Guidelines for Chronic Care Model Intervention, Research Paper Example

Hyperlipidemia is a complex condition that is characterized by a number of factors that include elevated triglyceride and cholesterol levels, which are often exacerbated by genetic factors and poor dietary choices (American Heart Association, 2015). This condition also demonstrates a greater need to understand the causes of the condition and its overall impact on patient care quality. Individuals with hyperlipidemia face critical risks that must be addressed in a timely manner, given the risks associated with heart disease, stroke, and other complications as a result of elevated LDL triglyceride levels and less than ideal levels of HDL triglycerides (American Heart Association, 2015). As a result, it is necessary to develop intervention strategies that will be useful in reducing high cholesterol and in restoring normal levels through proper nutrition and exercise, both of which impact health in a positive manner and reduce a variety of risks that impact this population group. These interventions must also include the ability to self-manage the strategy and to make a strong effort to reduce high cholesterol so that healthier outcomes are likely to occur.

Intervention Plan

For any patient who has been diagnosed with hyperlipidemia, it is important and necessary to develop strategies that will recognize the need for behavioral changes that encompass improved nutrition and increased exercise in order to accomplish the desired objectives in care and treatment. There must be a significant emphasis on proven methods to reduce LDL cholesterol levels and to recognize the root of these risks, which often include higher than ideal weight, poor nutrition, and limited physical activity. It is of critical importance that any proposed form of intervention will include a comprehensive treatment strategy and a course of action that will aim to reduce cholesterol and improve quality of life for the affected population group.

Many prevention-based strategies emphasize the modification of health-related behaviors in order to reduce cholesterol levels and to make a difference in patients’ quality of life (Isumi, Matsubara, Saeki, Imuta, & Mori, 2014). Under these conditions, it is important to identify the tools and resources that are necessary to improve health outcomes for these patients and to consider how behaviors play a critical role in shaping disease formation (Isumi et.al, 2014). It is known that “Initiatives being implemented as a part of health care in communities and workplaces to prevent hyperlipidemia have traditionally consisted of health education designed to affect behavior changes in people’s lifestyles (diet and exercise). The theories of behavioral science have been applied to health education designed to affect behavior change” (Isumi et.al, 2014). From this perspective, it is recognized that different theoretical models are applicable to hyperlipidemia and that any type of intervention that is likely to be successful will embody the strengths and opportunities associated with the modification of behaviors and self-confidence in executing these behaviors effectively (Isumi et.al, 2014).

It is necessary for interventions to support an environment in which patient care outcomes are likely to change when there are sufficient opportunities to encourage patients to have greater confidence in making these changes, while also promoting greater self-control over behaviors that will make a difference in patients who face the risk of hyperlipidemia or who already have the condition (Isumi et.al, 2014). Patients must learn that their behaviors are often contributory in nature and play a critical role in shaping how individuals respond to disease and what may occur when they are unable to modify their behaviors accordingly, thereby posing a greater risk of damaging organs and systems over time.

Self-Management Support

Hyperlipidemia-based interventions must demonstrate a valuable and flexible approach to addressing patient needs in a variety of settings. Self-management is a critical component of this process and requires ongoing attention and focus in order to enable patients to recognize the value of positive behaviors related to healthcare outcomes.  This may include the process of health coaching, whereby patients are provided with support and guidance from medical assistants or other experts to encourage greater self-management when not under the direct supervision of a physician or nurse (Willard-Grace et.al, 2015). The adoption of coaching for improved self-management is a likely scenario under which there will be positive and meaningful results that will have a positive and lasting impact on health, particularly if coaching is associated with permanent changes in behavior that include increased physical activity and improved nutrition. It is important to address these concerns and to be mindful of the opportunities that are available to patients with hyperlipidemia in order to reach their full health potential and to reduce cholesterol levels and subsequent risk of heart-related diseases.

