Models of Care and Self Management Flashcards
What is a
model of
care?
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.
Levels of Health Care for People
with Chronic Disease
Tier 4 Complex Tier 3 High Risk Tier 2 Stable Tier 1 Population
The 6 key elements of the CCM (chronic care model )are
- Delivery System Design (DSD)
- Self Management Support (SMS)
- Decision Support (DS)
- Clinical Information Systems (CIS)
- Community Resources (CR)
- Health Care Organisation (HCO)
Key Principles - Chronic Care Model
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.
Chronic Care Model aim
is to develop well-informed patients and a
healthcare system that is prepared for them
Chronic Care Model inclusion
▪ Cultural competency ▪ Patient safety ▪ Care co-ordination ▪ Case management ▪ Community policy
Innovative Care Model for Chronic
Conditions
-Macro (policy)
-Meso (health care organisations and
community)
-Micro (individual and family) approach
National strategic
framework for
chronic conditions
(2016)
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.
Chronic disease and Indigenous Australians
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.
The National Strategic Framework for Chronic Conditions (2016) Objective 3 is to
Target
Priority Populations
the strategy proposes to do this through (nsf obj 3)
✓ 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
Model of care for Aboriginal People
- Identification
- Trust
- Screening and assessment
- Clinical indicators
- Treatment
- Education
- Referral
- Follow-up
Chronic disease and Aboriginal people
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.
Key factors specific to initiatives for early detection and management of
chronic diseases among Aboriginal people are:
- 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
Empowering the patient
Health Literacy
Health Literacy
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
When a person understands the mechanisms and
processes that affect their health and how a proposed
treatment plan relates to these they
are more likely to
agree upon and adhere to the treatment plan and follow
health care advice
Self
Management
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
Negotiating self management that fits into life
Creating routines and plans of action
Seeking effective self management strategies
Considering costs and benefits of self management
Self-management includes
monitoring and managing signs and
symptoms of the condition and the effect the condition has on
physical, emotional, occupational and social functioning.
Supporting patients to manage their own conditions require a lot of
skills in the health professional. suchas
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
Medication
management
nurse role
- 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
Patient role/skills
•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
The health professionals role in facilitating self-management
Assessment skills - assessing Behaviour change skills Organisational strategies
Assessment skills -
assessing
Readiness for change • Risk factors • Support systems • Self-management ability
Behaviour change
skills
• Use of motivational interviewing • Understanding models of behavior change • Assisting with goalsetting, problem solving and action planning
Organisational
strategies
• Working in MD teams • Applying evidence to practice • Knowledge of community resources
GP Management Plan (GPMP)
A person with a chronic or terminal condition (with or without multidisciplinary care
needs) can have a GP Management Plan (GPMP)
GPMP and Team Care
Arrangements (TCSA’s)
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)
Patients with either a GPMP or a TCA can also receive monitoring and support services
from
a practice nurse or aboriginal and Torres Strait Islander health practitioner on
behalf of the GP.
types of models of care
Acute model
Chronic care model
Acute model
disease centred doctor centred focus in on individual secondary care emphasis cure focus 1;1 contact visit to the patient diagnostic information provided
Chronic care model
Person centred team centred Population health approach Primary care emphasis Ongoing care Prevention / management focus supporton self management Primary care emphasis
