Chronic Disease Model for Managing Type 2 Diabetes - Essay Example

Introduction Chronic health conditions involve the illnesses that cannot be cured but can be managed. The management of the chronic health conditions like type 2 diabetes requires adequate information with looks to the specific condition. The target of this plan is to provide a development need for a patient who is due to be discharged and is suffering from type 2 diabetes. The plan will be used by the patient, medical professionals and the community members. It is also important to note that the patient as well as the family members requires sufficient information about self-care activities. Self-care involves the activities that individuals, families or communities undertake for the purposes of enhancing health, preventing diseases, limiting illnesses and restoring health. Self-care therefore plays an important role during the process of managing the chronic health conditions (Audulv, Asplund & Norbergh, 2012). The self-care programs are also for the purposes of improving the outcome of the people with chronic health conditions after discharge process of community health service. It is also essential to note that the cost of care can be reduced through the self-care programs. Self-management involves what a person with chronic health conditions does actively for the purpose of managing the condition (Tinetti & Studenski, 2011). Type 2 diabetes mellitus is one of the chronic health illnesses that can reduce the life expectancy of an individual. This is due to the complications that it brings to the patient. People with type 2 diabetes mellitus are at a risk of such as cardiovascular disease, kidney failure, blindness and sudden death (Pasquier, 2010). Therefore, this paper is a supportive self-management plan for client with type 2 diabetes mellitus as a chronic health condition. Chronic Disease Model for managing type 2 diabetes Self-management support is one of the main elements of chronic disease model and it involves helping the family and the patient to acquire skills that are useful in managing the condition (Lehnert, et al, 2011). The patient and the family members will be provided with adequate of health and management information that is useful in managing type 2 diabetes including the dietary needs of the patient. Self -management tools will be provided to the patient and this includes diabetes health record that include smoking counseling, medication, nutrition therapy, physical activity, vision and skin care, checking blood glucose level and document complications. Moreover, managing sick periods that may involve rest, drinking plenty of fluids, eat healthy diet and seek for medical advice. Furthermore, taking diabetic oral medical (Ahmad, 2013). The patient will also be referred to the community resources for regular check-ups in order to ensure that the condition is well managed. Progress will also be assessed on a routine basis to determine how the patient is managing the condition. Delivery system design involves the division of labor to determine the role that each individual will play and care features that will be applied (Lawn & Schoo, 2010). A team composed of family members, social workers, psychologist, diabetic nurse educator and endocrinologist doctor will be put in place for assisting the patient after discharge process. Planned care will be involved in the design of the delivery system for the patient. The planned visits will be carried out for the purposes of determining how the patient is managing the condition well. Visits will be made to the patient by the social workers and healthcare professionals every week. Clinical information systems contain the development of a reminder system in the computer for the purposes of improving on compliance with the guidelines (Kirby, Dennis, Bazeley & Harris, 2012). A system will be developed for the purpose of providing a reminder and feedback system with regards to condition of the patient. The reminder system will be created through the use of computer software in order for it to be effective. All the guidelines will be considered and incorporated in the system for the purposes of ensuring that it reflects on the needs of the patient. Community resources include creating linkage with the community resources like the local healthcare facilities at the community. (Kralik, Price & Telford, 2010). The patient will be linked to the community resources that exist in the locality for the purposes of making any inquires or regular check-ups. The healthcare professions assisting the patient will also be linked to the community resources for the purposes of increasing efficiency with regards to the management of the condition. The patient will also be linked to the exercise groups as exercising is also part of managing the condition as it has a positive effect on the blood circulation (Bennett, 2010). The patient will be linked to self help and support groups for the purposes of helping them to manage the condition through the positive encouragement from the group members. Short term and long term goals In short term goals, self-awareness and acquiring knowledge will be useful in enabling the patient to fully understand type 2 diabetes for the purposes of ensuring that it well managed. The patient will be provided with sufficient and relevant information related to type 2 diabetes mellitus and should be able to understand his/her conditions and its level of risk after acquiring the knowledge. The acquisition of knowledge should enable the patient to develop self-efficacy through a detailed understanding of the condition (Lawn, McMillan & Pulvirenti, 2011). Moreover, attitude change is also a short term objective that will form a basis for encouraging the patient to manage the condition in the long run. Attitude