According to a report by World Health Organization (WHO) in 2008, the greatest challenge that the global health care system will face in this twenty-first century is an increasing burden of chronic diseases, especially in aged patients (Bodenheimer, 2010a). Due to modern lifestyles, human beings have been exposed to high-risk factors to chronic illness leading to greater changes in a healthcare system that is trying to accommodate chronic diseases burden using various models (Bodenheimer, 2010a).
The World Health Organization elaborates chronic diseases to be having various characteristics but not limited to; they leave residual disabilities, the diseases are normally permanent, majorly caused by pathological alteration that is not reversible, always require special education to the patient so as to promote rehabilitation and normally requires a long period of supervision (Stellefson & Stopka,2013). There are twelve major chronic diseases in aged people as listed by the Australian Institute of Health and Welfare that has the greatest impact on the health systems of Australia and most of other same level nations (Wilcox, 2013). These conditions include diabetes, asthma, lung cancer, stroke, heart disease, chronic obstructive pulmonary disease, oral diseases, chronic kidney disease, osteoporosis, coronary heart disease, colorectal cancer, and depression ((Wilcox, 2013).
The majorities of the aged people with chronic diseases are basically be managed using corroborative primary care by general medical doctors, nurses, nutritionist and other relevant staffs and also specialized services (Stellefson & Stopka, 2013). According to Bodenheimer in the year 2010, more than one hundred million in the United States have a minimum of one chronic condition, half of these people have more than two chronic diseases, about 90% of people with age more than 65 years have one or two chronic diseases and 25% of these had about four chronic illnesses (Alpert, 2016) . Due to these reasons, various studies have been conducted to explain and try providing solutions for proper care of an aged population with chronic diseases (Wilcox, 2013). This study seeks to review three scholarly articles that have been trying to seek solutions pertaining chronic diseases in aged care (Bodenheimer, 2010a).
The problem -the study seeks to identify various ways or methods used to deal with chronic diseases in the aged patients by critically reviewing three health articles.
Intervention-The study tends to employ systemic review of three evidence-based articles that demonstrate various methods used to take care of aged patients with chronic illnesses by summarizing the evidence, comparing the articles and interpreting the important applications to day by day health care. What are various models used in taking care of chronic conditions and why use these models.
Comparison- Most Chronic diseases in aged patients have no permanent treatment. The care and treatment given are for palliative purposes and to prolong life with reduced further complications and risks.
Outcome- With the provision of proper evidence, nurses and other health care provider can use the analyzed interventions and solution for proper patient care.
The search strategy followed a systematic review of chronic diseases care in aged patients. The following key terms and key area have been used published and online health articles concerning the same; types of chronic diseases, care of chronic diseases in aged patients, methods used in chronic diseases care, chronic diseases care, models, challenges faced during chronic diseases care, prevention measures, risk factors, management case scenarios, possible life span as related to chronic diseases in aged care, chronic condition, long-term care, heart disease, cancer, asthma, kidney disease, arthritis, hypertension, patient education, self-management, chronic care model. All articles not written in English are excluded.
The majority of patient with tobacco addiction, diabetes, hypertensions, depression, asthma, kidney diseases, chronic obstructive pulmonary disease, and hyperlipidemia are mostly inadequately treated resulting in old age problems and more complications (Bodenheimer, 2010a). A properly designed primary care has been proposed to look if the occurrences’ of these conditions can be minimized (Jimenez, 2016). Since the chronic disease seems to have less urgency as compared to acute diseases many health care providers are not concerned with the chronic infections under optimal management (Bodenheimer, 2010a). Due to the fact that mostly chronic care is treated as acute care, nurses and doctors normally fail to give adequate patient education regarding patient caring for their own illnesses (Jimenez, 2016). There are always few visits and follow up to ensure compliance is frequently ignored (Jimenez, 2016). Mostly caring for chronic ill patient normally involve passive patients who are not clearly informed and unprepared health care team which end up resulting in more problems at the end (Jimenez, 2016).
