Chronic care concept:

Long-term conditions and the role of nurse

in chronic care practice

Presented by: Piches Ruangsuksud, RN, MNS, PhD (Nursing science)

Assistant Professor, Adult Nursing Department
Faculty of Nursing, Khon Kaen University, Khon Kaen 40002 THAILAND
6th December 2021 1
Outline
Long-term Conditions: Long term condition in
1 perspective

2 Chronic care concept

Chronic illness: Social Determinants of

3 Health, impact and intervention

4 The role of nurse in chronic care practice

5 Management of Diabetes
2
 1.1 Long-term Conditions:
(Meerabeau & Wright, 2011;
The global Larsen & Lubkin, 2019)
challenge:
demographic
Nursing change The demand
provision for health care

Policy and
practice Long term Important
developments condition in Trends in
in managing perspective Healthcare
LTCs

Informal care Health

and social care inequalities
Home care

3
 1.2 Chronic illness
• “A long term conditions (LTCs) are a condition that cannot, at
present, be cured but is controlled by medication and/or other
treatment/therapies” (Brayford, H., et al., 2020)
• Disease Versus Illness: (Larsen & Lubkin, 2019)
 “Disease” refers to the pathophysiology of a condition.
 "Illness," in contrast, is the human experience of a disease and
refers to how the disease is perceived, lived with, and responded
to by individuals, their families, and healthcare professionals.
The pathophysiology of a disease predominates care;
however, to provide holistic care, one needs to recognize and
understand the illness experience of the patient and family.

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 1.2 Chronic illness
• Chronic illness is the lived experience of the individual and family
diagnosed with chronic disease. The individuals and family's
values impact their perceptions and beliefs of the condition and
thus their illness and wellness behaviors. (Larsen & Lubkin, 2019)
• Their values are influenced by demographic, socioeconomic,
technological, cultural, and environmental variables. The lived
experience is "known” only to the individual and family. (Larsen &
Lubkin, 2019)
• The term chronic illness is defined as a process of ‘long duration
and generally slow progression that requires ongoing
management over a period of years or decades’ (WHO, 2005A)

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1.2 Living with chronic illness
(Ambrosio et al., 2015)

Acceptance
Adjustment

หัวข้อการเรียนรู้

Integration Coping

Self-management
6
1.2 Living with chronic illness

Figure 1 Process of Living with chronic illness (Ambrosio et al., 2015)

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1.2 Chronic care model

Figure 2 The Chronic Care Model (Wagner, 2004; Wagner et al., 2001) 8
 1.2 Chronic care model
The Chronic Care Model (Wagner, 2004; Wagner et al., 2001)
The key principles of the model are:
• Mobilising community resources to meet the needs of individuals
with LTCs.
• Creating a culture, organisation and mechanisms that promote
safe, high quality care.
• Empowering and preparing people to manage their health and
healthcare.
• Delivering effective, efficient care and self-management support.
• Promoting care that is consistent with research evidence and
patient preference.
• Organising patient and population data to facilitate efficient and
effective care.

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 1.2 Chronic care concept: conclusion
• The World Health Organization recommends the use of the
Innovative Care for Chronic Conditions Framework (World Health
Organization, 2002) which is described as ‘an expanded,
internationalized adaptation of the earlier Chronic Care Model
developed by Wagner and colleagues’ (World Health Organization,
2005B).
• The Innovative Care for Chronic Conditions Framework extends the
Chronic Care Model by adding micro, meso and macro levels and
incorporates six guiding principles: evidence-based decision
making; population focus; prevention focus; quality focus;
integration; flexibility and adaptability (World Health Organization,
2002).

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1.3 Chronic illness: Social Determinants of Health

Figure 3 Social Determinants of Health (Dahlgren & Whitehead, 1993) 11

 1.3 Chronic illness: impact
(Brayford, H., et al., 2020)
• An LTC almost inevitably introduces uncertainty in the life of the
person, a threat to their life and identity and the way they manage
their regimens.
• Passive and helpless or hopeless responses are related to poor
outcome but a fighting spirit can lead to a favourable outcome.
• A sense of pessimism was related to a poorer adjustment over time.
People's coping styles played a great part in those who displayed a
better outcome.
• For example, lower depression and anxiety was found in those who
actively sought ways to cope with their condition, than those who
just accepted they had a new situation to deal with. Also, those with
better outcomes had acted quite swiftly to deal with their condition
as soon as diagnosis was made and showed improvement at follow-
up sessions.
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1.3 Chronic illness: impact

Figure 3 The challenge (Brayford, H., et al., 2020)

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1.3 Chronic illness: impact

Figure 4 Long term conditions account for (Brayford, H., et al., 2020) 14
1.3 Chronic illness: intervention

