures may include patient or health professional rated self-
efficacy, self- management behaviours, patients' health-related quality of life, health service utilisation,
patient/carer satisfaction with the service, service costs, or specific disease measures. This practice-based
research provides services with a strategic overview of the key principles and practices necessary for the
effective monitoring, management and improvement of their health services. The Plan, Do, Study, Act (PDSA)
cycle is one mechanism for undertaken this research in practice (Victorian Quality Council, 2005).
(19) Awareness of community resources
Broad understanding of available resources, supports, services and activities within the patient's community that
would be useful in supporting them and their carers/family. This involves an understanding of what the services
involve, how to access them and their appropriateness in being able to meet the patient's and their carer's
identified needs (Wagner, et al., 2001).
The core capabilities are further demonstrated in the case study attached to this resource (refer to CD-
ROM).
6.2 Prevention and Chronic Condition Self-Management Support Knowledge, Attitudes
& Skills across the Continuum of Care
The knowledge, attitudes and skills needed by the PHC workforce within the self-management
continuum are linked and involve progressive capabilities that are important for working with patients
to maintain wellness, detect and address risk factors early and to self-manage their existing chronic
conditions. Prevention is seen to apply across the entire spectrum from wellness to someone who has
early indicators of disease through to established chronic conditions. These capabilities are drawn
from the extensive literature review and consultation undertaken for the PHC workforce project, and
reflect the vision and philosophy, core and operational principles contained in this resource. The
knowledge, attitudes and skills identified by the national PHC Workforce project are inherent within
these capabilities.
Figures 6.2.1, 6.2.2 and 6.2.3 identify the baseline knowledge, attitudes and skills required by health
professionals to support patients to self-manage their health through the lifespan from maintenance of
wellness and prevention of illness, early detection and risk factor modification and self-management
of established chronic conditions respectively.
The three stages are separated to demonstrate a layering of interventions and associated skills.
However, in reality an individual with established chronic conditions may undertake a range of
activities that support wellness, have risk factors which increase the complications of the existing
chronic condition, as well as risk factors for developing additional chronic condition co-morbidities.
This staged model encourages the PHC worker to see the patient holistically on a continuum of
wellness, risk and established chronic conditions, and not to focus solely on the established chronic
condition.
16 Supporting Prevention and Chronic Condition Self-Management
Supporting Prevention and Chronic Condition Self-Management 17
Established Chronic
Early Intervention Prevention Condition
noitidno C / esaesi D cinorh C
Early Intervention
Prevention
noitcete D ylra E
Prevention
ssenlle W
18 Supporting Prevention and Chronic Condition Self-Management
Prevention Early Intervention Established Chronic
Condition
Early Intervention
Prevention
Prevention
noitcete D ylra E
ssenlle W
noitidno C / esaesi D cinorh C
Supporting Prevention and Chronic Condition Self-Management 19
Prevention Early Intervention Established Chronic
Condition
Early Intervention
Prevention
Prevention
noitcete D ylra E
ssenlle W
noitidno C / esaesi D cinorh C
7. Prevention and Chronic Condition Self-Management Care Planning
Self-management care planning is an example of how the PHC worker can demonstrate their use of
the core capabilities in practice.
Within the Chronic Care Model framework, international evidence confirms that a best practice
approach to self-management support is for each patient with a chronic condition or risk factors to
have a self-management care plan. This plan should be collaboratively developed with health
professionals and other supports (including carers), and should incorporate both medical management
and self-management. The self-management care plan incorporates and integrates many of the
underlying principles, values and core capabilities identified for the PHC workforce.
It should be derived from an assessment of self-management capacity and include:
n Knowledge; n Behaviours; n Attitudes; n Impacts of the condition; n Lifestyle risk factors; n
Barriers to self-management; and n Strengths.
The care plan should contain:
n Patient defined problems; n Patient defined goals; n Medical management; n A prioritised action
plan based on the self-management needs of the patient and their carer; n Community education
programs or resources; n Community support networks; and n Time for review and follow-up. This
includes the flexibility to acknowledge and anticipate
unexpected emergent events arising from co-morbidity and/or increasing frailty and some direction as
to what should be done in that circumstance.
The care plan should:
n Facilitate the patient's engagement in their own care and treatment; n Enhance the patient-health
provider relationship; n Enhance the patient's belief that they can make changes to achieve improved
self-management and
health outcomes; and n Enhance the patient's ability to maintain changes once improved self-
management and health
outcomes are achieved.