In 1998, Ed Wagner established and chronic care model as a guide to be used in managing and developing efficient chronic care (Smith, 2014). Chronic care model does not offer an immediate and instant solution rather offers a multidimensional solution to a long term problem (Stellefson & Stopka, 2013). Since care of most of the chronic diseases in an aged patient is performed within the primary care settings and nurses spend a significant amount of time with the patient with chronic illnesses, a chronic care model deals with a critical rearrangement of practice that uses intellectual thinking to develop such outcomes that are self-sustaining (Taylor, & Bury, 2013). According to chronic care model, the care of chronic diseases in aged patients take place within three-dimensional areas which include the whole community, the health care systems, and provider organization. (Taylor, & Bury, 2013) In addition to that, the chronic care model consists of six essential elements which include self-management support, delivery system designs, community policies and resources, healthcare organizations, clinical information systems and decision support (Taylor, & Bury, 2013).
In terms of community resources and policies, so as to make improvements in chronic care, provider organizations will need a good network link with the community recourses including self-help groups, senior centers, and exercise programs (Taylor, & Bury, 2013).Some of the community linkages with hospital include home care that provides case management at home and hospital arrangements to provide patient education classes. These linkages are much helpful to nurses at community-based clinics with fewer resources (Taylor, & Bury, 2013)
The health care organization includes goals, structure and values and the relationship with insurers, purchasers plus the following components of chronic care model; self-management support, clinical information systems, decision support and delivery system design(Jacobson &Cleveland, 2014). The motivation to take care of chronic illness depends on whether the organization leaders view chronic illnesses as one of their priority of car (Jacobson &Cleveland, 2014). The environment of an organization has a greater impact on chronic care since the revenues and expenses incurred usually determine whether the program will continue or not. In addition, when insurers and purchasers fail to support the organization, maintenance of chronic care is normally difficult to implement (Jacobson &Cleveland, 2014)
The major recommended solution for a chronic condition is that patients take responsibilities to take care of themselves (Jacobson &Cleveland, 2014). This is due to the fact that patients with chronic illness live with the diseases for a very long time thus they can be taught basic segments of self-care. This includes things like exercises, diet, self-measurement like blood sugar and weight and how to use some medication (Jimenez, 2016).The self-management support involves many corroborative measures so as to help the patient and families gain the required skills so as they can be able to take care of their patient at home with some self-management tools like glucometer (Jimenez, 2016)
To implement chronic care model in primary care, the delivery system design must be changed so as a clear division for chronic care is separated from the acute care. Doctors and nurses who take care of acute problems should develop a team to deliver services to chronic patients when a diagnose for a chronic condition is made (Jimenez, 2016)The family members are trained by the chronic care team to take care of the patient at home and also routine visits arrangements are planned and schedule (Jacobson &Cleveland, 2014).
To make a comprehensive clinical decision, it is important to use evidence-based clinical practice guidelines so as to provide the basic standards for the quality care of chronic illnesses and should be also be integrated into day to day planned reminders and updates or continues medical education (Jacobson &Cleveland, 2014) .The doctor and chief nurse reinforce other nursed in decision making when a problem arises by providing a clear guideline in care (Jacobson &Cleveland, 2014). Lastly, regarding the clinical information systems, the computer systems have three major roles. These roles include acting as reminder systems so as to help the primary care follow the clinical guidelines, as a feedback to show how the patients are performing and to provide data for future planning (Jacobson &Cleveland, 2014).
The point of Care Testing (POCT) involves both patient consultations and pathology testing that is normally dined in a rural clinical setting outside the laboratory (Brown, 2013). In terms of chronic diseases in aged cases, POCT has numerous advantages that help to design proper clinical management pathways. It is convenient to perform POCT using small portable medical devices where the test can bring result in a very short time generally ten minutes (Brown, 2013). Due to rapid results obtained, it is easy to make clinical decisions and support health status of a patient. Aged care nurses are trained to performed POCT tests that generally require a finger -prick blood sample other than whole blood collection as most tests are done(Brown, 2013)..