Figure 5 Long term conditions account for (Brayford, H., et al., 2020) 15
1.3 Chronic illness: intervention

Figure 6 Strategy to help people with chronic illness (Brayford, H., et al., 2020)
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 1.3 Chronic illness: IMPLEMENTATION PLAN
Ambitions Activities for year 1 Activities for year 2

Prevention To ensure patients with LTC To improve communication that

• To ensure models of (Diabetes, CVD, Respiratory
care support the wider and opportunistic) have their
determinants of health risk factors recorded (height,
and primary prevention weight, BMI, alcohol use, and
smoking status)
reflect the needs of vulnerable
isolated groups, those with low
literacy or learning difficulties, and
people who do not use digital or
social media

Identification To support case finding in To support acute discharge reviews

•To increase the primary care for patients with where the patient’s diagnosis is
detection of LTCs suspected COPD and/or unknown in primary care
•To detect disease at an breathlessness
earlier stage To support case finding in
•To increase the staging primary care for patients with
of disease at the point of suspected LTCs
diagnosis for LTCs (to be determined)

(Brayford, H., et al., 2020; Larsen & Lubkin, 2019) 17

 1.3 Chronic illness: IMPLEMENTATION PLAN
Ambitions
Management
• To provide information
and advice at the point of
diagnosis
• To provide ongoing
education, advice and
Support All patients with a
LTC will have a health and
wellbeing reviewed and
care optimised
• To proactively identify
patients at high risk of an
adverse event (e.g. an
emergency admission)
• To increase the level of
patients feeling enabled to
self-manage their LTC
• To identify and support
mental health needs for
people with a long term
physical health condition
(Brayford, H., et al., 2020; Larsen & Lubkin, 2019)
Activities for year 1
• To map the information available to
patients (and staff) at the point of
diagnosis
• To map the education available
throughout disease progression,
including methods of delivery
• To research digital platforms for the
delivery of education, communication
and remote monitoring
•To increase the number of annual
reviews for COPD, Heart Failure and
Diabetes; ensuring disease staging is
reviewed and updated, medication
optimised and care plan in place
Activities for year 2
• To develop required information for
patients (and staff) at the point of
diagnosis
• To develop required education for
specific LTCs (to be determined)
• To develop a structured self
management programme for patients
with moderate levels of activation
• To link LTC education programmes
with national communication events
and local initiatives
• To integrate mental health services
with other LTCs (to be determined)
18 3
 1.3 Chronic illness: IMPLEMENTATION PLAN
Ambitions Activities for year 1 Activities for year 2

Multi-Morbidity • To increase the number of annual • To develop an integrated

• To commission services
that provide a stratified
approach to patient
Managemen
• To support improved
information sharing across
organisational and social
care systems
•To commission an
integrated and specialist led
MDT approach to the
management of multi-
morbidities
• To proactively identify and
manage patient risk factors
reviews for complex patients (to be
determined) ensuring disease staging
is reviewed and updated, medication
optimised and care plans
• To consider alternative delivery
models of care, including alternative
workforce, and training requirements
Respiratory service model and the
ability to scale up to other disease
groups
• To develop an integrated service
model for LTCs (to be determined)
• To populate a Population Health
Management Pyramid for other LTCs
(to be determined)

(Brayford, H., et al., 2020; Larsen & Lubkin, 2019) 19

 1.3 Chronic illness: IMPLEMENTATION PLAN
Ambitions
End of Life/Palliative Care
•To focus on the needs of
the patient to understand
what is important to them
and ensure patients are
plugged into the
appropriate services
• To ensure patients at the
end of life stage of their LTC
receive appropriate care
and are supported to
remain in their preferred
place of residence
• To systemically identify
patients with a LTC who are
in the last year of life
(Brayford, H., et al., 2020; Larsen & Lubkin, 2019)
Activities for year 1 Activities for year 2
• To identify patients within the last • To populate a Population Health
year of life using the GSF Management Pyramid for other LTCs
(to be determined)
• To develop/ensure a rolling training
programme for staff regarding
advanced care plans, symptomatic
management of EOL care (care homes)
and having difficult discussions
•To populate a Population Health
Management Pyramid for Asthma,
Atrial Fibrillation, Stroke and
Parkinson’s Disease
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 1.4 The role of nurse in chronic care practice
• Role functions can be related to the rehabilitation of all individuals
with
Role LTCs
functions Components (Ford & Randall, 2011; Boscart, 2020)
Supportive. • Psychosocial support
• Emotional support
• Assisting with transition and life review
• Enhancing lifestyles and relationships
• Facilitating self-expression
• Ensuring cultural sensitivity
Restorative • Almed at maximising independence and functional ability
• Preventing further deterioration and/or disability
• Enhancing quality of life
• Includes assessment skills
• Undertaking essential care elements
Educative • Teaching self-care (for example health promotion, self-medication)
• Facilitating educational activities to increase competence and
confidence in activities of daily living
Life enhancing • All activities aimed at enhancing daily living experience, including, for
example:
• Relieving pain
• Ensuring adequate nutrition 21 3
 1.4 The role of nurse in chronic care practice
Self-management Support for People with Long-term Conditions
(Ministry of Health, 2016)