The care plan should incorporate condition-specific tasks to be carried out by the patient and
condition- specific and generic education (knowledge and skills) required by the patient. This
approach needs to consider the complexity that is brought to these tasks when co-morbid conditions
are present. A balance between holistic and condition-specific approaches is needed.
20 Supporting Prevention and Chronic Condition Self-Management
These skills include:
n Problem definition and goal setting; n Action planning; n Problem solving; n Emotional
management; n Pain management; n Psychosocial skills; n Cognitive change skills; n Relapse
prevention skills; and n Goal attainment skills (ie monitoring, reinforcement, creating accountability,
contingency
planning).
The self-management care plan should occur within a health system that provides ready access to
appropriate systems of self-management support that are:
n Based on a health promotion and population health view; n Evidence-based; n Adequately
resourced; with n Staff who are adequately trained, culturally sensitive to the patient's needs and who
support the
belief in the patient's ability to learn self-management skills.
A range of care planning item numbers is available to the PHC workforce through the national
Medicare Benefits Scheme. These are designed to:
n Provide opportunities for the provision of planned preventive and chronic care to people at risk of or
suffering from chronic and complex medical conditions; n Enhance coordination of care and
communication between the patient and their PHC providers; n Build inter-disciplinary
communication and working relationships between PHC providers; and n Coordinate the various
support services organised to support the patient's self-management of their
health.
These care planning items include the General Practice Management Plan (GPMP) and Team Care
Arrangements (TCA). Further item numbers are available for use by practice nurses or registered
Aboriginal Health Workers on behalf of a General Practitioner. These may be further supported by
allied health professionals (Australian Government Department of Health and Ageing, 2008).
The care planning items are complimented by a range of other items including:
n Health assessment; n Prevention; n Service Incentive Payments; n Mental health; n Quality use of
medicines; n Bulk billing incentives.
Supporting Prevention and Chronic Condition Self-Management 21

8. References
Australian Government Department of Health and Ageing (2008) Chronic Disease.
[Accessed 21st November 2008] http://www.health.gov.au/internet/main/publishing.nsf/Content/pcd-
programs-epc-chronicdisease http://www.health.gov.au/internet/main/publishing.nsf/Content/work-pr-
nigp-init http://www.health.gov.au/internet/main/publishing.nsf/Content/portal-Chronic%20disease
Australian Institute of Health and Welfare (AIHW) (2004) Australia's health, 2004. AIHW, Canberra.
Bandura A. (1977) Self-efficacy: Toward a unifying theory of behavioral change. Psychological
Review, 84:2,
191215. Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, Salivaras S.
(2003) The expanded
chronic care model: An integration of concepts and strategies from population health promotion and
the chronic care model. Hospital Quarterly, 7:10, 7382. Battersby M, Ask A, Reece M, Markwick M,
Collins J. (2003) The Partners in Health scale: The development
and psychometric properties of a generic assessment scale for chronic condition self-management.
Australian Journal of Primary Health, 9, 4152. Battersby M, Harvey P, Mills PD, Kalucy E, Pols
RG, Frith PA, McDonald P, Esterman A, Tsourtos G, Donato
R, Pearce R, McGowan C. (2007) SA HealthPlus: A controlled trial of a statewide application of a
generic model of chronic illness care. The Millbank Quarterly, 85:1, 3767. Braithwaite J, Travaglia
J. (2005) Inter-professional learning and clinical education: An overview of the literature.
Braithwaite & Associates, Chatswood, NSW. [Accessed 30th July 2008]
http://www.health.act.gov.au/c/health?a=sendfile&ft=p&fid=201524733&sid British Association for
Behavioural and Cognitive Psychotherapies (BABCP) (2005) Mapping Psychotherapy What is
CBT? What are cognitive and/or behavioural psychotherapies? Paper prepared for a UKCP/BACP
mapping psychotherapy exercise Katy Grazebrook, Anne Garland and the Board of BABCP July
2005. [Accessed 21st November 2008] http://www.babcp.com/silo/files/what-is-cbt.pdf Centre for
Cultural Diversity in Ageing (2008) Cultural awareness. CCDA. [Accessed 10th Sept 2008]
http://www.culturaldiversity.com.au/Resources/ServiceProviderResources/CulturalAwareness/tabid/8
1/ Default.aspx Dade Smith J. (2005) Education to improve population health outcomes in chronic
disease, Menzies School of
Health Research, Darwin. Glasgow RE, Davis CL, Funnell MM, Beck A. (2003) Implementing
practical interventions to support chronic Illness Self-management in health care settings: Lessons
learned and recommendations. Joint Commission Journal on Quality and Safety, 29:11, 563574.
