My goals, my guide: An innovative self management model, The Guided Care Model, embedded in a Chronic Disease Management service

Mrs Nicole Mcfarlane1, Ms  Alison Beauchamp2, Mr  Nicholas Hannah1

1Latrobe Community Health Service, Morwell, Australia, 2Monash University Department of Rural Health, Moe, Australia


My goals, my guide

This innovative model categorises clients according to ability to self-manage their condition. The categories provide a structured, multidisciplinary approach to care, within which clients participate in goal-setting. This project aimed to embed Guided Care into CDM service delivery and evaluate outcomes.

Study design: quasi-experimental. Setting: rural community health service. Participants: clients with diabetes and respiratory conditions enrolled in GCM. Process: care plans are completed for new clients to identify health goals. Baseline assessment includes scales from the Health Literacy Questionnaire (HLQ) and the health education impact Questionnaire (heiQ). Clients are categorised according to level of support needed to reach their goals; this determines multidisciplinary team input and follow-up frequency. Outcomes: changes in the HLQ/heiQ and goal attainment at 6-months. Clinicians were interviewed to identify factors influencing uptake of GCM.

Baseline data from n=162 clients shows 20% required a high level, and 57% a moderate level of self-management support. At 6-month review (n=50) significant increases in all HLQ/heiQ scales were seen. 68% reported achieving their goals. Clinicians viewed GCM as a holistic, client-centred approach. Challenges and enablers to its implementation were also identified.

Significance for Allied Health:
The GCM supports clients to build self-management capacity and offers AHPs a structured approach to planning intervention that meets the client’s need. AHPs are better able to support person centred management by actively partnering with the client to understand where they are in their chronic disease journey.


Nicole is the clinical lead of the chronic disease management team at Latrobe Community Health Service, working as both a senior Podiatrist and a credentialed diabetes educator. Nicole’s passion is high risk foot management and the challenges associated which led to her participating in the guided care project which looks at chronic disease self management ability despite medical complexity.