Flinders program

The Flinders Programme is an evidence-based approach that provides a structured, holistic approach to partnering and planning care with patients/clients that is person/family-centred and supports effective behaviour change.

What is the Flinders program?

The Flinders Program provides a generic set of tools and processes that enable clinicians and clients to undertake a holistic, structured assessment of self-management behaviours, to collaboratively identify key problems, issues and goals the person wants to focus on and a summary care plan that captures the actions and anticipated issues for the next 12 months. 

The aim of the programme is to provide a consistent, reproducible approach to assessing the key components of self-management that:

  • improves the partnership between the client and health professional(s)
  • collaboratively identifies problems and therefore more successfully targets interventions
  • is a motivational process for the client and leads to sustained behaviour change
  • facilitates communication and trans-disciplinary team care
  • allows measurement over time and tracks change
  • Has a predictive ability. For example, improvements in self-management behaviour as measured by the PIH scale, relate to improved health outcomes.

Developed in Australia at Flinders University, this programme is now used in multiple countries including parts of New Zealand.

Three key steps

  1. Assessment of self-management capacity & barriers with Partner’s In Health Scale (see appendices) and Cue & Response Interview©
  2. Identify the main problem from the client’s perspective using the Problems and Goals Assessment and formulate a key goal the client would like to work towards over the following 6- 9 months
  3. Formulate a care plan with:
    1. identification of mutually agreed issues and goals
    2. key action steps, roles and responsibilities to address issues and goals for the next 12 months
    3. monitoring and reviewing.

The Flinders tools

To conduct a comprehensive assessment and care plan, a set of tools have been developed.

The tools to assess self-management capacity are:

  • Partners in Health Scale
  • Cue and Response Interview
  • Problem and Goals Statement

The care planning tool is the:

  • Chronic Condition Management Care Plan

Use of these tools enables the health professional and the client to identify issues, form an individualised care plan and provide a system for monitoring and reviewing progress.


FlinCare™  is a web-based system, which contains the components of the Flinders Program™ and provides access for both the patient and health professional.

FlinCare software is now available for trial and has the following features:

  • Individual patient storage
  • Partners in Health Scale
  • Cue and Response Interview
  • Problems and Goal Setting Function
  • Care Plan Creation
  • Shared Calendar for Care Plan Tracking
  • Messaging Function

Visit the FlinCare™ website for more details. 

Closing the Gap Program

This program is an adaptation of the Flinders CCM Program and has been developed to improve the health outcomes of Aboriginal and Torres Strait Islander people living with, or at risk of developing chronic conditions, by empowering them to manage their health and well-being. Read more about the Closing the Gap Program

Learn more

The Flinders Program website The Flinders Human Behaviour & Health Research Unit, (FHBHRU) Flinders University
The Flinders program information paper Flinders University
Training options FHBHRU Flinders University


  1. Lawn S et al. Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital Avoidance Risk Program using the Flinders Chronic Condition Management Program. Aust Health Rev. (2017) Abstract
  2. Battersby M, Harris M, Smith D, Reed R, Woodman R. A pragmatic randomized controlled trial of the Flinders Program of chronic condition management in community health care services. Patient Educ Couns. (2015) Abstract
  3. Battersby MW, Beattie J, Pols RG, Smith DP, Condon J, Blunden S. A randomised controlled trial of the Flinders Program™ of chronic condition management in Vietnam veterans with comorbid alcohol misuse, and psychiatric and medical conditions. Aust N Z J Psychiatry. 2013 May;47(5):451-62. Abstract
  4. Lawn, S., Battersby, M., Harvey, P., Pols, R. & Auckland, A. (2009) A behavioural therapy approach to self-managing chronic conditions: The Flinders Program. Diabetes Voice, 54, 30-32.
  5. Battersby, M., Hoffmann, S., Cadilhac, D., Osborne, R., Lalor, E., & Lindley, R. (2009). “Getting your life back on track after stroke” A Phase 2 Multi Centred, Single Blind, Randomised Controlled Trail (RCT) of the Stroke Self-Management Program (SSMP) Vs the Stanford Chronic Condition Self Management Program (CCSMP) or Standard Care in Stroke Survivors. International Journal of Stroke, 4(2) 137-44. (View abstract)
  6. Battersby, M. W., J. Ah Kit, C. Prideaux, P. W. Harvey, J. P. Collins and P. D. Mills (2008). “Implementing the Flinders Model of self-management support with Aboriginal people who have diabetes:  findings from a pilot study.” Australian Journal of Primary Health 14(1): 66-74. (View abstract)
  7. Battersby, M., P. Harvey, P. D. Mills, E. Kalucy, R. G. Pols, P. A. Frith, P. McDonald, A. Esterman, G. Tsourtos, R. Donato, R. Pearce and C. McGowan (2007). “SA HealthPlus: a controlled trial of a statewide application of a generic model of chronic illness care.” Milbank Quarterly 85(1): 37-67. (View abstract)
  8. Roy, D. E., Mahony, F., Horsburgh, M. and Bycroft, J. (2011), Partnering in primary care in New Zealand: clients’ and nurses’ experience of the Flinders Program™ in the management of long-term conditions. Journal of Nursing and Healthcare of Chronic Illness, 3: 140–149. (View abstract) 

For more references, visit the publications section of the Flinders program website.