Glasgow RE, Orleans T, Wagner E, Curry S, Solberg L. (2001) Does the chronic care model serve
also as a
template for improving prevention? The Millbank Quarterly, 79:4, 579612. Hung DY, Rundall
TG, Tallia AF, Cohen DJ, Halpin HA, Crabtree BF. (2007) Rethinking prevention in primary
care: Applying the Chronic Care Model to address health risk behaviours, The Millbank Quarterly,
85:1, 6991. Huni NM. (2005) Enhancing psychosocial support of children affected by HIV/AIDS: A
special focus on memory work. Memory work: Coping strategies in the face of AIDS, Conference of
aidsfocus.ch, Swiss platform HIV/AIDS and International Cooperation, April 12, 2005, Berne. Jessup
RL. (2007) Interdisciplinary versus multidisciplinary care teams: Do we understand the difference.
Australian Health Review, 31:3, 330331. Johnson A, Paton D. (2007) Health promotion and
health services: Management for change, Oxford University
Press, Melbourne.
22 Supporting Prevention and Chronic Condition Self-Management
Katon WJ, Russo JE, Von Korff M, Lin EHB, Ludman E, Ciechanowski PS. (2008) Long-term effects
on medical
costs of improving depression outcomes in patients with depression and diabetes. Diabetes Care, 31:6,
1155 1159. Locke EA, Latham GP. (1990) A theory of goal setting and task performance, Prentice
Hall, Englewood Cliffs, New
Jersey. Michie S, Miles J, Weinman J. (2003) Patient-centredness in chronic illness: What is it and
does it matter?
Patient Education and Counselling, 51:3, 197206. Miller WR, Rollnick S. (1991) Motivational
interviewing preparing people to change addictive behavior, The Guilford
Press, New York. Muir Gray JA. (1997) Evidence-based healthcare: How to make health policy and
management decisions, Churchill
Livingstone, London. National Health Priority Action Council (NHPAC) (2006) National chronic
disease strategy, Australian
Government Department of Health and Ageing, Canberra. National Health Service (NHS) (2005)
Self care support: A compendium of practical examples across the whole
 system of health and social care, NHS, London. Pender NJ, Murdaugh CL, Parson MA. (2006)
Health promotion in nursing practice, 5th Edition, Pearson/
Prentice Hall, New Jersey. Prochaska J, Di Clemente C. (1983) Stages and processes of self-change
of smoking: Towards an integrated
model of change. Journal of Consulting and Clinical Psychology. 51, 390395. Prochaska JO,
Velicer WF. (1997) The transtheoretical model of health behavior change. American Journal of
Health Promotion, 12, 3848. Royal Australian College of General Practitioners (RACGP) (2006)
Putting prevention into practice: Guidelines for
the implementation of prevention in the general practice setting, 2nd Edition, RACGP, Melbourne.
Solomon P. (2004) Peer support/peer provided services: Underlying processes, benefits, and critical
ingredients. Psychiatric Rehabilitation, 27, 392401. The Diabetes Monitor (2008) [Accessed 21st
November 2008]
http://www.diabetesmonitor.com/dictionary/glossary_nhlbi.htm United States Department of Health
and Human Services, Office of Disease Prevention and Health Promotion
(2000) Healthy people 2010. [Accessed 21st November 2008] http://www.health.gov/healthypeople
Victorian Quality Council (2005) Better quality, better health care: A safety and quality improvement
framework for
Victorian health services, Victorian Government Department of Human Services, Melbourne. Von
Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. (1997) Collaborative management of chronic
illness.
Annals of Internal Medicine, 127, 10971102. Wagner E, Austin B, Von Korff M. (1996a)
Improving outcomes in chronic illness. Managed Care Quarterly, 4,
1225. Wagner E, Austin B, Von Korff M. (1996b) Organising care for patients with chronic
illness. The Millbank
Quarterly. 74, 511542. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi AE.
(2001) Improving chronic illness care:
Translating evidence into action. Health Affairs, 20:6, 6478. World Health Organisation (2002)
Innovative care for chronic diseases. Building blocks for action. Global Report,
WHO, Geneva. World Health Organisation (2005) Preparing a health care workforce for the 21st
century. The challenge of chronic
conditions, WHO, France.
Supporting Prevention and Chronic Condition Self-Management 23

9. Appendix
The Australian Better Health Initiative (ABHI) is a program of the Council of Australian
Governments developed to refocus the health system to promote good health and reduce the burden of
chronic disease across Australia. A key element of the ABHI is education and training of the current
and future Australian primary health care (PHC) workforce to support health service users to better
self-manage their chronic conditions.
