Chronic disease management

Chronic Diseases are long-term conditions that usually progress slowly over time. This includes conditions such as Heart Disease, Dementia, Diabetes, Chronic Kidney Disease, Asthma and Chronic Obstructive Pulmonary Disease (COPD), Depression, and Arthritis, among many others. Chronic Disease Management (CDM) is ongoing care and support to assist individuals impacted by a chronic health condition with the medical care, knowledge, skills and resources they need to better manage on a day to day basis. This may include regular visits and support from Doctors, other Primary Care Provider, community-based programs or referrals to specialist programs and services

Good Chronic Disease Management includes care and support that is:

• Proactive
• Team-based
• Well integrated with primary care (e.g. General Practitioner ) and the broader community
• Coordinated across providers and points of care
• Easily accessible
• Has a focus on health promotion and well being
• Encourages involvement of the individual and family in their own care and supports his or her ongoing self management

Nursing Home Medics is committed to working with individuals, General Practitioners, Specialists and community partners to improve Chronic Disease Management programs and services available to assist those impacted by a chronic health condition live a healthier, longer life.

Comprehensive Health Assessment

A health assessment of an older person is an in-depth assessment of a patient. It provides a structured way of identifying health issues and conditions that are potentially preventable or amenable to interventions in order to improve health and/or quality of life.

The purpose of this health assessment is to help identify any risk factors exhibited by an elderly patient that may require further health management. In addition to assessing a person’s health status, a health assessment is used to identify a broad range of factors that influence a person’s physical, psychological and social functioning.

Specific components of the health assessment for older people include:

• Measurement of the patients blood pressure, pulse rate and rhythm
• An assessment of the patients medication
• An assessment of patients continence
• An assessment of the patients immunisation status for influenza, tetanus and pneumococcus
• An assessment of the patients physical function, including the patients activities of daily living, and whether or not the patient has had a fall in the last 3 months
• The patients nutrition status
• An assessment of the patients psychological function, including the patients cognition and mood
• An assessment of the patients social function, including the availability and adequacy of paid and unpaid help, and whether the patient is responsible for caring for another person
• Any need the patient may have for community services
• Whether the patient is socially isolated
• The patients oral health and dentition

Preventive Health Care

When someone integrates healthy behaviour’s into their lifestyle, they are practicing preventive care. This type of care takes place before any signs or symptoms of a condition or disease have been detected.

Types of Preventive Care

Below are examples of different types of preventive care:

• Consistent Physical Activity – helps prevent chronic diseases such as heart disease and cancer, along with degenerative conditions effecting the muscles and nervous system such as multiple sclerosis and Parkinson’s disease.
• Proper Nutrition – eating a wide variety of nutritious foods helps keep the body’s systems functioning properly and can prevent conditions such as diabetes.
• Stress Management – helps individuals prevent short-term conditions such as ulcers and long-term conditions such as heart disease.
• Avoiding Tobacco – not smoking or chewing, along with avoiding second-hand smoke, can help prevent emphysema and lung cancer.
• Preventive Screenings – participating in screenings for cancer, heart disease and diabetes allows for proper diagnosis and early treatment.
• Blood pressure, diabetes, and cholesterol tests.
• Many cancer screenings, including mammograms and colonoscopies.
• Counselling on such topics as quitting smoking, losing weight, eating healthfully, treating depression, and reducing alcoholic use.
• Flu and pneumonia shots.

Palliative Care

The aim of palliative care is to achieve the best possible quality of life for the person with a life-limiting illness and provide support for their family and carers.

Palliative care:

• affirms life and treats dying as a normal process
• neither hastens or delays death
• integrates the physical, psychological, social, emotional and spiritual aspects of care, with coordinated assessment and management of each person’s needs
• provides relief from pain and other distressing symptoms
• offers support to help people live as actively as possible until death
• offers support to help the family during the person’s illness and in their own bereavement.

Some of the common medical conditions of people requiring palliative care include: cancer, HIV/AIDS, motor neurone disease, muscular dystrophy, multiple sclerosis and end-stage dementia.

Palliative care services can be provided in a range of settings including the home, hospices, aged care homes, hospitals and palliative care units. Palliative care can be provided by specialist palliative care teams or by doctors, nurses and carers using a palliative approach to their care.

