Care Coordination For People With Long Term Conditions

A long-term condition (LTC) is referred to the illness which has no cure but requires effective care along with pharmacological and therapeutic intervention for the patient to help them lead an enhanced life (Whitehead and Seaton, 2016). The LTC is seen to negatively affect the family relationship of patients by making them a burden of care on the family. Moreover, different patterns of health and factors are seen to influence the long-term health of patients and health inequalities are seen to adversely affect the adults with LTC. Thus, in this assignment, the health patterns, inequality factors and others that affect adult with LTC are to be discussed as well as the way they impact the adults are to be explained. A case study of a 50 years-old female suffering from chronic kidney disorder which is a long-term health condition is to be explained to inform the way different physical, psychological and social factors affects people with LTC. The different care strategies in multidisciplinary settings for coping LTC of the female is to be discussed along with the role of the nurse in promoting her self-care and health management.

According to Marmot Review, the patterns of health inequality and diseases in England, the UK that affects patients include lower social status, poor economic condition, inadequate housing facility, low income, lack of education and others (local.gov.uk, 2010). The low social status creates health inequality because people belonging from the poor social classes are often ignored of healthy diet, effective support for physical activity, enhanced healthcare resources and others for their incapability to effectively contribute to the society out of their poor economic condition and others (Hoebel et al., 2017). However, people from the higher social classes are seen to have adequate financial condition and show effective contribution in the society for its upbringing leading them to have effective availability of healthcare resources to promote their health (Singh et al., 2017). Thus, it leads the people of lower social classes to remain unhealthy and face increased hindrance with their long-term health condition out of lack of support. This is evident as the Marmot report informs that people living poor areas are seen to face nearly 17 years of more health disability due to long-term condition compared to the people of higher social class living in valued areas (local.gov.uk, 2010).

The lack of adequate amount of finances among the people of low socioeconomic condition creates health inequality. This is because they are unable to spend or bear the increased healthcare cost required for the long-term health complications out of financial constraints (Brydsten et al., 2018). As asserted by Patel et al. (2020), people with effective economic condition with long-term health condition are seen to live a better life with increased life expectancy. This is because they spent increased amount of money without facing financial constraints in arranging complex and advance quality care required for LTC to ensure their increased years of living. As argued by Brydsten et al. (2018), the lack of presence of persistent enhanced quality of care for long-term condition leads people suffering from the condition to face early death and lower lifespan. This is because intervention required for their enhanced health to support well-being is not available in turn causing early deterioration of their health to face fatal condition. It is evident from the Marmot review where it is mentioned that people from poor financial condition and neighbourhood show 7 years earlier death compared to people with higher economic condition (local.gov.uk, 2010).

The people belonging from poor neighbourhoods are seen to have inadequate housing facility where effective hygiene and living conditions are not present. In this condition, the people with long-term health condition as well as others are unable to access effective intervention and coordinate care required for their health and well-being making them suffer more intricately from the disease with increased complication (Marí-Dell’Olmo et al., 2017). However, people in the rich neighbourhood are found to have adequate housing facility that allows enhanced presence of various assistive technologies and social carer for helping people with long-term condition or other diseases access enhanced support for effective control of their health complications (Temel and Vaizoğlu, 2018). Thus, the health inequality pattern of poor housing facility leads people with LTC have inadequate resources and environment to control the complication in turn making them face worsen health consequences with the disease. As argued by Assari (2017), hindered health education among the people of poor classes creates health inequality. This is because uneducated people are unable to determine health complication faced by them at the early stage as well as lack information about the healthcare authorities to be approached that are present in their locality to avail care.

In long-term health condition people who are uneducated, it is seen that their lack of education regarding health leads them to access care with delayed approach in turn making them suffer from diseases. Moreover, the uneducated people are unable to approach proper healthcare authorities for their care due to lack of knowledge regarding them, in turn, making them suffer negative physical and mental health consequences compared to the educated people creating health inequality in the society (Troutman-Jordan and Heath, 2017). Apart from socio-economic health inequalities that influence health of individual, there are various other health determinants that affect the well-being of the people. Thus, the current case study regarding Ann is to be focused to understand the way different health determinants apart from health inequalities are affecting her long-term condition (LTC) that is chronic kidney disease (CKD). Ann is a 50-year old female who is divorced and has been employed as a head teacher in a school. However, after detection of her Chronic Kidney Disease (CKD), she has been unable to visit work for few months but is expressing keen interest to return immediately. She is cared by her 17-year-old daughter Tara who is sixth from college. Ann is seen to be attending the local dialysis unit twice weekly to manage her CKD condition at the earliest to be able to join work.

