Care Coordination for Chronic Diseases

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Nov 24, 2024

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1 Care Coordination for Chronic Diseases: Diabetes Name Institution

2 Care Coordination for Chronic Diseases: Diabetes Patient Description J.S. is a 68years old Caucasian female who has type 2 diabetes. Although she had good glucose control in the past, it has become difficult for her in the last three years. This is after her husband of 42 years died. She now lives alone and is responsible for taking care of herself. After the passing of her husband, her medical issues have exacerbated; she was recently diagnosed with chronic kidney disease and atrial fibrillation 8 months ago. Three months ago, cardiac testing showed she has had a myocardial infarction in the past and has since developed systolic heart failure. During the current visit, she also explains that she is experiencing swelling of the limbs. The self-monitoring data of her blood glucose reveals she has hypoglycemic episodes. She reports that she no longer knows what to eat as different specialists have recommended various diets; as such she is not sure of what to eat anymore. J.S. relies on Medicare to treat her chronic diseases. Current Plan of Care Her current diabetes care plan allows her to see five allied healthcare professionals every year. Currently, despite our facility having all diabetes specialists, she only sees our endocrinologist, nephrologist, and diabetes educator. She prefers to see a dietician and exercise physiologist closer to her home. Clinical Setting and Patients The clinical setting is a diabetic clinic within a large hospital. The clinic attends outpatient diabetic patients who visit the hospital. The staff at the clinic is assigned by the hospital. Currently, the staff is comprised of two endocrinologists, a diabetes care and education specialist, a registered dietician, an optometrist, a podiatrist, an audiologist, a nephrologist, a dentist, a pharmacist, a mental health professional, and an exercise specialist.

3 Other members of staff include two nurse practitioners, four diabetes specialist nurses, registered nurses nurse assistants, and lab specialists, among others. Diagnoses Seen in The Clinic At the clinic, staff endeavors to attend to all diagnoses associated with diabetes, in addition to treating and helping patients manage diabetes itself. This includes hypoglycemia, a condition that can be caused by some diabetes medication, and diabetes neuropathy which is the nerve damage that can occur due to diabetes. Also, patients with diabetic kidney and foot problems associated with diabetes are served. Diabetes can cause nerve damage which leads to poor blood flow in the feet leading to serious foot problems, such as callus. Diabetes can also damage a patient’s eyes leading to low vision or even blindness; therefore, clinicians also see patients for eye problems that are linked to diabetes. The clinic also has a dentist who sees patients for gum disease and other dental issues which are caused by diabetes. The staff also attends to patients with sexual and bladder problems, which are common in people with diabetes; these issues include loss of interest in sex, sexual dysfunction, retained urine, or/and bladder leaks which occur when diabetes damages blood vessels and nerves. Clinicians also see patients for depression which is also common among people with chronic diseases, such as diabetes, patients who have sleep apnea, and those with dementia. Proposed Care Coordination Model The proposed care coordination model is the “Transitional Care Model” (TCM). According to Morkisch, et al. (2022), this model offers hospital-to-home services that are coordinated by an advanced practice nurse. According to studies, this model is effective in enhancing outcomes of patients with chronic diseases, such as diabetes. This model helps patients transition from hospital care to home care. It is at home where many patients with

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4 chrome diseases struggle. Supporting them to care for themselves effectively can significantly help improve their health outcomes after leaving the hospital. Naylor et al. (2018) reveal that the TCM model is coordinated by advanced practice nurses who possess advanced skills and knowledge in caring for complex, chronically ill patients. They provide comprehensive planning starting from admission, throughout hospitalization, and follow-up after hospital discharge. They work closely with patients, diabetes specialists, physicians, family caregivers, social workers, nurses, and other members of the interprofessional care team to develop a patient- and family-centered care plan. They also educate patients and their caregivers on how to self-manage their complex healthcare needs. They tailor care to individual patients based on each patient’s goals through visits to patients while in the hospital, at home, to their primary care providers, with specialists, and via telehealth (Morkisch, et al., 2022). This model will significantly help J.S. and patients with similar diagnoses. The current problem with J.S. is that she sees visits different healthcare facilities for different diabetic-related care services. Although this is not bad, the problem is that there is no coordination between the specialists and healthcare professionals she visits. As such, she finds it difficult to integrate the different recommendations, such as on diet into a single care plan. With the TCM model, an APN will coordinate with all healthcare professionals involved in the care of the patient, from within or without the hospital to create a single, individualized plan for the patient. In this case, an APN would coordinate with all care professionals J.S. sees in our clinic and those she sees outside our hospital to develop a care plan for her (Naylor et al., 2018). This would help avoid the confusion she currently experiences.

5 The Model’s Fit into the Clinic Setting This model requires a large number of advanced practice nurses to effectively coordinate with the large number of diabetes patients seen at the clinic. Currently, the clinic is assigned a fixed number of advanced practice nurses who are only increased when the waiting lines are very long. For the new model to work, the clinic would need more advanced practice nurses to coordinate care with the large number of patients who visit the clinic. Therefore, the hospital would need to hire more advanced practice nurses to ensure care in other units is not compromised.

6 References Morkisch, N., Upegui-Arango, L. D., Cardona, M. I., Van den Heuvel, D., Rimmele, M., Sieber, C. C., & Freiberger, E. (2020). Components of the transitional care model (TCM) to reduce readmission in geriatric patients: A systematic review. BMC Geriatrics , 20 (1). https://doi.org/10.1186/s12877-020-01747-w Naylor, M. D., Hirschman, K. B., Toles, M. P., Jarrín, O. F., Shaid, E., & Pauly, M. V. (2018). Adaptations of the evidence-based transitional care model in the U.S. Social Science & Medicine , 213 , 28-36. https://doi.org/10.1016/j.socscimed.2018.07.023

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