Case Conferences

A Case Conference, better known as a Multi-disciplinary Case Conference is available for patients who have at least one medical condition that has been (or is likely to be) present for at least 6 months, or who is terminal, and who requires ongoing care from a Multidisciplinary Case Conference Team which includes both a Medical Practitioner and at least two other members (one of whom may be a second Medical Practitioner), and each of whom provides a different kind of care to the patient. Case Conferences provide the opportunity to plan for urgent or short‐term Health Care needs in a coordinated fashion, or to coordinate Medical Care for specific aspects of a Resident’s condition.

Falls Prevention Program

The Falls Prevention Program aims to reduce the incidence and severity of falls among older people and reduce the social, psychological and economic impact of falls on individuals, families and the community.

Our team of doctors make sure to prevent falls by applying the following guidelines

• Multidisciplinary team interventions
• Review medications, especially high-risk medications, such as sedatives, antidepressants, anti psychotics and centrally acting pain relief.
• Assess and manage bone health in residents who have, or who are at risk of, low-trauma fractures. This includes use of vitamin D and calcium, as well as formal treatments for osteoporosis.
• Check lying and standing blood pressure in residents at risk of falls.
• Ensure that residents with cognitive impairment are appropriately managed with behavioural strategies — avoid using physical and chemical restraints, where possible.
• Check that targeted and individualised falls prevention care plans are in place for residents and are based on screening or assessment.
• Ensure that preventing falls is part of routine care for all residents.
• Encourage all residents to participate in exercise classes.
• Ensure that mobile residents can walk around safely.
• Assess and develop a care plan for residents with urinary incontinence.
• Arrange supervision and assistance for residents with delirium or cognitive impairment (and who are not capable of standing and walking safely) during transfers.
• Comprehensive geriatric assessment
• Staff education
• Balance exercises
• Environmental adaptations
• Hip protectors
• Post-fall management.

Pain Management

Effective pain management in residential aged care facilities include patient beliefs and attitudes towards pain, communication deficits and cognitive impairment. Education programs, developments in observational behaviour scales and stepwise pain management protocols have enabled good progress to be made in addressing these obstacles and improving patient outcomes.

Background & Significance

• Physical pain is a significant problem for many older adults.
• It is estimated that at least 50% of community-dwelling older adults suffer from pain and among nursing home residents, as many as 85% experience pain.
• Despite its prevalence, evidence suggests that pain is often poorly assessed and managed in older adults.
• Pain is associated with depression, withdrawal, sleep disturbances, impaired mobility, decreased activity engagement, and increased health care use.
• For pain to be managed it must be systematically assessed.
• Other geriatric syndromes can be exacerbated by pain such as falls, de conditioning, malnutrition, gait disturbances, and slowed rehabilitation.
• Pain is a significant problem for older adults and can have potential negative impact on their independence, function, and quality of life.
• Pain management must be tailored to the type and severity of pain with medications that are safe and combined with other therapies to heighten effectiveness.
• Older adults, their families, and their care providers must be educated and empowered to effectively manage pain.

End Of Life Care

It is one of the certainties of life that one day, each of us, will pass away. For some, circumstances may exist where we can, with our families and friends, make the necessary preparations and seek to be as comfortable as possible during this final stage of life.

There are many different types of aged care services that can offer assistance for older people and their families and carers, whether at home or while in an aged care home. You might want to consider using these services to give you some extra help when you, or a person you care for, is approaching their end of life.

If you are caring for someone, there are ways you can help them feel as comfortable as possible during this stage. This may include providing emotional, social, cultural and spiritual support to both the person and the people around them, such as their family and carers.

Being a carer can be challenging, but as a loved one moves towards the end of their life, the emotional and physical stress and challenge can increase. It is important to understand that there are services for carers that can provide additional assistance during this time. This could include counselling or the assistance necessary to allow you to have a short break from your caring life (respite care).

Staff in the aged care home can help in developing a care plan to best support the care needs of the person, and their family and carers. A good care plan may:

• show how pain and other symptoms might be managed
• show how emotional and spiritual support could be provided
• show how cultural support could be provided
• help family members make decisions about care options
• help those involved know what to expect
• show how support to families and carers through the bereavement process could be provided.

Staff will also be able to assist with nursing support or pain management. If you think extra support is needed, you can ask staff if you can purchase additional staff hours to help.

