Community Care Services for People Living with Chronic Illnesses and Their Families PDF

COMMUNITY CARE SERVICES FOR PEOPLE LIVING WITH CHRONIC ILLNESSES AND THEIR FAMILY Community Care is a coordinated system of services that enables people of all ages with disabilities, chronic or acute illnesses to receive needed care in their homes and communities. Care i...

COMMUNITY CARE SERVICES FOR PEOPLE LIVING WITH CHRONIC ILLNESSES AND THEIR FAMILY Community Care is a coordinated system of services that enables people of all ages with disabilities, chronic or acute illnesses to receive needed care in their homes and communities. Care is delivered primarily by home care registered nurses and trained, certified personal care workers. Service delivery is based on assessed need and follows a case management process. GOALS OF COMMUNITY CARE SERVICES To plan and deliver comprehensive, culturally sensitive and effective home care services To assist people living with chronic and acute illness to maintain optimum health and independence in their homes and communities Ensure all clients who need home care services have access to services in the community, where possible Assist clients and their families to participate in the development and implementation of the client's care plan; and use available and appropriate community support services for clients' care. ELEMENTS OF COMMUNITY CARE SERVICES  Client/ Community Assessment The structured client assessment includes ongoing reassessment and determines client needs and services required. Assessment and reassessment processes can involve the client, family and other caregivers and/or service providers. This is essential to effectively address the prevention and management of chronic conditions. It also helps to identify populations for proactive care by a range of variables, for instance age, gender, ethnicity, socioeconomic status, and being at high risk of, or diagnosed with, specific diseases, illnesses or conditions. Systematically, targeting populations known to have a higher incidence of risk factors is critical to reducing health inequalities. It is also a very effective way to improve the health of the overall population. Olu-Abiodun, O.O   Home Care Nursing Services Home nursing services include: direct service delivery, supervision and teaching of personnel, personal care services and support to family caregivers. Through provision of proactive primary health care which focuses on health promotion, early intervention and disease prevention. The main intervention points for health promotion and prevention are: promoting health and wellbeing among those at risk, but not diagnosed with a chronic disease managing a diagnosed disease to slow the progression, prevent potential complications, and preventing other diseases from developing, preventing functional decline and disability through management, promoting wellbeing in the face of serious illness. Health promotion and prevention are often placed at the beginning of a linear system of care. However, there continue to be opportunities for intervention once a person is diagnosed with a chronic condition. A person with diabetes has an increased risk of cardiovascular disease and preventative measures can be taken to reduce their risk of developing it  Home Support Services Home support includes services such as: bathing; grooming; dressing; transferring; and care of bed-bound clients. Home management assistance can include general household cleaning, meal preparation, laundry and shopping.  Provision or Access to In-Home Respite Care This service is intended to provide safe care for clients and short-term relief for family and caregivers so that they can continue to provide care, thereby delaying or preventing the need for institutional care.  Access to Medical Equipment and Supplies This involves the provision of and access to medical equipment, supplies and pharmaceuticals to meet client needs in home and community. Olu-Abiodun, O.O   Information and Data Collection This is a system of record keeping and data collection for program monitoring, planning, reporting and evaluation activities, and to provide safe storage and handling of confidential client health records.  Management, Supervision and Monitoring This component includes the capacity to manage delivery of a quality home and community care program in a safe and effective manner, including professional supervision/consultation. Monitoring population health makes it possible to identify trends, develop appropriate programs and measure the results of interventions. The outcomes sought from a population health approach are: effective health promotion, early intervention and disease prevention reduction in health inequalities among ethnic groups, improved health of the whole population.  Established Linkages with other Services Linkages with other professional health and social services, both within and outside the community, may include coordinated assessment processes, referral protocols and service links with hospitals, physicians, respite care, therapeutic services, gerontology programs and cancer clinics. This involves the use of multidisciplinary team in delivery of chronic care, the majority of management takes place outside the hospital; the range of disciplines and providers may be greater, patients are involved in the monitoring and management of their condition and patients may require more information and support. People with chronic conditions have a wide range of medical and support needs. A team approach aims to reduce fragmentation of services and promote greater integration of care and support for the individual with a chronic condition. Interdisciplinary team care has been found to reduce the number of missed appointments, decrease hospitalization, decrease use of specialist care, and reduce costs. Olu-Abiodun, O.O  Additional services may be provided, depending on community needs and funding availability. Support services include, but are not limited to: rehabilitation and other therapies; adult day care; meal programs; in-home mental health; in-home palliative care; and specialized health promotion, wellness and fitness. Olu-Abiodun, O.O COMMUNITY NURSING CARE FOR PEOPLE LIVING WITH CHRONIC ILLNESSES AND THEIR FAMILIES Community-based nursing practice focuses on promoting and maintaining the health of individuals and groups, preventing and minimizing