Chronic Conditions - Models Of Care, Role Of Nurse, EVB approaches, Global Challenges & Culturally Safe Care Flashcards
(32 cards)
What is a model of care?
Broadly defines the way health services are delivered; it outlines the best practice and care services for a person, population or patient cohort.
What does a good model of care incorporate?
Evidence‑based practice grounded in theory, meets patient and provider needs, and evaluates measurable outcomes (feedback, timing, quality).
More qualities of a good model of care
Inclusive of key stakeholders, protects nurse wellbeing, multidisciplinary, equitable, culturally appropriate.
Describe the basic structure of the Chronic Care Model (CCM).
Health‑system: self‑management support, clinical info systems, delivery‑system design, decision support. Community: resources & policy. Productive patient–team interaction → better outcomes.
List the key features of the CCM.
Effective chronic‑condition management; coordinated, system‑wide approach; bridges knowledge–practice gaps; supports patients and providers.
Name the six elements of the CCM.
- Health‑system organisation
- Self‑management support
- Community resources & policy
- Delivery‑system design
- Clinical information systems
- Decision support.
What does “ICIC” stand for?
Improving Chronic Illness Care – an expanded CCM with five extra themes.
List the five additional themes in the Improving Chronic Illness Care (ICIC) model.
Patient safety, cultural competency, care coordination, community policy, case management.
What does “ICCC” stand for and who developed it?
Innovative Care for Chronic Conditions – developed by the World Health Organization.
In which settings is the ICCC model primarily intended to be used?
Low‑ and middle‑income countries.
Which behaviour‑change theory is commonly paired with chronic‑condition care for staging interventions?
The Transtheoretical (Stages‑of‑Change) Model.
Name the five core stages in the Transtheoretical Model.
Pre‑contemplation → Contemplation → Preparation → Action → Maintenance (± relapse).
What is the Stanford Model better known as?
The Stanford Chronic Disease Self‑Management Program (CDSMP).
Give two hallmark techniques used in the Stanford CDSMP.
Peer‑led group workshops; weekly action‑planning with feedback on self‑selected goals.
Why must outcome evaluation be built into any model of care?
To keep outcomes measurable, enable feedback and continuous improvement, and ensure accountability to patients and providers.
Which Australian national policy framework aligns with CCM principles?
The National Strategic Framework for Chronic Conditions (NSFCC, 2017).
How do Primary Health Networks in Australia commonly operationalise the CCM?
Via GP Management Plans (MBS 721/723), HealthPathways, nurse‑led telephone coaching, and coordinated community services.
Scenario: A rural Aboriginal patient with COPD misses follow‑ups due to lack of transport. Which two CCM elements address this barrier?
Community resources & policy (e.g., transport services) and Delivery‑system design (telehealth/outreach clinics).
Scenario: A newly diagnosed type‑2 diabetes patient feels unsure about adjusting diet and meds. Which CCM element and theory should guide your intervention?
Self‑management support plus the Transtheoretical Model or Self‑Efficacy theory to build confidence.
Why must Australian models of care be culturally appropriate?
To ensure cultural safety, address health inequities for Aboriginal and Torres Strait Islander peoples, and improve engagement and outcomes.
Which CCM element embeds evidence‑based guidelines into routine care?
Decision support.
Give one measurable outcome you could track to evaluate a chronic‑care intervention.
Examples: HbA1c reduction, improved PAM‑13 score, fewer unplanned ED visits, better EQ‑5D quality‑of‑life score.
What are the three system levels of the ICCC model?
Micro, Meso and Macro.
Who is involved at the ICCC micro level?
Patients & Family, clinical team and immediate support network.