The chronic kidney disease (CKD) is long-term condition in which kidneys of the adult are damaged leading to cause fluid retention that results in swelling of hands and legs along with additional health hindrances (Rojas-Valverde et al., 2019). The physical determinants of health that influences CKD exacerbation or management include the working environment, access to health-related resources, community design and others. Ann is suffering from CKD and willing to attend work would not lead to exacerbate the condition whereas it would help her to remain active in controlling the LTC. This is because she is already seen to be undergoing dialysis twice a week. The dialysis leads individual with CKD to ensure their blood remain purified and unnecessary built-up of waste does not occur as a result of damaged kidneys in the condition (Chang et al., 2016). According to NHS, regular and timely diagnosis is the initial health treatment for people with CKD in controlling the exacerbation of the LTC (NHS, 2019). Since Ann is following required treatment, therefore returning to work would not exacerbate her health condition regarding CKD. However, people with CKD are found to express difficulty in performing strenuous work activities. This is because they feel fatigued as a result of the shortage of oxygen carried to the red blood cell known as anemia caused by CKD (Wilkinson et al., 2019). Since the physical working environment of Ann is within the school as head teacher where no strenuous working activities are required to be done, therefore, returning to work would not create hindrance or worsen her health condition regarding CKD.

The community design influence LTC management because the design which allows presence of effective healthcare service delivery in the local community for the people with LTC leads them to effectively continue their care and support required for healthy living. This is because the individuals with LTC are already found to be stressed with their health issues and making them to travel less distance in availing care lower their hindrances in availing care as well as low overall expenditure on the care by cutting down travelling cost. Moreover, avoiding travelling long distance by adults with LTC leads them to manage work schedules more effectively without delaying work as they are able to save extra time to be spent while travelling long distance to avail care (Vanholder et al., 2017). Thus, presence of this nature of community design where care if available for Ann in the nearest locality would help her lower overall cost and hindrance in availing care as well as manage work with proper schedule. In the case of Ann, it is seen that the dialysis care which is important for her immediate management of CKD is present in the locality. Therefore, she does not require to spend extra time or avail unnecessary advantage from the employer in the school to managing her dialysis as well as work. Thus, returning to work by Ann with CKD would be beneficial as it would keep her engaged in social life as well as would not act in negative way in delaying her care as she can accordingly schedule her dialysis time with the work time to avail care.

The social determinants of health include economic stability, education, neighborhood healthcare environment and others (Storm et al., 2016). The economic stability is important for people suffering LTC because continuous and life-long healthcare is required that needs increased expenditure of finances in managing the health condition and ensure well-being of people (Sepanlou et al., 2017). Since Ann is divorced and cared by her daughter who is still studying, she is the only earning member a deduced within the case study. Thus, Ann's decision to return to work would be beneficial for her health condition as working would help her to make steady income and earn adequate finances in supporting her healthcare and dialysis regarding CKD to lead a healthy life. The NHS Kidney Care, in England in their recent report mentioned that managing chronic kidney disease (CKD) requires £434 million and £620 million to be spent each year by the population which is increased expenditure compared to other LTC such as breast cancer, colon cancer, skin cancer and others (kidneycareuk.org, 2019). This indicates that huge amount of finances per person may be required by people suffering from CKD. In case of Ann, since she is availing care from the NHS, she would not require direct investment to be made to avail care. However, presence of her steady income is required as she is needed to make general contribution with her taxes which indirectly reaches the NHS to support her in availing care.

The presence of enhanced education is required in LTC so that the people suffering from the disease understand the risk towards their health and avail adequate care services to be continued in managing their steady health (Wimalawansa, 2019). In case of Ann, it is seen that she is highly educated due to which she has been provided the position of head teacher in the school. Moreover, it indicates that Ann has sound knowledge and attitude to understand the important of continuing her dialysis along with work. This would lead her avoid discontinuing the care for CKD while joining work in turn creating no chances of deteriorated health condition to be faced by her. However, it is seen that Ann's daughter is solely responsible for managing care for her mother which makes Ann a burden of care on her. She is mentioned to be teenager who has to manage college along with studies and thus additional responsibility in managing her mother would create increased burden on Tara.

The person with CKD requires effective care to ensure their vital health statistics such as glycemic level, blood pressure and others are managed (Corcillo et al., 2017). Therefore, the social condition of sole care burden on Tara to support her mother Ann may cause exacerbation in her CKD condition. This is because Tara solely may not be able to effectively manage the care for Ann without assistance from others. The Young Minds organisation mention that in the UK young carers who are below the age of 18 years are found to miss minimum 48 days of school on an average and nearly 68% of them are bullied directly due to their responsibility of being the carer (youngminds.org.uk, 2020). The young carers by missing school becomes unstable to maintain proper grades which affect their progress in developing better future (McDougall et al., 2018). In case of Ann, sole responsibility of her care on daughter Tara who is 17-years-old would affect her education by making her mis school which is also detrimental for her future growth and career. Therefore, an additional carer is required from the family or any social carer is to be appointed to support Tara in taking care of Ann to ensure better quality life for the daughter as well as effective healthcare for Ann.

