Care for Chronic Illness Research

Introduction While treating the chronically ill, a major challenge is developing a plan of care that addresses the specific needs of a patient and a caregiver.Care for Chronic Illness Research You need to be in close touch with patients and their support group, family and peers, to come up with an ideal plan. In this course project, you are going to develop a plan of care for a chronic illness group of your choice using the Healthy People 2020 Topics. While executing the tasks of this project, remember that while you need to give a general overview of the biomedical considerations of the case, the focus should always be on the psycho social elements. Your perspective in this care plan should be the patient’s goals rather than those of the medical team. Each week, you will complete a part of this project. You will submit a final completed project in Week 5. Be sure to take the time to carefully complete each of the weekly assignments and then put it all together in Week 5. Ensure that you save a copy of this course project after you have submitted it at the end of this course. You are expected to resubmit this project along with the other course projects at the end of the Registered Nurse (RN) to Bachelor of Science in Nursing (BSN) program. File Transfer Protocol (FTP) details will be provided in the Capstone course. Identifying a Group Identify an area of chronic illness of specific interest to you and that is represented as a Healthy People 2020 topic (healthy people.gov). Explain your choice and your interest in it. Prepare a questionnaire utilizing your knowledge of health and illness, with the aim of acquiring all information you need from patients to prepare a plan of care for the specific illness group. Submit your information in a 4- to 5-page Microsoft Word document. Care for Chronic Illness Research In addition to your questionnaire, be sure to include the following details in your paper. Chronic Illness of interest Morbidity and comorbidity of the disease Impact of the chronic illness and patient morbidity and the affect to overall health of nation Healthy People 2020 goals and objectives for specific illness group Support your responses with examples. On a separate references page, cite all sources using APA format.

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Use this APA Citation Helper as a convenient reference for properly citing resources. This handout will provide you the details of formatting your essay using APA style. You may create your essay in this APA-formatted template. Week 2 Project The Impact of Chronic Illness Identify one person from the illness group you chose in Week 1. The person should not be a patient at the facility in which you work. You can use friends, family members, or coworkers. Do not use the person’s name in the paper but only initials. Administer the questionnaire you created in Week 1 to that person. Compile the data and analyze the responses to better illustrate where this person, his or her family, and friends are in relation to accepting the diagnosis in relation to the standard health or illness definitions. The analysis should also include coping skills, treatment, and support aspects of the illness. Identify how this will direct care plan development for the chosen illness group.

What is a chronic condition?
There are many definitions of “chronic condition,” some more expansive than others. We characterize it as any condition that requires ongoing adjustments by the affected person and interactions with the health care system.

The prevalence is rising
2005 data showed that more than 133 million people, or almost half of all Americans, live with a chronic condition. 1 That number is projected to increase by more than one percent per year by 2030, resulting in an estimated population of 171 million requiring chronic disease management.

Management of multiple chronic conditions requires a transformation in health care
Almost half of all people with chronic illness have multiple conditions. As a result, many managed care and integrated delivery systems have taken a great interest in correcting the many deficiencies in current management of diseases such as diabetes, heart disease, depression, asthma and others. 2, 3, 4

Those deficiencies include:

  • Rushed practitioners not following established practice guidelines
  • Lack of care coordination and planned care  Care for Chronic Illness Research
  • Lack of active follow-up to ensure the best outcomes
  • Patients inadequately trained to manage their illnesses

Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive – responding mainly when a person is sick – to one that is proactive and focused on keeping a person as healthy as possible. 5, 6, 7 To speed the transition, in 1998, Improving Chronic Illness Care created the Chronic Care Model, which summarizes the basic elements for improving care in health systems at the community, organization, practice and patient levels. Evidence on the effectiveness of the Chronic Care Model was summarized in 2009. 16

Primary care practices play an important role in front line management of chronic disease
The MacColl Center for Health Care Innovation built an online resource that gives practices access to the same tools and approaches used by 31 of the most effective, team-based primary care practices in the United States. The Primary Care Team Guide 17 presents practical advice, case studies, and numerous resources that help practices become high-functioning teams and markedly improve care. Assessments identify where practices need to focus. Ensuring access to high quality, team-based care is one of the most effective interventions for improving the health of people with chronic illness.