In 2007, as part of the ABHI, the Flinders Human Behaviour and Health Research Unit (FHBHRU),
in conjunction with its project partners, received funding from the Commonwealth Department of
Health and Ageing to:
n Develop a chronic condition self-management support curriculum framework for Australian
undergraduate or entry level medical, nursing and allied health professional education; and n
Investigate the training and information options to support chronic condition prevention and self-
management in primary health care.
These projects built upon previous work by FHBHRU in the survey and development of
recommendations for self-management support in undergraduate allied health curricula and an audit
of Medical Schools' curricula assessing chronic condition self-management content. In addition, they
recognise prevention and early risk factor identification as part of the continuum of self-management.
9.1 The Curriculum Framework Project: Key findings from consultative activities
The curriculum framework was developed after extensive auditing and consultation with medical,
nursing and allied health schools, and professional, accreditation and registration bodies, on course
content and curriculum delivery issues involving the teaching of self-management support in the
tertiary education setting in Australia. The Project team was advised by members of the project's
national reference group, which included representatives from:
n The Committee of Deans of Australian Medical Schools; n The Council of Deans of Nursing and
Midwifery; n The Australian Council of Pro-Vice Chancellors and Deans of Health Science; n The
Australian Nursing and Midwifery Council; n Allied Health Professions Australia; n The Consumers
Health Forum; n Representatives with recognised relevant expertise in the application of a variety of
self-management
approaches in clinical and community settings in Australia; and n Representatives from a range of
States and Territories across Australia.
Results showed that whilst self-management support education was considered important by the vast
majority of schools and the knowledge of theoretical elements of self-management support were
usually being taught, very few schools were explicitly teaching or assessing the skills and attitudes
that would ensure a new graduate was competent in providing self-management support in clinical
practice.
24 Supporting Prevention and Chronic Condition Self-Management
9.2 The Primary Health Care Workforce Project: Key findings from consultative
activities
Likewise, the objectives of the PHC workforce project were to identify and assess the gaps in the
training and information options available to practising PHC professionals to assist them to support
their patients to prevent chronic conditions through adoption of healthier lifestyles, early identification
and management of risk factors and/or effective self-management of any existing chronic conditions.
This was done through a needs assessment with the current primary health care workforce and an
audit of current training options available to them.
The Project team was advised by members of the project's national reference group, which included
representatives from:
n Key representatives from professional bodies and clinicians who represent the medical, allied health
and
nursing workforce in Australia; n Recognised experts in self-management; n Training organisation
representatives; n The Consumers Health Forum; n The Chronic Illness Alliance; n The Australian
Chronic Disease Prevention Alliance; n Health Consumers of Rural and Remote Australia Inc.; n
Carers Australia; and n Representatives from a range of States and Territories across Australia.
The Needs Assessment found that:
n There is an overall lack of understanding, competence and practice of self-management support
among
PHC professionals; n Translation of training into practice is a major problem, and more quality
control of training programs is
needed; n The PHC workforce appears not to have the full set of skills needed to support patients'
behaviour change.
More psychosocial skills were also seen as needed; and n A systemic approach is required to
implement self-management training models, facilitated by
organisational support, and accreditation from professional bodies.
The Needs Assessment also found that:
n Training and understanding vary between different professions; n Training opportunities are more
limited in rural and remote areas and in some states; n Specific needs of the Indigenous health
workforce continue to be compounded by social determinants of
health and broader systems issues impacting on Indigenous populations; and n Although a
prescriptive approach to health care tends to dominate practice, the workforce are keen to
develop more skills in behaviour change techniques and to undertake more multidisciplinary training
and training that is translatable to practice.
Supporting Prevention and Chronic Condition Self-Management 25
Consumers and Carers reported that:
n Health professionals need more skills in order to listen and ask the patient their views and
perspectives; n Health professionals need more knowledge of community resources available to
support the patient with
chronic conditions and their carers; n Health professionals need to work more from a position of
identifying patients' strengths and current
capacities than is currently the case; n Health professionals need to be more collaborative with
patients, carers and each other; and n Patients need to be involved more in education and training of
the PHC workforce, from development,
delivery and evaluation, through to accreditation.
The Audit of existing training and resources found that:
n Universities provide the vast majority of training to the PHC workforce; n There is little training
targeting prevention; n Integration of skills/components and translation of knowledge and skills into
practice is uncertain; n Evaluation of training needs improving; n Urban areas have better access to
training; n Training is often expensive; and n Workshops continue to be the main mode of delivery.
26 Supporting Prevention and Chronic Condition Self-Management