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1:1 Case Management - Coggle Diagram
1:1 Case Management
Chronic Condition Management
CHRONIC CONDITION
: disability and disease conditions that people liver with over 6 months, have long-lasting and persistent effects
The AU perspective
: preventable as they share modified risk factors (SNAP)
EVERYONE pays the price - patients, families, communities, health system, government
High demand on health system - ageing population, increase life expectancies, increased burden of comorbidities
Challenges to CCM
Fragmented system with services working in isolation, uncoordinated care
Difficulty accessing services required
Service duplication, absence or delay
Low uptake of digital health
Feeling disempowered, frustrated, disengagement
WHO identified areas of improvement
Focus shift from episodic --> ongoing, regular care
Policies supporting CCM
Information sharing across all settings
Integration across different arms of healthcare
Intersectoral collaboration
Upskilling of healthcare workers
Emphasise central role of patient
Emphasize role of PREVENTION on CCM and complications
Support for patients and families within the community
Innovative Care for Chronic Conditions Framework
MACRO LEVEL
: Positive policy environment
Strengthen partnerships
Integrate policies
Support legislative frameworks
Provide leadership and advocacy
Promote consistent financing
Develop/allocate human resources
MESO LEVEL
Community
Raise awareness, reduce stigma
Leadership and supports promotes better outcomes
Mobilise/coordinate resources
Complementary services
Healthcare organisation
Continuity and coordination
Quality encouraged via incentives and leadership
Healthcare teams organised and equipped
Information systems
Supporting self management and prevention
MICRO LEVEL
: interagency collaboration, working with patients and families, with healthcare team motivated and community partners informed
6 Principles of ICCCF
Evidence based decision-making
Population health approach
Focus on prevention
Quality focus
Integration
Flexibility and adaptability
Case Management
Client-centred care
Person-centred
Emotion support
Individualised
Evidence-based
MDT involvement
Partnership approach
Nurse's role in CCM
Management of disease to reduce exacerbations
Prevent transition from impairment --> disability
Encourage patient to take an active role
Culturally-sensitive care
Integrate medical care
SELF CARE
: the ability to promote health, prevent disease, maintain health and to cope with illness and disability with/without the support of health system
Factors affecting self-care
: experience, motivation, cultural beliefs, self-efficacy, access, support network, habits, functional and cognitive abilities
Barriers to self-care
: physical, psychological, cognitive, economic, social and cultural
Strategies to overcome self care barriers
Motivational interviewing
:
Engage-Focus-Evoke-Plan
OARS
Obtain better understanding of client health beliefs and behaviours
Enhance self-efficacy
Collaborative goal-setting
Peer support
Theory of Change: Health Belief Model
PERCEIVED SUSCEPTIBILITY
: presumed susceptibility to acquiring disease/harmful state
PERCEIVED SEVERITY
: presumed severity in extent of harm resulting from disease/harmful state due to specific behaviour
PERCEIVED BENEFITS
: belief in advantage of strategies to reduce risk of disease/harm state due to specific behaviour
SELF-EFFICACY
: confidence in ability to pursue behaviour
PERCEIVED BARRIERS
: beliefs concerning actual/imagined costs of behaviour
CUES TO ACTION
: precipitating forces that make people feel need to take action
Self Management
Role of Nurse
: Providing information, teaching disease specific skills, promoting healthy behaviours, problem-solving, emotional support, regular follow-ups, encouraging patient participation
Constructing a Personal Action Plan
ASSESS
: beliefs, behaviour, knowledge
ADVISE
: provide specific information about risks and benefits of change
AGREE
: collaborative goals based on patient interest and ability
ASSIST
: identify barriers, strategies, problem-solving techniques and support
ARRANGE
: specify follow-up plan
Empowerment