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My Shared support plan Name:.......................................................................................................
Date............/........... /...............
or affix label here
D.O.B:............/........... /............... Sex:.............................. UR Number:.....................................................
My healthcare team & planned visits/services for the next 12 months Role/Service
Name & Contact Details
Jan
Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec
Participant in planning process
Has a copy of plan
Aboriginal Health Practitioner
yes
yes
Care Coordinator
yes
yes
GP
yes
yes
Pharmacist
yes
yes
Specialist/ Nurse Specialist
yes
yes
OT/Physio/Dietitian/ Psych/Dental
yes
yes
Other
yes
yes
Care Plan Reviews
yes
yes
Sign off - Patient / Client What other plans are in place?
1
No. Per Year
Other considerations
ŠFHBHRU Flinders University 2014
Signature................................................................................. Date ................../................./.....................
Initial
About This Assessment The purpose of this flipchart is to talk with you about how to manage your health better. We will have a talk about: • How your mob and others can support your health • What keeps you strong • The things that are stopping you from living a healthy life • The steps you want to take to live a healthier life
Starting Point: The Health Yarn Do you worry about your health problems? Have you tried to make any changes to improve your health? Is there anything that makes it hard for you to make changes? Do you think you would like to make changes? Note: We recommend that clients have a Health Assessment (MBS 715) then the Flinders’ Self-Management Care Plan,which with a disease specific care plan forms the basis for a for a GP Management Plan (GPMP) (MBS item no 721). The GPMP then leads to a Coordinated Team Care Arrangement (MBS item no 723).
2 ©FHBHRU Flinders University 2014
Managing my Health Better The Steps to developing My Health Story My Journey Problem and Goals
Important people in my life /My Mob
My Strengths, Needs and Worries Partners in Health Cue and Response
I am strong because
Reviewing My Progress Symptom Action Plan Monitoring Diary
3 ŠFHBHRU Flinders University 2014
My SelfManagement Care Plan
Important people in my life /my mob Write or draw your own
Kinship / Culture Obligations / Family links
My Trust Circle
Put own photo’s here
4 ©FHBHRU Flinders University 2014
ORDER I am strong because...
Notes
pp Mentors pp Land
pp Support
pp Spiritual belief
Emotional
Cultural
pp Family
Bio -Medical
pp Art and craft
pp Go to country pp Dance
pp Health centre
pp Medication pp Know about illness, tests and results
Measures
pp Work
Social
Results
Physical pp Hunting
pp Exercise
pp Teach kids
5
pp Good tucker ŠFHBHRU Flinders University 2014
pp Music
My Strengths, Needs and Worries Partners in Health
1
Partners in Health - Cue and Response
Worries (Cue and Response)
I know about my health problem
Notes
Knowledge of my health problems • Tell me more about your health problem (e.g. what caused it, effects, symptoms)
• What do you think could happen to you with this problem? • Does your family/carer understand your health problem?
my score
my health worker’s score
2
agreed score
Knowledge of treatment and medications medicines and treatment
• Have you had any problem from your medicines? 30 P redniso lone 25mg Take T d W h foo MISS E O tablets daily wit RICA AHCHEE 11 J A N 2010
• What could happen if you stopped the medicines? • Does your family/carer understand your medicines?
3
my score
my health worker’s score
I take my medicines every day
Medication and treatments
agreed score
• Is there anything that makes it hard for you to take medicines? • Do you use bush medicines or any other tablets to feel better?
my score
my health worker’s score Please note: Questions in bold should be asked
agreed score ©FHBHRU Flinders University 2014
6
My Strengths, Needs and Worries Partners in Health
4
My doctor/health worker and I listen and talk well together
Partners in Health - Cue and Response
Worries (Cue and Response)
Notes
Involvement with my doctor/health worker • Do you feel your doctor/health worker is listening to you? • Do you feel included in making decisions about your health?
my score
5
my health worker’s score
agreed score
Accessing services respect my culture
• How does the health service show that they respect/don’t respect your culture? • Is there anything else that stops you from using these health services?
6
my score
my health worker’s score
I attend all my appointments
Attending appointments
agreed score
• What makes it hard for you to attend your appointments? (e.g. transport problems, costs, physical disability)
7
my score ©FHBHRU Flinders University 2014
my health worker’s score Please note: Questions in bold should be asked
agreed score
ORDE
My Strengths, Needs and Worries Partners in Health
7
I know when I am getting sick by watching things such as: blood sugar, weight, shortness of breath, pain, sleep problems, mood changes my score
8
Partners in Health - Cue and Response
Worries (Cue and Response)
Notes
Watch my symptoms • What are the warning signs that you need to check for your health problem? (e.g. pain, shortness of breath, blood sugar, peak flow, weight) Blood Sugar Levels 10 9 8
High
7
Low
6 5
• Do you know why checking your health signs helps?