the progression of disease, and improving quality of life. Community-based care is generally focused on the individual or family; although efforts may be undertaken to improve the health of the whole community, the individual or family unit is the main focus. The primary concepts of community-based nursing care are self-care and preventive care within the context of culture and community. Two other important concepts are continuity of care and collaboration. They include the following: ASSESSMENT - Assessment of the person in community settings, including the home, consists of collecting information specific to existing health problems, including the patient’s physiologic and emotional status, the community and home environment, the adequacy of support systems or care given by family and other care providers, and the availability of needed resources. In addition, the ability of the individual and family to cope with and address their respective needs is evaluated. Other aspects of assessment include the home environment, safety factors (e.g., smoke alarms, obstacles, safety bars in the bathroom), adequacy of facilities required for the patient’s care and recovery, food preparation and storage facilities, bathroom facilities, access to a telephone, and the availability of family and community supports. ESTABLISHING GOALS - Once the problem has been identified for a specific patient, along with the specific medical problems and related social and psychological issues, the next step involves establishing the goals of care. The establishment of goals should be a collaborative effort with the patient, family, and nurse working together, for the attainment of a goal is unlikely if it is primarily the nurse’s and not the patient’s. Care delivery should be guided by a care plan that is focused on goals derived from a communication process that elicits the evolving values and preferences of the person and his/her family over time. ESTABLISHING A PLAN TO ACHIEVE DESIRED OUTCOMES - Once goals have been established, the next step consists of establishing a realistic and mutually agreed upon plan for Olu-Abiodun, O.O achieving them and identifying specific criteria that can be used to assess the patient’s progress. Set priorities and goals/outcomes in collaboration with client. Write goals/desired outcomes. Select nursing strategies/interventions. Consult other health professionals. Write nursing interventions and nursing care plan. Communicate care plan to relevant health care providers. IDENTIFYING FACTORS THAT FACILITATE OR HINDER ATTAINMENT OF GOALS - The next step involves identifying environmental, social, and psychological factors that might interfere with or facilitate achieving the goal. In the case of the patient with COPD, for example, not having sufficient resources could prevent him from hiring a home health aide. For this reason, the nurse might want to explore carefully the issue of resources with the patient and, if there are financial constraints, enlist the services of a social worker, with the patient’s consent, to explore possible community resources IMPLEMENTATION - Implementing Interventions, Possible interventions include providing direct care, serving as an advocate for the patient, teaching, counseling, making referrals, and case- managing (arranging for resources). Reassess the client to update the database. Determine the nurse’s need for assistance. Perform planned nursing interventions. Communicate what nursing actions were implemented: Document care and client responses to care. Give verbal reports as necessary. The commonality of these various roles is that the nurse maintains a focus on community needs as well as on the needs of the individual patient. Primary, secondary, and tertiary levels of preventive care are used by nurses in community-based practice depending on the health care need of the patient. The focus of primary prevention is on health promotion and prevention of illness or disease, including interventions such as teaching regarding healthy lifestyles, dietary modifications, exercises, etc. People with chronic illness need health care information to participate actively in and assume responsibility for much of their own care. Health education can help these individuals to adapt to illness, prevent complications, carry out prescribed therapy, and solve problems when confronted with new situations. It can also prevent crisis situations and reduce the potential for re- hospitalization resulting from inadequate information about self-care. Olu-Abiodun, O.O One of the goals of patient education is to encourage people to adhere to their therapeutic regimen. Adherence to a therapeutic regimen usually requires that the person make one or more lifestyle changes to carry out specific activities that promote and maintain health. Common examples of behaviors facilitating health include taking prescribed medications, maintaining a healthy diet, increasing daily activities and exercise, self-monitoring for signs and symptoms of illness, practicing specific hygienic measures, seeking periodic health evaluations, and performing other therapeutic and preventive measures. Secondary prevention centers on health maintenance and is aimed at early detection and prompt intervention to prevent or minimize loss of function and independence; it includes interventions such as health screening and health risk appraisal. Tertiary prevention focuses on minimizing deterioration and improving quality of life. Tertiary care may include rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. EVALUATION - The final step is evaluating the effectiveness of the interventions. In chronic illness, maintaining the stability of the condition while at the same time preserving the patient’s control over his or her life and a sense of identity and accomplishment is the primary goal. Success may be defined, however, as merely making progress toward a goal when a patient finds it difficult to implement rapid and drastic changes in the way that he or she does things. Collaborate with client and collect data related to desired outcomes. Judge whether goals/outcomes have been achieved. Relate nursing actions to client goals/outcomes. Make decisions about problem status. Review and modify the care plan as indicated or terminate nursing care. Document achievement of outcomes and modification of the care plan. Olu-Abiodun, O.O