The Chronic Care Model (CCM) and HIV, Coursework Example

The Chronic Care Model (CCM) and HIV/ AIDS Management in Primary Care Settings

Abstract

Patients diagnosed with HIV/AIDS require specific care and treatment that can prolong the length and quality of their lives. It is imperative that patients in this group receive the tools and resources that are required to improve their health and to receive continuous care and treatment on a regular basis. Using the Chronic Care Model can be an advantage for treatment of patients with HIV/AIDS who require ongoing treatment and subsequent psychosocial support to manage the disease throughout their daily lives. Healthcare providers must be prepared to exercise their knowledge and experience in providing support to these patients and to recognize that these skills are imperative in improving the quality of life of this group through continuous monitoring and evaluation. The Chronic Care Model demonstrates the importance of treating HIV/AIDS as a chronic disease that requires a comprehensive plan of care. Therefore, healthcare providers must collaborate with patients and use this model to effectively manage the disease and its impact on human health.

HIV/AIDS represents a challenging set of circumstances that impact how patients are evaluated, diagnosed, and receive ongoing treatment for this disease state. The complex nature of HIV and AIDS requires an examination of critical performance measures and strategic models that will have a lasting impact on patient care outcomes and will aim to improve the quality of life for patients with the disease. The ability to manage the disease state with a course of medication is of critical importance to this patient population, and this must begin with early diagnosis and treatment that will have positive and lasting impacts for these patients. There are a number of different models that may be adopted by healthcare providers in order to be effective in treating an HIV/AIDS patient population. However, the Chronic Care Model (CCM) is often considered to be a viable resource and an opportunity to examine the different perspectives of this model and how it is instrumental in managing HIV/AIDS patients.

The emphasis in treating this population must largely focus on effective management to reduce long-term health risks and to manage HIV/AIDS as best as possible with the intent to preserve health and wellbeing. Currently, HIV/AIDS does not have any cure; therefore, disease management is of critical importance and provides a basis for examining principles that will govern care and treatment for this patient population to sustain an acceptable quality of life for these patients.  The primary purpose of this paper is to describe the application of the Chronic Care Model to a sustained coordination of targeted healthcare for this population.

HIV/AIDS and the Chronic Care Model

The Chronic Care Model presents a unique set of criteria that embody the principles of high quality continuous care can manage the risks and progression of HIV/AIDS. This process requires nurses and other healthcare providers to understand the needs of their patients and to recognize how to best care for these patients over the long term. The care and treatment of patients with HIV/AIDS requires an analysis of the different needs of this patient population and a means of recognizing the value of clinical practice guidelines and expert knowledge in order to meet expectations for these patients.

A collaborative stance can strengthen the caregiver’s ability to manage chronic care effectively, noted as follows: “Program collaboration and integration of prevention services can be expected to maximize opportunities for prevention, reduce delays between infection and diagnosis and between diagnosis and treatment, and improve adherence to risk reduction behaviors and to treatment regimens for infectious diseases, substance use disorders, and mental disorders” (Chorba et.al, 2012). In this context, it is important for an organization to be proactive in its efforts to provide a high level of healthcare and to take the steps that are required to treat all patients in the act of preserving their quality of life for as long as possible.

HIV/AIDS treatment requires an examination of the different perspectives that will provide patients with the best possible resources to contribute at a high level and to make a difference in the lives of patients. The concepts related to integrated care for these patients involve a coordinated plan of care that will emphasize areas that involve a variety of needs and expectations, such as length-of-stay and case management tools (Minkman, 2012). As a result, it is important to develop a strategic approach that will embody the needs of the client base and promote a means of understanding the dynamics of comprehensive care and treatment that embody a model of ongoing care for chronic disease (Minkman, 2012).

It is expected that the coordination of care requires a long-term approach that will have a lasting impact on the direction of care and recognize the importance of integrated tools to improve outcomes for these patients (Minkman, 2012). It is important to develop a strategy that will emphasize the value of patient care outcomes and to be cognizant of opportunities to improve quality of care for these patients (Minkman, 2012). Integrated care must be a critical component of any chronic care model because this drives the development of new perspectives to accommodate patient needs at all stages of the disease.