4 3 2 1 0
1
Months
2
3
4
5
6
7
8
9
11
10
12
• How often do you check these signs and symptoms? • What makes it hard for you to do this?
my health worker’s score
agreed score
Knowing what to do when feeling sick when I feel I am getting sicker
• What do you do when you’re getting sicker? • Do you have a written action plan? • How does your family support you when you get sicker?
my score
9
I am able to move around easily and do the things I like
my health worker’s score
agreed score
Moving around easily / Physical impact • Has anything become a bit harder to do? (e.g. showering, walking, household jobs, work) (Describe) • Is there anything you can’t do now because of your health problem? • How much does your health problem stop you from going out of your home?
my score
my health worker’s score Please note: Questions in bold should be asked
agreed score ©FHBHRU Flinders University 2014
8
My Strengths, Needs and Worries Partners in Health
10
I cope with how my health affects my feelings
Partners in Health - Cue and Response
Worries (Cue and Response)
Notes
Coping with emotional impact • Do you ever feel as though things are too much for you? (e.g. feeling tired, can’t be bothered) (Describe)
• How do you feel about your life at the moment? • Do your problems ever make you feel down?
my score
my health worker’s score
family/friends
Visiting family and friends (social impact)
11
agreed score
• How does your health problems affect you maintaining a social life and visiting family and friends (too tired, transport etc) • What aspects of your social life would you like to change?
12
my score
my health worker’s score
Overall I lead a healthy life
Healthy lifestyle
agreed score
• What do you do that could make you sicker? (for example smoking, alcohol, diet, inactivity, stress, drugs, gambling) • We have talked about many things, is there anything else you want to add?
9
my score ©FHBHRU Flinders University 2014
my health worker’s score Please note: Questions in bold should be asked
agreed score
My Journey Open-ended Questions
Problem and Goal Notes
What do you see as your main worry?
What happens because of this worry? How does this worry change the way you live? Are there things you do more or less of? (eat, exercise, go out, smoke, sit?) Are there things you don’t do at all? How does your worry make you feel? (angry, sad, lonely, worried, cross)
My worry about this problem
Specific actions: What would you like to achieve in the next 6-9 months?: Timelines: How long and how often: Conditions: (Ask a friend to come along)
My Goal (Should be SMART - Specific, Measureable, Action-based, Realistic, Timely) My progress towards achieving this goal
10 ŠFHBHRU Flinders University 2014
My Self-Management Care Plan Important People / My Mob
I Am Strong Because
My Main Worry score
My worry about this problem
score
My progress towards achieving this goal
My Goal Identified issues
(including self-management) From C&R and goal
11 ŠFHBHRU Flinders University 2014
What I want to achieve Steps to get there
Who will help? Who will do it?
Date to be reviewed
Progress
(e.g. no progress, some progress, completed)
Score
My Self-Management Care Plan Identified issues
(including self-management) From C&R and goal
What I want to achieve Steps to get there
Who will help? Who will do it?
Date to be reviewed
Progress
Score
(e.g. no progress, some progress, completed)
Doctor / Heath Professional
Sign off - Patient / Client
/
/
/
/
Signature................................................................................. Date .................. ................. ..................... Signature................................................................................. Date .................. ................. .....................
MBS Item 721
MBS Item 723
I have a copy of My Health Story
ŠFHBHRU Flinders University 2014
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My Care Plan & Health summary Title:
First Name:
Surname:
Preferred Name: Date of Birth:
Age:
Gender:
pp Male
pp Female
Address :
Post code:
Phone Number(s):
HRN
pp Aboriginal pp Torres Strait Islander
Pension No:
Type:
DVA No:
Medicare No:
P
Type:
Gold Card
Expiry Date:
Centrelink Concession No: Doctor: Carer:
Phone:
Address:
Next of Kin / the key people I want included in my care plan: Name: Phone Number:
13
Relationship to you: Address:
Post code:
Diagnosis
4.
1.
5.
2.
6.
3.
7.
Allergies (or Nil Known)
2.
4.
1.
3.
5.