Patients with hyperlipidemia must be provided with significant opportunities to advance their healthcare-related objectives through self-management, particularly once they learn how to modify dietary intake and expand their exercise regimen, coupled with any required medications to reduce cholesterol levels over time. A greater emphasis must be on the development of self-management tools that will empower patients and which will facilitate their success in managing and potentially reversing the disease. It is believed that these activities will be effective in limiting the risks associated with hyperlipidemia and the long-term complications that may occur in some cases. There must be a greater emphasis on understanding the needs of this patient population and in determining what steps are required to achieve improved health and wellbeing for this group of patients. It is believed that these activities will play a significant role in shaping the environment in which patients are able to improve their self-management of the disease with the intent to reverse the condition in the future. This is a realistic expectation in some cases, but may not apply to others; therefore, it is necessary to evaluate each and every case individually in order to determine which factors will be most effective in treating the condition in the affected patients. Furthermore, these tools will be valuable in the development of screening tools and methods to improve quality of life for patients who are at risk of developing the condition and who sustain elevated cholesterol levels.

Community Resources

Patients with hyperlipidemia are likely to experience a number of specific challenges associated with the disease that require further analysis. Therefore, it is important to consider the availability of community-based resources that impact patient health and wellbeing. For example, social workers possess a strong knowledge and resource base that may offer a positive contribution to patients with chronic diseases such as hyperlipidemia, since they are able to work in a collaborative context with other disciplines in order to effectively treat a disease state in order to prevent additional complications (Findley, 2013). From this perspective, it is also important for those in the social work field to contribute to chronic care at a high level, using their knowledge and expertise to ensure that patients receive interventions in the community setting that will support their overall health and wellbeing, rather than to detract from the progress that has been made in this regard (Findley, 2013). It is important for social workers to utilize the chronic care model in a community context to ensure that patients with chronic diseases such as hyperlipidemia receive the appropriate care and treatment so that patients do not experience any type of limitations that could interfere with their ability to receive high quality care and treatment on a consistent basis (Findley, 2013).

Follow-Up/Outcome Assessment Plan

Patients with hyperlipidemia must be continuously monitored on a regular basis in order to prevent lasting complications as a result of the disease, and this is best achieved with the use of comprehensive screening tools that are designed to properly diagnose the condition in a timely manner and to recognize the types of treatment methods that are available to patients in order to begin reducing LDL cholesterol levels (Branstetter, Main, & Bragg-Underwood, 2015). Healthcare providers must be able to treat the condition in a timely manner and aim to recognize the value of screening for the condition within target age groups; this includes women over the age of 45 and men over the age of 35, respectively (Branstetter et.al, 2015). Furthermore, patients should receive the appropriate tests to determine HDL/LDL levels, including TC, HDL-C, and LDL-C, while also recognizing what values are considered to be at normal levels (Branstetter et.al, 2015).

It is also known that “Lifestyle modifications are the foundation of all treatment of hyperlipidemia and the prevention of heart attack and stroke. The treatment of obesity (body mass index > 30) is approached through a healthy diet and regular exercise, making sure that the individual has consumed fewer calories than expended through exercise in a day” (Branstetter et.al, 2015, p. 24). This reflects the importance of understanding how the disease impacts patients and what steps are required to ensure that patients are able to improve their self-management of the disease and engage in behaviors that will have positive and lasting benefits for their health (Branstetter et.al, 2015). Patients who are overweight are obese and who have the condition must take all possible steps to lose weight, as this will enable them to achieve greater success in managing and even potentially reversing the condition over time (Branstetter et.al, 2015). Through an understanding of the tools and options that are available, patients will likely recognize their own responsibility in managing the condition and in aiming to preserve their health and quality of life when the appropriate steps are taken through behavioral and lifestyle modifications to improve their condition. Most importantly, patients must be able to recognize the dangers of this condition and must be able to overcome their fears of change through continuous support and focus from healthcare providers.

There are a number of factors to consider in evaluating and assessing patients with hyperlipidemia, including individual risks, genetic circumstances, and other concerns, all of which may play a role in contributing to the prevalence of the disease. In addition, it is also important to recognize physical characteristics that impact the health of these patients, including weight and symptoms related to the disease. Patients must be monitored regarding their weight and to modify their behaviors in accordance with established guidelines in order to reduce elevated LDL levels and to participate in behaviors that will have a positive impact on their health and wellbeing over the long term. Since the risk of heart disease and stroke are more significant with a diagnosis of hyperlipidemia, it is more important than ever to monitor patient’s HDL/LDL cholesterol levels in order to effectively treat the condition with medication and through lifestyle changes. Nurses and other healthcare providers must be responsible for working closely with patients and communicating plans of care that will have a valid and meaningful impact on their health and wellbeing over the long term.