Research Question

The research question that guided this examination and application of the Chronic Care Model was: How can healthcare providers adapt the Chronic Care Model (CCM) to care for long term survivors of HIV/AIDS? This group of patients is likely to benefit from these tools this model provides, and must understand and use all required forms of clinical diagnostics and testing to facilitate the appropriate treatment methods throughout the course of the disease.

Definition of Terms

For the purposes of this paper, the following terms are used

AIDS: Is the acronym for Human Immunodeficiency Virus.  AIDS is the final stage of HIV infection.

Antiretroviral therapies: One of the most common treatment methods for patients with HIV/AIDS to manage the disease and improve quality of life.

Chronic Care Model: is a model of care delivery which examines the comprehensive nature of disease management for patients with chronic diseases.

HIV: is an acronym for Human Immunodeficiency Virus.  A virus that infects human beings by weakening and destroying important cells that fight off disease and infection.

Literature Review

Treating patients with HIV/AIDS requires a significant cost commitment, particularly when patients receive long-term antiretroviral therapy, routine laboratory tests, and routine visits; therefore, models of care must integrate a number of critical areas that impact patients and provide them with the resources that are required to be successful in treating the disease at a high level (Sloan et.al, 2012). The use of antiretroviral therapies when an early diagnosis is made provides further evidence of the need for long-term care and treatment that leads to subsequent cost increases (Sloan et.al, 2012). As a result, the burden of these costs is substantial and requires healthcare experts to place greater value on patient care quality to improve life expectancy and with an aim to reduce treatment costs over the long term (Sloan et.al, 2012).

A systematic review of the Chronic Care Model conducted in 2014 demonstrated the importance of this model in the management of other diseases, such as chronic obstructive pulmonary disease (COPD).  According to Goering, Krumwiede, and Pope-Osaghae (2014), the Chronic Care Model provides numerous benefits to the COPD patient population and supports effective understanding of the elements that impacts this group and its symptoms.  Therefore, it is important to identify specific factors under which patients will likely respond to the Chronic Care Model intervention by minimizing bias and study criteria in order to have significant impact on patient outcomes.

It is recommended that healthcare providers must identify the importance of recognizing the Chronic Care Model for its general value and significance to practice for improved quality of life and health to the adult COPD population. This review emphasizes how to best manage chronic diseases with the tools that are available and to be proactive in working towards a set of fundamental concepts which work in conjunction with each other to improve quality of life for these patients (IHI, 2015). From this perspective, it is necessary to facilitate knowledge and training for healthcare providers to accommodate patients requiring chronic care and to recognize the value of improving outcomes through patient-based experiences to continuous care and treatment (IHI, 2015). Under these conditions, it is likely that patients will receive advanced care and monitoring to improve their lives on a continuous basis.

Chronic Care Model

The Chronic Care Model is comprised of several components that aim to address and manage chronic diseases as best as possible. For example, characteristics such as patient safety, cultural competency, coordination of patient care, community-based approaches and policies, and case management must be included in the model in order to achieve the intended results in managing chronic diseases effectively (Group Health Research Institute, 2015). Use of the model in the care of people with HIV/AIDS engages patients in their own plans of care and supports their knowledge of the disease and how it impacts their health (Group Health Research Institute, 2015).

One of the critical areas that require further development is in developing targeted diagnostic tools and resources, as this enables greater accuracy in diagnoses and in managing the long-term impact of HIV/AIDS on different communities (Schito et.al, 2012). From this perspective, it is important to develop a strategic approach that will positively influence when and how patients are diagnosed, as well as the tools that are required to be effective in meeting expectations for patients as they move forward to the treatment phase (Schito et.al, 2012). Therefore, the costs of care must be evaluated on a continuous basis and serve as the starting framework for the expansion of services that are both cost effective and appropriate for these patients; particularly those who are taking antiretroviral therapies for very long periods of time that incur significant financial obligations for patients and insurance providers (Schito et.al, 2012).

HIV/AIDS Self-Management

HIV/AIDS self-management is a complex process that requires ongoing support and guidance from healthcare experts in order to empower patients to effectively manage their care on a daily basis, particularly when their condition remains stable. It is important to develop strategies that will be effective in meeting the expectations and needs of the client base, along with developing the tools that are required to facilitate positive self-management experiences for these patients. There are many critical factors to consider with respect to HIV/AIDS patients that involve self-management and support a greater understanding of the dynamics of patient needs and expectations with this diagnosis.