ŠFHBHRU Flinders University 2014
White Card
My Care Plan & Health summary Hospital Admissions/Accident & Emergency Department Visits
MBS Item No
Admitted
Discharged
Description
Diagnosis or Problem
How often
715
Aboriginal and Torres Strait Islander people Health Assessment
9 months
721
Prepare GP Management Plan
12 months
723
Coordinated Team Care Arrangement
12 months
729
Contribution to a Multidisciplinary Care Plan or a review of a Multidisciplinary Care Plan prepared by another provider
3 months
731
Contribution to review, prepared by residential aged care facility
3 months
732
Review of a GP Management plan or Coordinate a Review of a Team Care Arrangement
3 months
10997
Services for a person with a GPMP, TCA or Multidisciplinary Care Plan x 5 per year
2501 -2558
Practice Incentive items
900
Home medicine review
Date
Where
14
Please note this list is not comprehensive. Refer to www.health.gov.au/mbsonline ŠFHBHRU Flinders University 2014
My Care Plan & Health summary Medication Record Medication Generic or Trade Name
Strength
What Medication is For
Frequency M
L
D
Prescribing Doctor N
Date Commenced
Date Ceased
Disease Specific Care Plan/s MBS Item No
Type
Date
MBS Item No
Type
Date
Diabetes
yes
yes
Renal
yes
yes
Arthritis
yes
yes
Asthma
yes
yes
Other
yes
yes
yes
yes
yes
yes
yes
yes
15 ŠFHBHRU Flinders University 2014
My symptom action Plan What is it?
Patient Diary Patient’s name: ............................................................................... DOB.............................................
The Symptom Action Plan and Diary are designed to help you and your doctor manage your illness. Regular recording of your symptoms (e.g. breathlessness) and measures (e.g. peak flows) in the Diary helps identify the signs that indicate if your illness is getting worse or better.
Doctor’s name:.....................................................................................................................................
The Symptom Action Plan identifies what action you should take when these signs appear. These changes in your symptoms can then be used to change your Symptom Action Plan.
pp Social – home environment (e.g. falls)
Who completes the forms?
Number of admissions in the past 2 years.......................................................................................... Reasons for admission:........................................................................................................................
pp Medication – not taking medication as prescribed (e.g. cost, forgetfulness, side effects) Mix up (e.g. confusion, collapse) pp Other.............................................................................................................................................
You and your doctor should complete the Diary together. The Symptom Action Plan is to be completed by your doctor.
Date completed: ...................................................Date to be reviewed:............................................
How do I use it?
I measure and manage my symptoms in the following way:
Some patients carry the Symptom Action Plan with them (e.g. in their wallet or handbag) so that they can check it, as the need arises.
..............................................................................................................................................................
If in doubt?
then I.....................................................................................................................................................
The Symptom Action Plan and Diary are tools to help you manage your illness. If for any reason you are in doubt about what to do then contact your doctor for advice. If your doctor is not available then contact the emergency department of your local hospital.
When/If.................................................................................................................................................
When/If.................................................................................................................................................
then I..................................................................................................................................................... When/If................................................................................................................................................. then I..................................................................................................................................................... If unsure contact your doctor on ............................................................(phone) or the Emergency department of your local hospital on ................................................................(phone)
©FHBHRU Flinders University 2014
16
My Monitoring diary Date
Time
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Symptom or measure
Patient Monitoring Diary Measurement
Mild/moderate/ severe level or reading
Comments Duration
(e.g. What were you doing before those symptoms appeared? How did you respond? Did your symptoms/measures become worse, improve or stay the same?)
Flinders Closing the Gap Program™ – My Health Story Online ISBN: 1 920966 41 2 Copyright Statement © Flinders Human Behaviour and Health Research Unit, Flinders University 2014 This Manual is copyright. Apart from any use permitted under the Copyright Act 1968 (Cth), no part of this Manual may be reproduced, published, communicated to the public or adapted without the prior written authorisation of Flinders Human Behaviour and Health Research Unit. This Manual was funded and developed by the Commonwealth Department of Health and Ageing through the ‘Helping Indigenous Australians Self-Manage their Chronic Disease’ initiative. Requests and enquiries concerning authorised use of this Manual may be addressed to the Flinders Human Behaviour and Health Research Unit, Flinders University, GPO Box 2100, Adelaide SA 5001 or emailed to fctgp@flinders.edu.au.
18 ©FHBHRU Flinders University 2014
Acknowledgements This Resource (My Health Story) was produced by the Flinders University of South Australia with funding from the Commonwealth Department of Health & Ageing under the Closing the Gap in Indigenous Health Outcomes Initiative. Flinders Human Behaviour & Health Research Unit has developed the Flinders Closing the Gap Program™ in conjunction with a nationwide consultative team including Aboriginal and Torres Strait Islander people, health professionals and health organisations. We acknowledge the contribution of “My Mob” and “Strengths” tools by Professor Tricia Nagel of the Menzies Aboriginal and Islander Mental Health Initiative and the NT Department of Health. The success of any project depends largely on the support and assistance of many others. We would sincerely like to thank those people and groups who have been instrumental to the successful development of this program. Professor Malcolm Battersby Director, Flinders Human Behaviour and Health Research Unit, Department of Psychiatry, Flinders University
My Health Practitioner contact details