change is important for the patients in terms of assisting them to develop a positive attitude towards his/her condition (Kralik et al., 2010). This is useful in reassuring the patient condition can be adapt with positive progress such as diet and reduce consumption of smoking and that can be made in when the patient already understands his condition. Also this will eliminate the atmosphere of fear and stress that are usually associated with the chronic conditions by constantly reassuring the patient that the condition requires management (Armstrong, Thiébaut, Brown & Nepal, 2011). On the other hand, in long term goals, taking ownership of the health needs will enable the patient to recognize and manage the body symptoms, taking medications, goal setting, decision making and problem solving through the provision of adequate information and simple equipment. Moreover, it will support the patient to monitor and manage the symptoms and side effects of type 2 diabetes on their own. In addition, adjusting assists the patient to make sense of the illness and confront the lifestyle changes by adapting to the new lifestyle. It may take long for the patient to get used to living with the condition due to many changes like dietary changes that will have to be put in place (Speros, 2011). Modifying will enable the patient to manage uncertainties through positive attitudes and deal with setbacks and focusing on possibilities needs. It will support the patient to deal with any stigma such as stressed and frustration that can be associated with type 2 diabetes mellitus. After adjusting, the patient should be able to deal with his medical condition associated with type 2 diabetes mellitus. Some people usually believe that the condition cannot be managed and it is like a death sentence (Soan, Street, Brownie & Hills, 2014). Intervention strategies, tasks and personnel involved Collaborative care strategy is one of short term intervention strategies that will involve improving partnership between the patient and the health professionals. The strategy will involve creating awareness with regards to the management and risks of the chronic health condition. Collaborative care also involves a motivational process for the patient to create self-efficacy (Schulman-Green et al., 2012). It will also focus on educating the family members with regards to the care of the patient. Obtaining the social and spiritual resources for assisting the patient will also be useful to the patient. Collaborative care strategy will also focus on addressing the social and environmental challenges within the community. Lifestyle issues and dietary needs will also be addressed and the personnel that will be involved include medical health professional, social care workers, support group members. The strategy will be evaluated after two week to determine its success. Also, it will be considered successful if the patient has sufficient knowledge about his health condition and all the personnel are working as team for the positive outcome of patients’ condition. The level of support from the family members will also be evaluated. A high level of support from the family members will be an indication of success of the strategy. Effective direct and indirect communication with patient and by using technology communication is a short term strategy that will be put in place. This strategy will involve carrying out health literacy for the purposes of providing information to the patient (Hall, Stellefson & Bernhardt, 2012). Effective communication will involve the use of indirect contact like messaging or texting the patient for the purposes of determining their successes and challenges in managing the condition. Coaching will also be carried out for the purposes of encouraging the patient to manage the condition (Vincent & Sanchez Birkhead, 2013). Establishing direct one-on-one contact with the patients for the purposes of providing them with information will also be carried out. The strategy will be considered successfully if the technology is used in facilitating and supporting patient’s health (Wennberg, Marr, Lang, O'Malley & Bennett, 2010; Benzo, et al., 2013). It involves the use of the phone and computer programs for the purposes of carrying out the monitoring process with an example of the response of the patient to medication. The evaluation will be carried out every week after its introduction. Medical healthcare professionals and social workers will be involved in the process. Goal setting and organizing resources will also form an important long term strategy and it will involve seeking healthcare resources for the purposes of supporting the patient in the management process. Psychological resources will be sought for the purposes of strengthening the patient to manage the condition (Adili, Larijani & Haghighatpanah, 2006) and encouraged to seek spiritual resources in order to nurture their spirit and acknowledge the higher power. Social resources will also be sought in order to provide social support to the patient with estimating effectiveness of self-management. It is also important to seek community resources like financial assistance and environmental assistance (Lawn & Schoo, 2010). Medical healthcare workers, community members and social care workers will be actively involved in the process. The strategy will be considered successfully if the patient is able to set his/her own goals with regards to the management process. The ability of the patient to receive social and finical support from the community will also be considered during the evaluation. The evaluation will be carried out after 4 weeks as some of the aspects are continuous. A support strategy involves developing interactive web pages for communicating with the patient and it will be part of the long term