In Australia, there is a good evidence base practice that the use of POCT has enhanced and promoted the health care delivery especially in patients with chronic diseases like diabetes mellitus (Khalil, 2012) .The POCT has facilitated strong community engagements in country hospitals and in the remote rural health centers. For example the Quality Assurance for Aboriginal and Torres Strait Islander Medical Services (QAAMS) which is one of the biggest POCT program funded by the Government of Australia for the last two decades has shown to be effective in taking care of aged patients in the rural communities where control of glycemic levels in diabetic patients has demonstrated a significant improvement (Khalil, 2012).
The Australian government recent POCT has focused on caring and treatment of chronic conditions where about 5000 patients spread relatively equally in 53 general practices as trials across the country (Alpert, 2016). These trials were used to test the following; Urine ACR, INR, HbA1c, and lipids. Based on the results from the trials, urine ACR, HbA1c, total cholesterol and triglycerides shows that chronically ill patient can use this test at home for monitoring but HDL cholesterol and INR should be performed at larger improved health care facilities (Khalil, 2012). The immediate results that are provided by POCT were also associated with chronic ill patient adherence and compliance with the treatment as compared to taking them to hospital laboratory time to time (Khalil, 2012).
From the POCT programs, it is evidenced that the program model in caring for aged patients with chronic diseases is a success in both urban and in rural communities particular in Australia (Brown, 2013). However, a critical analysis in terms of cost and mode of delivery would be needed before implementing the PCT since the Medicare rebates are currently not available for POCT in aged care facilities (Brown, 2013).
The implementation of POCT in Australia will need the following major keys to success in management of chronic diseases in aged patients; the aged care nurses should be trained so as to make them competent in performing POCT in aged care facilities and at homes, there should be a way to ensure that POCT performed is the correct standard and produce the same results as in the pathology laboratory and all POCTs done should be electronically captured and send to a central data to keep information for improvement and national planning (Smith, 2014)
One of the major challenges of care or the elderly patients in Australia is due to the fact that there is a huge shortage of doctors and nurses available to take care of the increasing number of aged patients (Brown, 2013). If POCT were to be practiced, the general doctor would just be monitoring and guiding the advancement since the test is immediate and can be done by nurses (Brown, 2013). This would make the patients benefit due to prompt treatment as the POCT to save time and minimize delay.
All patients suffering from chronic conditions self-manage their diseases. This is the fact that aged chronically ill patient cannot escape (Bodenheimer, 2010b). Each and every day the patient is responsible for their diet, exercises and to what extent he or she is going to take certain drugs. No matter how the healthcare professions do or say, the patients are in control of their self-management. The most important thing is how they do it after leaving the clinic (Bodenheimer,2010b).
In traditional practice, the doctors and nurses were perceived as the overall decision makers with patients who are ill participated very little in making decisions concerning their illness (Bodenheimer, 2010b). However, due to emerging models patients with chronic diseases are the key decision makers of their own illnesses with doctors and nurses just giving support (Smith, 2014). This partnership embraces two major components which are similar but also separable. This includes the self-management education and the collaborative care (Bodenheimer, 2010b). The collaborative care involves patient and the health care team doing the decision together and the self-management education involves the patient being enforced by skills and health information so that they can be able to make proper decisions concerning their health (Smith, 2014).
The collaborative care credits patient with the same expertise as similar to the doctors. The paradigm suggests that the doctors and health care team have the skills and knowledge to deal with the diseases the patients are having (Jacobson &Cleveland, 2014). On the other side the patients have knowledge and skills on how to deal with their own lives, that is, the patients knows more what they need in their lives than health care team (Jacobson &Cleveland, 2014). When the healthcare providers view themselves as the experts the health care delivery will remain to be frustrated since there will be no one to help the patient behave as the way of the expertise (Jacobson &Cleveland, 2014).