Poly – Pharmacy

Poly-pharmacy is the administration of many drugs at the same time or the administration of an excessive number of drugs” is frequent among the elderly as they often suffer from chronic diseases with concomitant pathologies. If poly-pharmacy is legitimate in some cases, it can also be inappropriate and in all cases carries the risk of adverse effects or drug interactions. In aged care facilities, poly-pharmacy is a major issue in terms of quality and efficiency of care and health expenditures. It is thus essential to examine extent of poly-pharmacy in these facilities.

The risks associated with poly-pharmacy can lead to increased adverse effects, falls and decreased risk of medication compliance

Our team of doctors can aid in the reduction or avoidance of poly-pharmacy in the following ways:

• Domiciliary medication management review (DMMR)
• Screening patient drug profiles
• Assessing the effects of comorbid conditions
• Reviewing potential drug-drug interactions

Family Meetings

Family meetings make sure that everybody is aware of issues and concerns that need to be dealt with, that things are openly discussed and decisions are made collectively. Family meetings are one way in which families can be involved, empowered and supported by management staff. They can be a proactive way of managing and planning care.

These meetings can be invaluable, and should be considered on:

• Gather or share information
• Break difficult news
• Reach an understanding on what is needed by your family member
• Evaluate the resources, services and supports available
• Discuss ways that different family members can contribute
• Resolve conflicts
• Make decisions
• Plan for the future
• Referral to palliative care
• Confirmation of disease progression
• Discontinuation of treatment or when maximal medical management has been reached
• Discharge is planned from an inpatient setting
• The patient’s condition changes and goals of care need re-assessing.

When considering a family meeting it is important to decide who should be present, such as relevant members of the multidisciplinary team, family, GP, community and or /care organisations. The patient and their family should also be asked who they think should be present.

In-Service Education to staff and carers

Nursing home medics promotes in-service education to the staff members of aged care facilities by updating their clinical skills and knowledge which helps to improve the quality of care of the residents in the facility. For nursing home medics the well-being of residents is of utmost priority. On the request of the facility we can provide on-site education sessions conducted by our doctors.

Geriatric syndromes

Geriatric syndromes are multi factorial and shared risk factors—including older age, cognitive impairment, functional impairment, and impaired mobility. The syndromes included are:

• Losses in activities of daily living
• Cognitive dysfunction
• Delirium versus dementia
• Depression
• Dizziness
• Osteoporosis
• Falls
• Sensory loss
• Nutrition and weight loss
• Pain
• Substance abuse
• Urinary incontinence
• Constipation
• Pressure ulcers
• Fall

Our experienced team is capable of managing these medical conditions.

Dementia / Alzheimer’s Disease

What is dementia?

Dementia describes a collection of symptoms that are caused by disorders affecting the brain. It is not one specific disease. Dementia affects thinking, behaviour and the ability to perform everyday tasks. Brain function is affected enough to interfere with the person’s normal social or working life.

Who gets dementia?

Most people with dementia are older, but it is important to remember that not all older people get dementia. It is not a normal part of ageing. Dementia can happen to anybody, but it is more common after the age of 65 years. People in their 40s and 50s can also have dementia.

What causes dementia?

There are many different forms of dementia and each has its own causes. The most common types of dementia are Alzheimer’s disease, Vascular dementia, Parkinson’s disease, Dementia with Lewy bodies, Fronto Temporal Lobar Degeneration (FTLD), Huntington’s disease, Alcoholic related dementia (Korsakoff’s syndrome) and Creutzfeldt-Jacob disease.

Is it dementia?

There are a number of conditions that produce symptoms similar to dementia. These include some vitamin and hormone deficiencies, depression, medication clashes or over medication, infections and brain tumours. It is essential that a medical diagnosis is obtained at an early stage when symptoms first appear, to ensure that a person who has a treatable condition is diagnosed and treated correctly. If the symptoms are caused by dementia, an early diagnosis will mean early access to support, information, and medication should it be available.

Can dementia be inherited?

This will depend on the cause of the dementia, so it is important to have a firm medical diagnosis. If you are concerned about the risk of inheriting dementia, consult your doctor or contact Alzheimer’s Australia to speak to a counsellor. Most cases of dementia are not inherited.