Organizations must be prepared to manage the needs of these patients in different ways and promote a level of self-awareness that will influence how they are able to manage the disease at a high level to minimize complications. As a result, there are a number of approaches that are likely to be considered with respect to self-management, such as socio-ecological concerns, particularly for patients who live in communities and societies where HIV/AIDS is highly stigmatized (Ansari, Ansari, Al-Safarani, & Ayub, 2013). It is believed that in many cases, “The impact of stigma is particularly negative due to the common perception that the infected individual is to blame or should be held personally responsible for this condition” (Ansari et.al, 2013, p. 3). As a result, it is likely that some patients will experience levels of stigma that are extremely difficult to overcome and which create limitations in how they are able to self-manage their care, particularly if they are not provided with the resources that are necessary to address the condition effectively (Ansari et.al, 2013). Many patients must be able to adapt to different types of stigma and aim to overcome these issues as best as possible to achieve greater self-management of the disease, in spite of its difficulties (Ansari et.al, 2013).

Self-management in the context of chronic disease takes on many different forms, depending upon the type of disease, the symptoms that are evident, and other primary concerns that impact how they are able to manage the illness effectively and without delays to improve quality of life (Schulman-Green et.al, 2012). There are a number of definitions of self-management that must be considered, including the following: “medical management, such as taking medications and attending medical appointments; behavioral management, such as adapting lifestyle or life roles; and emotional management, including processing emotions that arise from having a chronic illness” (Schulman-Green et.al, 2012). From this perspective, it may be argued that there are significant factors related to understanding how to translate these broader definitions of self-management into real-life situations that require practical and timely decision-making in this regard (Schulman-Green et.al, 2012).

It is expected that there must be a greater understanding of these terms and the recognition of different tools and resources that will influence patient outcomes and provide support for patients as they develop their own approach to self-management that will work best for them. All patients possess their own motivations regarding self-management that are grounded in individual life experiences with the disease; therefore, these must be addressed on a continuous basis in an effort to improve quality of life through a combination of self-management activities and support from the healthcare community on a regular basis. It is expected that there must be a greater understanding of the dynamics of care and treatment that will impact patient outcomes and an ability to exercise effective decision-making to improve self-management for these patients.

HIV/AIDS Models of Care

HIV/AIDS creates complexities that require a sound and practical approach to the delivery of a model of care for the disease. This process requires an effective understanding of the dynamics of care and treatment and an ability to recognize the severity of the disease, the treatment methods that are required, and the daily activities that will promote greater quality of life for these patients (Deeks, Lewin, & Havlir, 2013). It is important to develop strategies that will enable patients to access the necessary resources on a continuous basis and to be cognizant of their options, taking their own circumstances into account. It is known that “even within the most sophisticated health care systems, effective delivery of HIV-related care is far from ideal.

The “treatment cascade” is now a commonly used conceptual model that quantifies the delivery of services to persons living with HIV across the entire continuum of care.  In order to maximize the benefits of therapy on an individual and community levels, at risk individuals need first to get tested, and those who are infected have to access care, start treatment, stay in care and remain adherent to HIV therapy” (Deeks et.al, 2013). Under these conditions, it is likely that patients will require ongoing evaluation and support from a number of perspectives, including but not limited to diagnostic tools and resources, emotional guidance, and expert knowledge with the intent to enable patients with HIV/AIDS to be empowered at the highest possible level and to improve their quality of life, in spite of the disease. This will enable patients to have an opportunity to address their health concerns in a professional manner and obtain the resources that are required to meet their needs effectively and without delays that could compromise their care and treatment.

HIV/AIDS Patient Needs and Expectations

Patients with HIV/AIDS require a continuous level of support and guidance in order to be successful in managing the progression of the disease. This requires a delicate balancing act that involves self-management, continuous monitoring by healthcare providers and other tools that is likely to influence a patient’s ability to overcome the challenges of the disease in different ways. From this perspective, the Chronic Care Model fills a void under which patients with chronic disease require comprehensive care and treatment in order to manage a disease and preserve quality of life in the process (Pasricha et.al, 2012). This requires an examination of the different tools and resources that will be effective in meeting expectations for these patients and in determining what is required to facilitate an effective response to care and treatment for this patient population (Pasricha et.al, 2012).