This mode of care insists that it is the responsibility of the healthcare team to encourage the chronically ill patients to solve their own problems but not giving order as such have been evidenced to promote non-adherence and compliance (Alpert, 2016). The model suggests that the internal motivation of aged patients is more applicable that the external motivation that insists it is better for patient and nurses to build each other with ideas for a better outcome (Alpert, 2016). The traditional care involves the health care providers blaming the patients for their shortcomings like being noncompliant with the medication. However, the collaborative care the health care has to accept the validity of patient’s problems and such things like adherence and non-compliant are not applicable (Jacobson &Cleveland, 2014).
Traditional patient education impacts disease specific information like diet, exercises, causing agents and prevention measures but in self-management education, chronically ill patient are empowered with skills to manage themselves (Jacobson &Cleveland, 2014). The self-management education offers problem-solving skills, allows the patient to propose the required set of actions complements the patients and help the patient to identify their own problems (Alpert, 2016).
The author in improving primary care for patients with chronic illness, Thomas Bombheimer have demonstrated that chronic care model has a lot of benefits when it comes to caring for aged patients with chronic diseases(Smith, 2014) . Chronic care model provides of six essential elements which include self-management support, delivery system designs, community policies and resources, healthcare organizations, clinical information systems and decision support (Smith, 2014). Those six elements provide a clear guideline for the proper care of aged patients with chronic illnesses. However , implementation of these elements is the problem. Thomas argues that the for the organizational provider to implement chronic care model, it must have enough recourses. If insurers and purchasers fail to provide enough financial support, the model will end up failing or taking too long to be fully functional (Kiechle, 2012).
Halls and Khalil have demonstrated that the point of care testing is another way to improve taking care of patients with chronic diseases such as diabetes (Brown, 2013). The authors argue that POCT can be used to make work easier in rural areas thus helping in follow up and easy treatment (Kiechle, 2012). The POCT saves time by providing prompt laboratory results and can be used at home and aged care facilities (Brown, 2013). However, the implementation of POCT will require further research in terms of the cost incurred and also further training of nurses will be needed(Brown, 2013).
The American Doctors Association have shown that the collaborative care and self-management education can be the saving option when it comes to dealing with patients with chronic illnesses (Bodenheimer,2010b). The evidence shows that patient that understand their illnesses and are empowered with enough skill have the capability of adhering to medication and treatment plus possibly reducing the complications that may arise ( Pulvirenti, et al., 2012). However, self-management care is difficult to be applied to patients with mental problems like depression since they have an imbalance thought process (Bodenheimer, 2010b).
In improving the chronic diseases in aged, the evidence shows that it requires a multidimensional support. Nurses will be using the chronic care model to address the multi-factional nature of chronic problems (Wilcox, 2013). This will help in successful interventions of chronic diseases that require a complex set of actions in terms of addressing the psychological, lifestyle and physical problems of aged chronically ill patients. Furthermore, the model will help in making policies in the country that are long term and helping ( Pulvirenti, et al., 2012)
The point of care testing is a good program that health care professions will be using in rural areas especially when there is a shortage of nurses and doctors to make an easy diagnosis and help in managing the patient progress (Brown, 2013). The POCT can also be used to manage lifestyles and medical problems (Kiechle, 2012). POCT in aged care facilities will enable the care of the health care providers to be able to predict the outcomes due to the availability of prompt results (Kiechle, 2012).
The self-management model in health profession will enable the patients with chronic infections to make such decisions that will lead to the betterment of care (Smith, 2014). Chronic ill patients will have a mandate when it comes to decision making thus promoting adherence and compliance to medications and treatment (Smith, 2014). This will also reduce the cost of treatment as the patients will have more knowledge and skills to take care of them and come to the hospital for consultation only (Alpert, 2016).
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