Chronic diseases are affecting increasing numbers of patients. As they are among the most common, costly, and complex medical conditions, chronic illnesses place a heavy burden on patients, their families, and society, and present treatment challenges for physicians. Practicing safe medical care can help improve overall outcomes for those suffering from chronic diseases and reduce physicians’ exposure to medico-legal risks.

Avoiding or delaying costly complications in the prevention and management of chronic diseases requires a broad skill set, a proactive approach to care delivery, and a patient-centered approach.1

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chronic disease management strategies

Focusing on health promotion, disease prevention, and early detection is an optimal strategy for successful chronic disease management. Physicians can help patients understand and take responsibility for some of the underlying clinical risk factors seen in a range of chronic diseases. The Canadian Medical Association’s Policy Statement, The Role of Physicians in Prevention and Health Promotion, states that physicians should incorporate all levels of health promotion and disease prevention into their practices.2Care for Chronic Illness Research

A patient-centered approach is valuable when caring for patients with chronic diseases. Physicians should advise patients of the prognosis of their illness, how the illness can impact their lifestyle, and suggest solutions to cope with changes at work and at home. Patient adherence to investigation and treatment plans can sometimes be difficult to achieve. Physicians should take steps to educate patients about their disease, encourage proper self-care, and reinforce key messages about the health condition, as appropriate. When reasonable alternatives are available, physicians should avoid making assumptions about what treatments patients will select but rather discuss these options with patients. Patient consent remains paramount during this entire process. Doctors should also recognize when patients (e.g. some new immigrants or elderly persons) may need more help to manage their health.

Because harm can arise from poorly controlled health conditions, and because patients may be suffering from multiple diseases simultaneously, careful attention may be required when caring for patients suffering from chronic diseases. For example, it may be necessary to carefully watch for interactions among medical conditions and interactions among treatments including medications.

Cultural influences can also impact patients’ self-care and chronic disease management. For example, a patient’s or family’s attitudes towards food, weight, and exercise can impede or encourage the necessary changes in an individual patient’s approach to self-care. Physicians will need to help patients feel empowered to take responsibility for their health.

Chronic disease sufferers also need to know when they should access healthcare services and whom to contact. Physicians and patients should create an action plan including the symptoms that merit a doctor’s visit, follow-up protocols, a list of required tests, how to manage medications, and information patients should track to assist the healthcare providers in monitoring their condition (e.g. blood sugar levels, weight, blood pressure).Care for Chronic Illness Research

Care coordination

As physicians work collaboratively with other healthcare providers, it is important to coordinate care for patients with chronic diseases. Comprehensive assessment and goal-based care planning are significant components of the treatment plan. Patient care coordination is enhanced by sharing information appropriately, collaborating with other healthcare professionals, as well as preparing effective referrals and consultations. Different providers may vary in their therapeutic goals and this speaks to the need for good communications among st providers.3

Physicians should also have measures in place to ensure all members of their practice know their roles and responsibilities. These can include assisting with care coordination, clear documentation, proper information transfer, efficient test results management, and comprehensive follow-up procedures.

Mitigating the risks

Caring for patients who suffer from chronic diseases can be challenging. However, physicians can take steps to mitigate the medico-legal risks associated with this care:

  • Emphasize health promotion and disease prevention activities with patients. Physicians should consider available resources and tools to help educate patients so they can make informed decisions and be engaged in their own care, for example telling patients about support groups for those with the same condition.
  • Be familiar with any relevant clinical practice guidelines provided by appropriate specialty societies.
  • Work with patients and other healthcare providers to develop comprehensive, patient-centered care plans. Patients should be involved in their care and take part in treatment decisions whenever possible.Care for Chronic Illness Research
  • Consider the role of electronic medical records and electronic communication. As technology advances, when feasible, physicians may opt to monitor chronic disease patients remotely and have patients involved in managing their health.
  • Help patients access care when they need it. Practice management procedures and booking systems should support patients to see their doctor or another member of the care team, when needed. Consider including a process to help with timely follow-up and missed appointments. Written follow-up and discharge instructions are helpful.
  • Communicate effectively and consistently with patients and other healthcare providers, where appropriate.
  • Document patient discussions, treatment decisions, and agreed upon responsibilities.
  • Manage test results and coordinate care cautiously. In a collaborative care setting, roles and responsibilities of the various health care providers should be clarified. The most responsible physician generally has overall accountability for directing and coordinating the care and management of an individual patient at a specific point in time.
  • Evaluate patient outcomes regularly, with the involvement of the patient.Care for Chronic Illness Research