Models of Care and Self Management

Question 1

What is a
model of
care?

Answer 1

Describes concepts or aspects of health care and
how they interrelate with each other
▪ It is a framework that articulates how health care
services are delivered and managed to meet the
needs of people with chronic conditions.

Question 2

Levels of Health Care for People

with Chronic Disease

Answer 2

Tier 4
Complex
Tier 3
High Risk
Tier 2
Stable
Tier 1
Population

Question 3

The 6 key elements of the CCM (chronic care model )are

Answer 3

1. Delivery System Design (DSD)
2. Self Management Support (SMS)
3. Decision Support (DS)
4. Clinical Information Systems (CIS)
5. Community Resources (CR)
6. Health Care Organisation (HCO)

Question 4

Key Principles - Chronic Care Model

Answer 4

empowering people to manage their
conditions, providing effective and responsible self-management support,
and organising community resources to meet the needs of people with longterm conditions.

Question 5

Chronic Care Model aim

Answer 5

is to develop well-informed patients and a

healthcare system that is prepared for them

Question 6

Chronic Care Model inclusion

Answer 6

▪ Cultural competency
▪ Patient safety
▪ Care co-ordination
▪ Case management
▪ Community policy

Question 7

Innovative Care Model for Chronic

Conditions

Answer 7

-Macro (policy)
-Meso (health care organisations and
community)
-Micro (individual and family) approach

Question 8

National strategic
framework for
chronic conditions
(2016)

Answer 8

directed at
decision and policy makers. It is a
useful resource for governments,
non government sector, stakeholder
organisations, local health service
providers, private providers, industry
and communities that provide care
and education for people with
chronic conditions, their carers and
families.

Question 9

Chronic disease and Indigenous Australians

Answer 9

Chronic conditions are the leading cause of the health gap between Indigenous Australians
and Non-Indigenous Australians. The burden of chronic disease is greater in Aboriginal and
Torres Strait Island Australians and they tend to develop disease earlier.

Question 10

The National Strategic Framework for Chronic Conditions (2016) Objective 3 is to

Answer 10

Target

Priority Populations

Question 11

the strategy proposes to do this through (nsf obj 3)

Answer 11

✓ providing a culturally competent workforce
✓ being flexible to meet local needs and minimise the need for travel to receive health care
✓ be inclusive of Aboriginal and Torres Strait Islander people as part of the health workforce wherever
possible

Question 12

Model of care for Aboriginal People

Answer 12

1. Identification
2. Trust
3. Screening and assessment
4. Clinical indicators
5. Treatment
6. Education
7. Referral
8. Follow-up

Question 13

Chronic disease and Aboriginal people

Answer 13

These key factors are:
• Aboriginal community support and involvement;
• Effective local area partnerships and working groups;
• Participation and professional development of Aboriginal health workers;
• Adequate resources and coordination between existing human, financial and
physical resources and initiatives.

Question 14

Key factors specific to initiatives for early detection and management of
chronic diseases among Aboriginal people are:

Answer 14

• Accessible early detection and intervention programs;
• Local multidisciplinary teams or taskforces with clear roles and responsibilities;
• Locally agreed evidence-based clinical protocols;
• Accessible early detection and intervention programs

Question 15

Empowering the patient

Answer 15

Health Literacy

Question 16

Health Literacy

Answer 16

Health Literacy – the capacity of a person to understand,
access and negotiate her or his requirements including
navigating the health care system, to maintain optimum
health throughout life

Question 17

When a person understands the mechanisms and
processes that affect their health and how a proposed
treatment plan relates to these they

Answer 17

are more likely to
agree upon and adhere to the treatment plan and follow
health care advice

Question 18

Self

Management

Answer 18

Understanding how individuals living in the
community manage their health and make meaning
of the experience with supportive care is essential in
delivering efficient, cost-effective, appropriate, and
respectful care

Question 19

Negotiating
self
management
that fits into
life

Answer 19

Creating routines and plans of action
Seeking effective self management strategies
Considering costs and benefits of self management

Question 20

Self-management includes

Answer 20

monitoring and managing signs and
symptoms of the condition and the effect the condition has on
physical, emotional, occupational and social functioning.

Question 21

Supporting patients to manage their own conditions require a lot of
skills in the health professional. suchas

Answer 21

good assessment skills and
communication skills. Cultural awareness capability and knowledge of
collaborative care planning are essential. have an understanding of health risk factors and
health promotion activities

Question 22

Medication
management
nurse role

Answer 22

• Monitor therapeutic effects and side effects of medications
• Monitor patient management plans of care
• May need to write prescriptions if prescribing privileges
• Education about medications

Question 23

Patient role/skills

Answer 23

•Organisation
•Tracking
•Self-monitoring (e.g. BP, weight, BGL)
•Record keeping
•Using technology (e.g. medication planners and reminder systems)
•Obtaining refills from pharmacy
•Organising follow-up appointments for monitoring (e.g. bloods or other lab
tests) and getting prescriptions
•Communication with nurse/doctor to report issues/side effects/problems

Question 24

The health professionals role in facilitating self-management

Answer 24

Assessment skills -
assessing
Behaviour change
skills
Organisational
strategies

Question 25

Assessment skills -

assessing

Answer 25

Readiness for
change
• Risk factors
• Support systems
• Self-management
ability

Question 26

Behaviour change

skills

Answer 26

• Use of motivational
interviewing
• Understanding
models of behavior
change
• Assisting with goalsetting, problem
solving and action
planning

Question 27

Organisational

strategies

Answer 27

• Working in MD
teams
• Applying evidence
to practice
• Knowledge of
community
resources

Question 28

GP Management Plan (GPMP)

Answer 28

A person with a chronic or terminal condition (with or without multidisciplinary care
needs) can have a GP Management Plan (GPMP)

Question 29

GPMP and Team Care

Arrangements (TCSA’s)

Answer 29

A person with a chronic or terminal medical condition and complex care needs,
requiring care from a multidisciplinary team can have a GPMP and Team Care
Arrangements (TCSA’s)

Question 30

Patients with either a GPMP or a TCA can also receive monitoring and support services
from

Answer 30

a practice nurse or aboriginal and Torres Strait Islander health practitioner on
behalf of the GP.

Question 31

types of models of care

Answer 31

Acute model

Chronic care model

Question 32

Acute model

Answer 32

disease centred
doctor centred
focus in on individual
secondary care emphasis
cure focus
1;1 contact visit to the patient
diagnostic information provided

Question 33

Chronic care model

Answer 33

Person centred
team centred
Population health approach
Primary care emphasis
Ongoing care
Prevention / management focus
supporton self management
Primary care emphasis