There must be a significant focus on different areas of the Chronic Care Model in order to identify performance-driven measures and outcomes, among other areas (Pasricha et.al, 2012). Most importantly, there must be a greater focus on the continued growth and development of the practice model so that patients are able to address their health under the guidance of professional knowledge and expertise. It is evident that these tools will provide further evidence of the need to evaluate patients and to make decisions on their behalf that will have a greater impact on their quality of life, particularly for those patients living with HIV/AIDS.

Clinical Decision Support

The clinical decision support model requires healthcare experts to provide input and guidance regarding the needs of patients, particularly those with chronic diseases such as HIV/AIDS (Robbins et.al, 2012). The use of electronic medical records systems and other tools are essential contributors to the overall delivery of care and treatment for patients and in supporting an environment where they are able to address common concerns more effectively (Robbins et.al, 2012). Therefore, decision support tools must be adapted for use in models associated with chronic care, particularly as there are significant factors related to the continued growth and development of the support environment that will influence patient care needs effectively (Robbins et.al, 2012).

Patient care for patients with HIV/AIDS poses a continuous challenge for healthcare experts, as they must be able to utilize analytical data and resources that will have a lasting impact on outcomes (Robbins et.al, 2012). It is important to develop an effective strategy that will encompass the needs of this patient population and that will provide a means of understanding the dynamics of patient care that will contribute to successful results for this group (Robbins et.al, 2012). Patient care outcomes must be evaluated in the context of decision support systems and through the analysis of data that will shape how a chronic care model is observed for patients with HIV/AIDS.

Patients with HIV/AIDS also require a continuous level of support and guidance that is generated through different forms of technology, as this reflects a need to integrate these tools into the practice environment. The use of clinical information systems is essential to the discovery of new forms of data that will support the expansion of models to improve chronic care and to be cognizant of the value that is provided by healthcare experts in the context of care for patients with HIV/AIDS. It is believed that healthcare providers must learn how to modify their approaches to HIV/AIDS so that they are able to provide patients with the necessary resources to improve or sustain their health over the long term, and this is accomplished through efforts such as decision support systems that will address areas of need (Pasricha et.al, 2013).

It is also important to identify areas whereby there are likely to be new directions that could impact quality of patient care at a high level, and with the use of decision support tools, these observations could be identified and new developments could occur that support how patients receive care and treatment for the disease. With a clinical decision support system in place, it is likely that patients suffering from HIV/AIDS will receive care and treatment that is highly specific for their needs and that will provide a basis for developing new methods to manage these patients with their best interests in mind. These systems also generate data and statistics that will promote new evidence-based procedures and methods that could have a positive impact on patient outcomes and provide a greater understanding of the dynamics of care and treatment that are likely to influence how patients manage the disease, both under the watch of healthcare professionals and in a self-management capacity.

This reflects a means of generating and adapting data in such a way that it supports the development of new perspectives to facilitate how patient needs are evaluated in order to successfully manage outcomes to improve quality of life. When patients receive treatment and care that is grounded in a larger analytical framework, their chances of improving their health are likely to increase, thereby supporting the legitimacy of these systems and in determining what is required to improve the long-term outlook for these patients across different areas.

Clinical decision support systems must demonstrate a high degree of technical capacity and support an environment in which there are significant opportunities to improve the care and treatment of patients who have been diagnosed with HIV/AIDS. This process requires an examination of different tools and resources that will influence outcomes and demonstrate the value of knowledge and resources in order to enable a strategy to be sustainable and appropriate for these patients over the long term. It is not feasible for patients to experience significant changes in their care and treatment, as it is believed that proven methods will go a long way in providing some stability for a patient’s health status; however, this also requires the development of programs and criteria that are specific to patients with HIV/AIDS, while simultaneously building a model that is grounded in prior evidence, experience, and knowledge in different ways that will have an ongoing impact on patients with HIV/AIDS.