strategy. Support strategy also involves establishing blogs and chat room for the purposes of encouraging the patient to express themselves and make inquiries (Benzo et al., 2013). The use of social media networks like face-book and twitter will be used for interacting with the patient. Health professional team and support group members will be include in the process. The strategy will be considered effectively if the patient fully embraces the support systems including the social media and is fully cooperating with the personnel involved. An evaluation will be carried out after four weeks. Examination of effectiveness of the self-management plan The examination of the self-management plan is important in determining the ability of the plan to assist the patient manage the condition effectively. The plan will be considered effective if the patient is able accept his condition in the short term and be knowledgeable in terms of managing the condition. The patient should be able to develop a positive attitude and self-efficacy for the purposes of managing the condition in the long term (Merkes, 2010). This is considering that the chronic health condition has to be managed for a number of years. With regards to diabetes mellitus, the patient will have to manage the condition for the rest of his life and hence the importance of change of attitude. Confidence and positive attitude is also an important indication that will be used to determine the ability of the plan to succeed in enabling the patient to manage the condition (Jeon, et al, 2010). It is also significant to note that the patient has to accept his condition for the purposes of the plan to be successful. This means that the patient should be prepared to start adjusting to the new life as a lot of changes will have to be made on the daily routine and life of the patient (de Bruin et al., 2012). The plan will also be considered successful when the patient will be able to monitor his own condition and know of any signs and symptoms. The patient will be able to manage the condition easily when they are aware of the symptoms and any effects that it may have. Taking medication at the right time is also an important indication of success of the plan. This is considering that the patient may easily forget to take certain medication during certain period (Bauer, Thielke, Katon, Unützer & Areán, 2014). It is also important for the patient to be able to monitor his/her blood glucose level and blood pressure in the case of type 2 diabetes mellitus. The plan will also be considered successful when the members of the family fully support and understand the condition of the patient. This is considering that the management of the condition may also prove to be difficult for the family members due to the changes in the activities and life of the patient. The plan will also be considered successful when the patient will change his lifestyle to ensure that the condition is fully managed. It is important to note that the lifestyle of the patient has to change in terms of diet and daily activities (Shaw, et al, 2014). Summary of professional plan Goals for managing type 2 diabetes Strategies/Intervention Tasks/action Evaluation self-awareness and acquiring knowledge Collaborative care strategies •Enabling the patient to fully understand type 2 diabetes to ensure that it is fully managed •Patient must be award about the risk level of his/her health condition •knowledge should enable the patient to develop self-efficacy. •Educating the family members with regards to the care of the patient. It will be evaluated every two weeks for determine if its success. High level of support from the family members will be evaluated. Attitude change Effective direct communication with patient and by using technology communication. Encourage the patient for manage the condition. Coaching will be carried out for empowering and building confidence. Reassure the patient can be adopting with positive progress. Evaluation will be carried out on a continuous basis every week after its introduction for patient care improvement. Taking the ownership of health needs Goal setting and organizing resources Able to manage body response such as managing symptoms and side effects of type 2 diabetes. Able to follow up and keep an appointment, setting goals, making decision and problem solving. *Consider effectively if the patient comprehensively embraces the support systems. It will be evaluated after four weeks. Adjusting Support strategies *psychological resources will be sought for strengthening the patient and how to deal with stigma. *Encourage patient for spiritual resources. *Seek community resources like financial and environmental assistant. *Considering set goals for management. *Ability for patient to receive financial support. *Evaluation will be after four weeks. Conclusion It is evident that self-management plays an important role in enabling an individual with chronic health condition to better manage their condition. Type 2 diabetes mellitus is one of the chronic health conditions that require self-management. It is evident that the chronic health model is useful in assisting the patients with chronic health condition to manage their condition. The self-management plan has outlined several goals and objectives for the patient that will be useful in managing the condition. The goals are relevant to the condition of the patients and hence its ability to enable the patient to manage the condition effectively. Different intervention strategies have been out in place for the purposes of enabling the patient to manage the condition. It is evident that the strategies will be useful in terms of providing guidance to the patient with regards to how the condition will be achieved. 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