Week 1 - Introduction to Chronic Disease Management Flashcards
What is the definition of CDM?
- Mental / physical health condition that last for more than 1 year
- Has a functional impact on person
- Required ongoing medical attention
What are the physiological factors of chronic diseases?
- Age-related diseases that increase with age: artheroscerlosis, rheumatoid, Alzheimer’s, cancer)
- Inflammaging: prolonged low grade inflammation associated with aging due to cytokine dysregulation
Prevalence of chronic disease conditions in SG
- Hyperlipidemia
- Hypertension
- Diabetes
What are the non-modifiable risk factors for chronic disease?
- Age
- Race
- Genetics
What are the modifiable risk factors for chronic disease?
- Sedentary lifestyle
- Smoking
- Obesity
- Diet
- Alcohol use
What are the characteristics of Acute Disease?
- Abrupt onset
- Limited duration
- Usually single cause
- Diagnosis & prognosis commonly accurate
- Specific therapies available
- Technological intervention usually effective
- Cure likely with return to normal health
- Normal people inexperienced; require professional knowledge
What are the characteristics of Chronic Disease?
- Gradual onset
- Unfolds overtime
- Usually caused by multiple factors
- Diagnosis often uncertain; prognosis obscure
- Indecisive technologies & therapies
- No cure; require management overtime
- Uncertainty pervasive
- Normal people might have some knowledge
What are the consequence of chronic diseases?
- Physical issues - mobility, pain, fatigue
- Injuries - resulting from falls / wounds
- Cognitive issues - memory, confusion, executive dysfunction
- Communication issues - expressive and receptive language
- Psychological issues - anxiety, depression, stress
What are the components in the Chronic Care Model?
- Health system (organization of healthcare) - program planning for better care of chronic disease
- Self-Management Support - patients role in managing their own care
- Decision Support - integration of evidenced based guidelines into daily clinical practice
- Delivery System Design - focus on teamwork and expanded scope of practice
- Clinical Information System - developing information systems to provide relevant client data
- Community Resource and Policies - developing partnership with communities to support & meet patient’s needs
Definition of self-management
Individual’s ability to manage the symptoms, treatment, physical and psychological consequences & lifestyle change inherent in living with a chronic condition
What are some centre-based care services available?
- Senior care centres
- Day rehabilitation centers
- Day care services
- Dementia day care centres
What are some home-based care services available?
- Home medical
- Home nursing
- Home therapy
- Palliative home care
What are some social & family care services available?
- Active aging centre
- Caregiver support group
- Meals-on-wheels services
- Escort services
- Befriending services
- Family-centres
Who is the Singapore Programme for Integrated Care for the Elderly) SPICE Program for?
Elderly with high care needs and requires slow stream rehabilitation & nursing care
Who is the Transitional Convalescent Facilities in Nursing Homes for?
For patients who need a longer duration of rehabilitation with an objective of retuning to the community
ABC to support seniors
- A: active aging for healthy seniors (HPB, pioneer generation office, people’s association involved)
- B: befriending for lonely seniors (people’s association, VWO involved)
- C: care & support for frail seniors (AIC, VWO involved)
Senior Mobility and Enhancing Fund (SMF)
- Allow seniors to top up funding for transport, subsidised eldercare, dialysis centres or assistive equipments (e.g. WC)
Enhancement for Active Seniors (EASE)
Provide safer & more comfortable home to improve mobility (i.e. ramps, grab bars)