Multi-Morbidity of HIV/AIDS

It is known that “There are growing concerns that the multi-morbidity associated with HIV disease may impact healthy aging and could overwhelm some health care systems, particularly those in resource-limited regions that have yet to fully develop a Chronic Care Model” (Deeks, Levin, & Havlir, 2013). From this perspective, it may be argued that there must be a greater emphasis on the continued growth and development of new perspectives to accommodate patients and to be proactive in meeting the needs of this patient base. Patients who lack the necessary resources to effectively treat HIV/AIDS often face critical health challenges that are difficult to overcome and which express a need to further investigate new approaches to manage patient care outcomes effectively and on a consistent basis to meet the expectations of this population group.

The following case study will focus on patients with HIV/AIDS who require continuous care and treatment for the disease, which includes prescribing and monitoring the effects of medications, proper nutrition, physical activity, proper medical care, and proper monitoring. These patients must work in conjunction with the expert knowledge of healthcare providers in order to achieve success in self-management and in supporting chronic care in an effective manner. This patient population is likely to benefit from the integration of the Chronic Care Model as a means of improving health and wellbeing throughout the life span. Full cooperation between health care provider and patient is required to achieve the desired objectives and the anticipated results.  The case study is created as an amalgam of many patients, so no personal information or individual can be recognized.

Case Study

For a patient with HIV/AIDS, the daily routine of medications and continuous monitoring may take their toll on psychosocial health and wellbeing and may even further compromise health due to stress and other concerns. In the context of these concerns, patients must receive care and treatment which is consistent with the core values and beliefs of healthcare practice and which provide an additional layer of support to patients who require these services. It is necessary to evaluate these conditions and to be proactive in working towards a set of conditions that will positively impact patient health, while also providing ongoing resources to assist in the challenges of daily living.

All names and potential identifiers have been changed in the case study to protect the identity of the patients.  For example, a female patient Candie who contracted HIV/AIDS at the age of 22 has been living with the disease for 12 years and continues to struggle with the treatment regimen, particularly as she wants to have her first child with her husband of ten years. She is twelve weeks gestation and in her first trimester. She takes a Nucleoside /Nucleotide Reverse Transcriptase Inhibitor Truvada one tablet oral daily, Reyataz a Protease Inhibitor 300 mg oral daily, and Norvir a Protease Inhibitor 100 mg oral daily.  She must take this regimen during pregnancy, after delivery and thereafter.

The patient struggles with depression and the fact that she is diagnosed with HIV. She struggles daily to swallow her antiretroviral drugs. Dr. Lauren Foster a family nurse practitioner with a doctorate in nursing practice states that taking the medications is not the patient’s problem, however every time the patient looks at her pills before she swallows them her medications are a reminder of the virus that she has. Instead of being reminded of being diagnosed with HIV she would rather not swallow her medications. The patient has missed doses and has been referred for counseling.  For this patient, who often struggles with the treatment regimen and some of its side effects, it is imperative that she is able to receive the appropriate level of support from the healthcare community to address her needs, expectations, and prognosis before, during, and after pregnancy.

Since the health of her child is a critical priority, it is important for the client to receive ongoing psychosocial support from expert providers in order to prepare for and manage her desire to have a child as best as possible. This requires careful monitoring of her medications and viral load to minimize any possible risk to her unborn child during pregnancy, as well as managing all possible risks during delivery. Based upon these conditions, it is important to be proactive in working with the client to meet her needs and expectations and to recognize the value of supporting a dynamic that will encompass a Chronic Care Model to address her needs on a comprehensive basis. This diagnosis requires an ongoing commitment to care and treatment for the client that includes routine monitoring of her viral load and medications in order to minimize any possible risks during pregnancy and to be fully aware of any other conditions that could impact her quality of life over the long term. Therefore, the Chronic Care Model can promote an examination of these conditions in order to effectively prevent complications and other challenges that could impede pregnancy for this client.

