Question

M.D. is 69 years old, visits her GP for a repeat prescription of perindopril arginine 2.5 mg. She was diagnosed with heart failure and heart disease 1 year ago (LVEF < 40%) after a myocardial infarction and was started on carvedilol 12.5 mg. M.D. moved into a retirement village 1 year ago after the death of her husband. She is an active member of the walking group, but over the last 3 weeks she has had increased shortness of breath and fatigue after a steady 20 minute walk at the park. Since then she has reduced her level of physical activity and has also noticed swelling in her ankles despite her usual fluid tablets. She tells you that she has been having packaged soups instead of regular meals, because she finds it convenient, and is drinking more water than previously recommended (< 1.5 L/day was recommended after her heart failure diagnosis). Her medical history includes dyslipidemia, osteoarthritis, stable ischemic heart disease, and hypertension. Her current medicines (all once daily) are carvedilol 12.5 mg, aspirin 81 mg, atorvastatin 20 mg, celecoxib 200 mg, controlled-release isosorbide mononitrate 60 mg and furosemide 20 mg. M.D. currently weighs 70 kg (up by 4 kg from last visit 6 months ago) and her blood pressure is 140/82 mmHg. Serum biochemistry (urea, creatinine and electrolytes) was normal when tested 6 weeks ago. LDL was 100 and HDL was 52. Her estimated creatinine clearance was 60 mL/min.

Discuss how the chronic care model can be used to assist M.D

Answer 1

A Chronic Care Model is preferred for diseases which required ongoing or continuous care example: diabetes mellitus, hypertension, COPD etc.. This model mainly focuses on providing self- management support, delivery system design, decision support, clinical information systems, community care support.

In the case mentioned M.D has a medical history of hypertension, dyslipidemia, osteoarthritis and stable ischemic heart disease and she has been diagnosed with heart disease a year after she developed myocardial infarction and presently she is living is a retirement village. Considering all the above factors the following management support can be provided.

Self-management support:

• This involves both the patient and provider in identifying problems setting goals, developing relative care plans and monitoring the results.
• Providing the patient with the basic information on her present condition and also on the pre-existing conditions and its effects on her health could help her reconsider her choice of meals she takes daily.
• Helps patient set few goals by identifying the barriers and the reason for not being able to maintain her diet and follow the suggested treatment. Working toward the goals could help achieve a positive outcome.
• The goals set need to be documented and the patient should be advised and encouraged to follow the same
• This support can help the patient maintain her diet, fluid intake, physical activity and reduce weight.

Delivery system

• This includes co-ordination with other providers like her primary care provider to understand her condition better and plan care, carefully for effective results and ensure that the care planned is provided.
• This includes establishing required follow-up visits as part of her routine care

Decision support

• Combining the specialist and primary care and checking with the patient if she has been following the care planned or if she is finding it difficult if yes the check for the reason and help the patient make appropriate decisions
• Letting the patient take her own decisions without providing appropriate clinical based information could lead to other complications affecting her health
• Providing information on the clinical practice guidelines can help the patient better in making decisions.

Clinical information system

This mainly helps in the protecting the complete medical history of the patient which can be referred when planning care for the patient.

Community care support

• Patient is an active member of the walking group, however due to increased shortness of breath and fatigue she reduced her level of physical activity
• Community programs and organizations help check the weight, blood pressure, glucose levels etc.. and if any abnormal levels identified they will be referred to a community doctor.
• Encouraging the patient to attend such community programs can help her keep a track of her health status.

As discussed the chronic care model helps in various ways with its main focus on identifying the problems, setting goals, developing care plans and ensuring that the planned care is provided to the patient.