Table 1 Summary of intervention schedule and components
Flinders Program componenta | Planning and action for: | |
|---|---|---|
Condition management | CVD risk management | |
Assessment 1 (week 1) Flinders tools: Partners in Health (PIH), Cue & Response | Patient and trial nurse use Flinders tools to identify all risk factors, chronic condition and psychosocial issues and decide which require action. | Using additional tools and resources:  • NVDPA Guidelines for the Management of Absolute Cardiovascular Disease Risk  • Flinders Program health behaviour assessment tools  • Trial nurse database of resources,  • Nurse and patient review CVD risk and lifestyle and agree plan for behaviour change among:   − Smoking cessation – details below   − Diet and exercise – details below   − Alcohol use – SA Alcohol and Drug Information Service (ADIS) resources   − Lipid-lowering / BP medication via GP |
Assessment 2 (week 2) Flinders tools: Problems & Goals (P&G), Flinders Care Plan | ||
Flinders Care Plan for following 6–12 months shared by trial nurse, patient, psychiatrist, mental health care coordinator and general practitioner (GP). | ||
Follow-up (week 1–4) | At flexible negotiated follow-up and review contacts (6 in total), the trial nurse: • Monitors outcomes of the care plan using PIH and P&G scores • Assists the patient to achieve goals using motivational and problem-solving approaches and informational and community-based resources • Uses the structured framework of the Flinders Program to coordinate care e.g.,:   − as needed, assists access to identified disease specific services e.g. self- management education, home medication review, GP Management Plan and Team Care Arrangements, Chronic Disease Dental Scheme, as per care plan   − as needed, assists access to services and coordinates communication between patient and services, social work, Occupational Therapist assessment, Patient Assistance Transport Scheme, financial counselling, local activity groups/courses, Disability Employment Services, Housing, other as per care plan • Reviews and updates Flinders Care Plan as required. | |
Follow-up (week 6) | ||
Follow-up (week 8) | ||
Follow-up (week 12) | ||
Follow-up (week 16) | ||
Follow-up (week 20) | ||