The client was referred to a mental health counselor in order to be evaluated for her depressive state and her overall level of anxiety when taking the required medications to treat her HIV. The patient has been struggling with taking her medication in a timely manner and finds it very difficult to do so in the required timeframe. Upon evaluation of the patient, the mental health counselor made several recommendations to the patient, including a series of meditation exercises. These exercises were prescribed to the patient as a means of enabling her to achieve a greater state of relaxation when she is preparing to take her medications. Since this is stressful time in her routine, it is necessary to counteract her reactions to taking medication by developing a strategy to improve her ability to better manage her medication and treatment plan on a regular basis. This will not only help the client to relax, but it will also improve her adherence to her medication regimen and how it will impact her health over the long term.

Meditation exercises will also enable the client to experience a greater sense of calm and satisfaction in knowing that she is able to manage her HIV condition effectively through improved medication adherence.  This is an important step for the client to take; therefore, adopting meditation exercises is a powerful means of facilitating a relaxed state and an effective approach to managing her HIV and the long-term outcomes that are likely to be achieved by taking her medication as required. The communication between the mental health counselor and the client must be open, honest, and productive in order to enable the client to adopt this type of intervention and the behaviors that accompany it in favor of improving her health and reducing the risks associated with an increased viral load.

Based upon the alternatives proposed in the Chronic Care Model, it is important to address all aspects of the patient’s care and treatment, using a multidisciplinary approach that will address her physical, emotional, psychological, social, and spiritual needs as appropriate. The CCM offers a means of identifying various areas of need, using different forms of communication and an emphasis on exploring different options that will work best for the patient under the circumstances. The CCM is flexible in different ways and may offer the patient different options under which she is able to manage her health at an optimal level. It is expected that this model will enhance her quality of life, enable her to focus on the areas that are most critical in maintaining optimal health status, and support her needs comprehensively through active communication and a greater focus on patient-centered care.

Table 1 Comparison of the Chronic Care Model and the Expanded Chronic Care Model.

The plan of care for a patient with HIV/AIDS requires an understanding of the key requirements involved in care and treatment, including prescribing medications, nutrition, physical activity, and routine monitoring by healthcare professionals. There must be a greater emphasis on self-management in order to be successful in treating the condition and in minimizing the risk of symptoms and progression of the disease. With this perspective in mind, the following parameters are considered:

• Monthly monitoring of patients through visits with the healthcare provider.
• Monthly discussions regarding nutrition, physical activity, and general health concerns.
• Quarterly bloodwork and monitoring of patients through follow-up, including a discussion of symptoms, viral levels, and whether or not medications must be modified.

Summary, Recommendations, and Conclusion

Patients with HIV/AIDS possess critical challenges that require comprehensive care and treatment on an ongoing basis to improve quality of life. Due to the nature of the disease, it is necessary to identify a model that will encompass the needs of this patient population and provide further engagement of healthcare experts in the plight of these patients. It is believed that a Chronic Care Model must embody the core values and beliefs of healthcare practice and combine many areas of expertise in order to provide these patients with a level of care and treatment that will meet expectations and provide further evidence of a model that will support a comprehensive approach to care and treatment. Under these conditions, it is important to recognize the value of patient care needs and expectations in conjunction with the Chronic Care Model and to be cognizant of the stigma associated with HIV/AIDS, particularly in some communities and societies. There must be a greater emphasis on achieving comprehensive care and treatment and in facilitating a strategy that will accommodate these needs for patients on a continuous basis.

Some patients who lack these resources are unlikely to sustain long-term survival, while other patients may have access to these resources and in turn, are able to overcome health obstacles throughout the course and progression of the disease. From this perspective, it is important to recognize the value of developing new ideas and approaches to patients that will impact how they self-manage the disease on a daily basis. It is imperative to develop an effective strategy for patients that will have a positive impact on outcomes and how patients receive care and treatment throughout the life span. Patients will largely benefit from these tools and are likely to achieve greater success in managing the disease over the long term.

The Chronic Care Model is particularly useful for family nurse practitioners because it provides them with a means of addressing many different types of chronic illness that require routine monitoring and treatment. Although HIV/AIDS is the focus of this discussion, a variety of diseases may be impacted by the CCM with similar results; therefore, its widespread application is strongly encouraged. In addition, it is necessary to adopt this model as a means of communicating with patients, sharing ideas, and encouraging self-management in order to improve quality of life and to sustain high quality care at all times.

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