The prevalence of chronic conditions is increasing in Australia with more than half of the population aged 65-84 years having five or more long term conditions, which now contributes to 80% of disease burden in Australia [1-3]. It is imperative that successful models of care are implemented to manage the growing burden. There is a growing consensus that clients have a more active role to play in defining and reforming healthcare, particularly in chronic disease management, where clients monitor and manage the majority of their own care, related to their illness, day-to-day [4-6]. Benefits of self-management support programs have been provided and are recommended by the Australian Institute for Primary Care [1,7-9].

In Australia, people with chronic or terminal conditions present for six months or longer are eligible for a General Practitioner (GP) management plan. The management plan provide financial rebates for GPs to manage chronic or terminal medical conditions by preparing, coordinating, reviewing or contributing to plans for ongoing care. The rebates for GPs recognise the increased time required to structure and co-ordinate the often complex care required for these clients [10].

Clients with chronic conditions often require multiple service providers in addition to their GP care. Self-management support (SMS) programs are delivered by health care staff trained in delivering SMS. There are many models of self-management strategies currently in use in Australia including Stanford, Flinders, motivational interviewing, and health coaching [11]. Key principles of SMS includes; shared decision making, which encompasses formulating health goals, using planned evidence based care, improving support and access to resources to assist in self- management and systematic monitoring of the patients health status at agreed intervals [12].

Previous research in SMS in the area under study had been limited to staff implementation of SMS training [13,14]. The findings from these studies highlighted difficulty in implementation of SMS related to staff’s perception that current service delivery models did not accommodate SMS and the difficulty in changing clinician practice from traditional information provision models to shared decision making with clients [13-16].

A new model of primary health care in rural Victoria, Australia, undertook provision of a chronic disease worker (CDW) with a component of the role to accept referrals from GP’s for clients with chronic conditions. The CDW utilised the GP care plan to implement the required care and coordinate referral to various providers, while at the same time build self-management skills with each client. The CDW had previously undertaken training in SMS for chronic disease. This pilot project aimed to explore the difference between clients receiving care under the usual General Practice care plan model versus that receiving self-management support from a CDW.

The area of the study was three small townships with a total combined population of 9,486 people, located in one shire and serviced by one community health and wellbeing program as a consortium. The shire has a known ageing population with high rates of chronic disease [17-19].

The chronic disease worker identified all clients from the local community health service receiving SMS. The researcher provided a plain language statement describing the study, a survey and a reply paid envelope to all clients receiving SMS, which was mailed out by the administrative staff, two months post visit. The CDW was blinded to the survey to prevent change in practice which may have biased results.

Practice nurses at the medical clinics in the three townships agreed to identify and mail out a plain language statement describing the study, a survey and a reply paid envelope to clients with a GP care plan for chronic conditions. The practice nurses were not blinded to the survey in order to gain compliance with recruiting for the research study. The surveys took approximately 10 minutes to complete and were voluntary. All surveys were returned by reply paid post to the researcher.

All clients (over the age of 18) allocated a GP care plan at consenting medical clinics were invited to participate in this study. This was estimated to be approximately 27 clients. This was the usual care group (GP). In the SMS group an estimate of approximately 36 people were expected to be eligible to participate.

Clients were surveyed using the Patient Assessment of Care for Chronic Conditions (PACIC) survey. The PACIC is a 20 item survey which asks clients opinions about their contribution to their care and treatment, the provision of information, collaborative goal setting, person-centred care planning and referral networks. The PACIC is a brief, validated patient self-report instrument to assess the extent to which clients with chronic illness receive care that aligns with the chronic care model-measuring care that is patient-centred, proactive, planned and includes collaborative goal setting; problem-solving and follow-up support [17].

The PACIC tool consists of five scales and an overall summary score, each having good internal consistency. The PACIC is only slightly correlated with age and gender, and unrelated to education. It is only slightly correlated (r=0.13) with the number of chronic conditions. The PACIC demonstrates moderate test-retest reliability (r=0.58 during the course of 3 months) and is correlated moderately, (r=0.32- 0.60, median=0.50, P<0.001) to measures of primary care and patient activation [17].

The PACIC is a practical, client-level assessment of the chronic care model implementation. It is suggested as the preferred tool for evaluating the chronic care model, and demonstrates significant positive correlation with improved client outcomes such as medication adherence, improved rates of exercise, quality of life, reduced hospital admission and self-rating of overall health [18,19].

The proposed SMS intervention supports and enhances the goals set by clients as part of their GP care plan. The aim of the SMS intervention is to provide a healthcare environment that delivers information in a way that supports; patient- centred care, health literacy, evidence based practice, timely referrals and healthcare recommendations that are appropriate to the clients health conditions. Clients receive an initial assessment including six areas for current best practice management. The assessment is focused on relevancy of needs, in terms of capacity, including financial, physical and cognitive needs. Clients self-rate how they are managing in each of these areas. The six areas addressed are;

1. Manage medications effectively

2. Engage in specific treatment activities

3. Monitor and act on symptoms

4. Attend services and appointments

5. Manage triggers and risk factors

6. Manage healthy lifestyle factors

Current health behaviours are assessed using the stages of change model and goals are set by the client and documented in a personal self-management plan. Goals are reviewed at subsequent visits with the CDW. When the client feels that they are managing in these areas and can continue working on their health care goals themselves they are discharged from the self-management program.