Chronic Care Model and Supporting Theory

The challenges associated with chronic diseases require an understanding of the dynamics of patient care quality and what steps are required to ensure that patients receive the appropriate care and treatment in a timely manner to prevent long-term complications (O’Donnell, 2014). This reflects a need to further examine the different constructs of chronic care models and to determine how to best address existing gaps in research and knowledge in order to accomplish the desired objectives. Most importantly, patients must be able to receive the appropriate level of support when they have a chronic disease and be able to self-manage the disease effectively and without limitations. There must be a significant emphasis on quality of care and treatment, along with other factors that will effectively contribute to the alleviation of symptoms and an approach to managing the disease that will have lasting benefits for all patients. Therefore, the chronic care model is one alternative that is necessary in addressing the key factors and contributors to care and treatment that will positively impact healthcare outcomes over the long term. This model will also enable nurses and other care providers to evaluate patients on a comprehensive and long-term basis, rather than focus on the events taking place over the short term.

The association of attachment theory to the chronic care model is relevant because it represents a means of understanding the nature of adhering to self-management techniques to support patient needs (Ciechanowski, Katon, Russo, & Walker, 2001). From this perspective, it is important to develop strong relationships between patients and providers in an effort to produce the desired results, while also considering other factors that influence favorable patient outcomes (Ciechanowski et.al, 2001). Attachment theory is also relevant to this example because patients will likely adhere to all required self-management techniques when they have stronger relationships with their healthcare providers, such as nurses, as these relationships engage patients in a supportive and beneficial set of experiences (Ciechanowski et.al, 2011). It is also likely that patients will expand their adherence to the required intervention and self-management plan of care when they are held accountable for their actions, and this may be facilitated by an environment where there is significant support and guidance for patients that is achieved on a regular basis (Ciechanowski et.al, 2011). Theories associated with the chronic care model are worthy of examination because they reflect the importance of learning more about what drives the factors related to chronic disease and how to best manage these issues effectively and in a timely manner to prevent further risks and complications.

Conclusion

Hyperlipidemia, otherwise known as high cholesterol, is a complex disease that requires the appropriate diagnosis and treatment in order to minimize complications and the risk of other disease states, such as heart disease. It is important for patients to be evaluated by healthcare providers in a timely manner so that they are able to reverse the disease and to minimize long-term risks to their health and wellbeing. Therefore, timely interventions must occur and must provide patients with the tools and resources that are required to achieve success in all areas of treatment and guidance for this condition. These interventions will also demonstrate the importance of the chronic care model in support of comprehensive patient care and treatment for this population group.

Interventions should emphasize self-management that includes improved dietary intake and increased physical activity as part of a comprehensive plan of care for this patient population. In addition, community-based resources must play a role in providing knowledge and support for patients, along with the adoption of the chronic care model in order to engage patients in understanding their diagnosis and in achieving optimal support and guidance from the healthcare community to treat, reverse, and prevent the disease in patients who demonstrate a higher level of risk as best as possible.

References

American Heart Association (2015). Hyperlipidemia. Retrieved from http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/Hyperlipidemia_UCM_434965_Article.jsp

Ciechanowski, P. S., Katon, W. J., Russo, J. E., & Walker, E. A. (2014). The patient-provider relationship: attachment theory and adherence to treatment in diabetes. American Journal of Psychiatry.

Ciechanowski, P. S., Katon, W. J., Russo, J. E., & Walker, E. A. (2014). The patient-provider relationship: attachment theory and adherence to treatment in diabetes. American Journal of Psychiatry.

Findley, P. A. (2014). Social work practice in the chronic care model: Chronic illness and disability care. Journal of Social Work, 14(1), 83-95.

Izumi, H., Mastubara, M., Saeki, K., Imuta, H., & Mori, M. (2014). The Effectiveness of Hyperlipidemia Prevention Intervention Designed to Affect Behavior Change: Focus on Changes in Health Behavior. Open Journal of Nursing, 4(13), 962.

O’Donnell, R. R. (2014). New models for chronic disease management in the United States and China. Family Medicine and Community Health, 2(4), 13-19

Willard-Grace, R., Chen, E. H., Hessler, D., DeVore, D., Prado, C., Bodenheimer, T., & Thom, H. (2015). Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial.The Annals of Family Medicine,13(2), 130-138.