Health care priorities for self-management support

Patient centred: Self-management support programmes should
empower people with LTCs to take a leading role in their care
planning

Psychological support: It may be necessary to provide

psychological support so that people can self-manage

Cultural relevance: Programmes should be culturally

sensitive and appropriate for diverse ethnic groups

Systematic follow-up: Primary care providers should undertake

clinical assessment and follow-up care 22
 1.4 The role of nurse in chronic care practice
Self-management Support for People with Long-term Conditions
(Ministry of Health, 2016)
Multimorbidity
Self-management For people with multimorbidity, a person-
education centred and integrated approach to
SME provides people with LTCs supporting management is particularly
Self- important.
01
with the knowledge, skills and
motivation they need to make management
decisions. It also increases their Equity
capacity and confidence to apply
in context Equity is the absence of avoidable
these skills in daily life
02 or remediable differences among
groups of people, whether
Principles of self- those groups are defined socially,
economically, demographically or
management support
06 geographically
Use evidence-based practices
and processes that improve 03
self-management support in
primary care
Self-management
Self-management support
05 04 Self-management is about enabling people
with LTCs to ‘make informed choices, to adapt
Supporting self-management involves new perspectives and generic skills that can be
educating people about their condition and applied to new problems as they arise, to
care and motivating them to care for practice new health behaviours, and to
themselves better. maintain or regain emotional stability’
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 1.4 The role of nurse in chronic care practice
Self-management Support
for People with Long-term stages for Diagnosis, Living for today,
support Progression, Transitions, End of life
Conditions
(Ministry of Health, 2016;
Web-based and mhealth solutions are available
Boscart, 2020) Use of technology
to provide self- management education and
solutions
self-management support
Self-management
in practice Expected Self-management programmes should help people with
outcomes LTCs to live longer, healthier, more independent lives

Components self-management support programmes are:

1) health literacy 2) cultural relevance
of self-
3) behaviour change 4) the role of the health professional in
management
support
supporting self-management

Care Personalised care planning is a tool that enables people with LTCs to self-
planning manage. It encourages them to choose their treatment goals

Examples of measures for LTC-related outcomes are: Patient assessment of chronic

Measuring
illness care (PACIC), Partners in Health Scale, Health education impact evaluation
outcomes questionnaire (HeiQ), etc
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 1.5 Management of Diabetes

Definition Treatment of
of diabetes
How is Patient self- hypoglycemia
diabetes monitoring
diagnosed? of blood
glucose
Treatment Treatment
of diabetes with insulin
Treatment of How should
hyperglycemia illness be
Acute- managed?
Education chronic
complication
Diet,
Excercise

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(Meerabeau & Wright, 2011; Rowan, 2015)
 1.5 Management of Diabetes
Nursing intervention performed by community
nurses (Community Health Service Unit) (Ruangsuksud, 2021)
human potential development

Health monitoring at home

Enhancing knowledge

Screening services for diabetes

risk groups
The diabetes mellitus clinic
service
Family volunteer system
development
Providing services to care for persons
with diabetes mellitus in emergencies 26
 1.5 Management of Diabetes
Nursing intervention performed by the village
health volunteers (under the supervision of community nurses)
(Ruangsuksud, 2021)

Health monitoring at home

Screening services for

diabetes risk groups

Promotion of people and family

model in healthcare

Campaign to encourage diet consumption behavior

modification patterns to control blood sugar levels

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 1.5 Management of Diabetes
The condition factors that allow communities to
manage diets for diabetic care (Ruangsuksud, 2021)

Modeling of health care at the

individual and family level

The volunteering development

to take part in health care

Condition Promoting healthy

1 factors that
contribute to
the
communities

persistence of Participatory
the local management
cultures

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 1.5 Management of Diabetes
The condition factors that allow communities to
manage diets for diabetic care

Empowering and
strengthening communities
in sustainable agriculture

The condition
Improving healthy food options

2
factors that
resulted in the new and nutrition education in school
culture (healthy
community)
extended to dietary
therapy in diabetes Using Information (Thailand
mellitus Community Network Appraisal
Program and Rapid Ethnography
Community Assessment Program )
for community food management

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