Apart from dialysis, Ann requires effective care strategies developed by the nurse in consultation with multidisciplinary professionals to more actively control and manage her chronic kidney disease as long-term condition. The NICE guidelines mention that people with CKD are to be involved in active physical activity on enhancing the performance or functioning of the kidney (NICE, 2015). This is because enhanced physical activity leads to create positive alteration in the renal hemodynamics by promoting enhanced blood flow and effective protein and electrolyte excretion (Fukushima et al., 2019). The nurse caring for Ann to promote physical activity by her is required to refer her to a physical trainer. This is because physical trainer has adequate knowledge and skills in supporting the patient with CKD to perform specific physical exercise that is good for their health condition (Mafra et al., 2018). The NHS England and UK Renal Registry are found to work in partnership for providing empowerment of CKD patients for which they provide coaching for physical exercise through trainers over phone, online or email to the patients (NHS, 2017). Since the services are provided virtually, therefore a single trainer is able to provide attend many patients at the same time in turn creating no issues of waiting list (NHS, 2017). Therefore, physical activity services required for Ann could be easily available to ensure she is capable to be empowered in managing hr own health.

The importance of support groups for people suffering from CKD as LTC is that the peers help the person suffering from the disease to remain encouraged in following care goals and treatment. This is because in support groups, the peers share their practical knowledge of coping and dealing with the condition of the disease (kidneycareuk.org, 2019a). Therefore, the nurse while caring for Ann is required to involve support groups in her care strategies for CKD. This is because the support groups could provide guidance as well as encourage her in emotionally coping with raised LTC (kidneycareuk.org, 2019a). The support groups for CKD are mainly used for emotional support for the CKD patients in coping their long-term treatment and feel boosted to continue care. In the groups, no physical activity training is provided as no physical trainer are present and a single psychiatrist is present to continue the group discussion (kidneycareuk.org, 2019a). The disadvantage of including physical training in the group support is that it would create lack of space and time where the patients can share their emotions to cope with LTC.

In the case of Ann, the nurse is to involve renal social workers in delivering care to her to ensure Ann effectively manager her condition with CKD as LTC. The renal social worker is experienced and educated individual who provide training to the patients with CKD and their families in all areas of life including financial, lifestyle adjustment, emotional and others before as well as after the initiation of dialysis (Seekles et al., 2019). The renal social worker could help Ann to develop new routine in life to manage dialysis as well as her job along with would act as assistance for Tara to lower here burden of care for her mother. Therefore, nurse caring for Ann is to develop consultation with social support agencies in the locality of Ann to arrange a renal social worker who would help her in the process of making effective life adjustment after initiation of dialysis as well as act to provide personal care to enhance her health and well-being.

In the study by Ko et al. (2017), it is mentioned that increased protein intake among adults suffering from CKD is to be avoided. This is because high protein presence in the body increases glomerular hyperfiltration and intraglomerular pressure which damages the glomerular structure leading towards aggravation of CKD condition in patients. Thus, minimum protein intake of 0.6–0.8 g/kg/day is recommended for adults with CKD to be taken in with diet. In contrast, the study by Oppelaar and Vogt (2019), mentioned that high salt intake is to be avoided by patients who are suffering from CKD. This is because increase presence of salt in the body leads to create sodium imbalance that makes the kidney to execute reduced functioning and remove low amount of water causing the individual to develop high blood pressure. It causes adversity in CKD condition as it created strain on the kidney to function beyond its efficiency (Qian, 2018). Thus, the nurse in arranging care strategies for Ann is required to include a dietician who would provide a dietary chart to be followed by the individual. This is because it would help Ann to determine the amount of salt and protein to be taken along with which foods are to be involved in the diet for living effectively with controlled CKD.

The presence of chronic kidney disease (CKD) as long-term condition often leads the adults to face negative impact on their skeletal system. This is because kidney failure leads to reduce adequate supply of calcium and vitamin D to the bones and causes disbalance in the phosphorous content in the blood (Gollie et al., 2018). According to NICE, the people with glomerular filtrate rate (GFR) is less than 30 ml/min/1.73 m2 suffering from CKD require their serum calcium and phosphate along with parathyroid hormone and vitamin D to be monitored and measured regularly (NICE, 2015). In case of Ann, the nurse requires to determine the GFR is lower than 30 ml/min/1.73 m2 to determine whether the person require regular monitoring of her calcium, phosphorous, vitamin D and PTH level. This is because the level of the mentioned vitals is required to be managed in CKD condition which is faced by Ann to avoid her bone density and skeletal system to be negatively affected. In order to monitor the mentioned vitals, the nurse is to arrange health and social care workers from local healthcare and support agency where Ann lives so that they would act to monitor and support her in this condition.

omoting self-care for Ann is to educate the patient regarding the importance of keeping her blood pressure low and factors to be considered that could cause the blood pressure to be increased. This is because it would make the patient aware of the need and way to maintain normal vitals for health in CKD condition in turn encouraging them to take self-care (Lin et al., 2017). The nurse in case of Ann is to educate her as well as Tara who is Ann’s only carer regarding the way to measure blood pressure and keep it within control. This is because it would make Ann avoid being burden of care on Tara for measuring and monitoring her health condition related to CKD to some extent in turn leading to be self-sufficient in taking care. The role of nurse while caring for CKD patient is to educate them about the nature of foods to be avoided in consultation with the dieticians (Havas et al., 2017). This is because dietary intake plays a vital role in managing CKD in patients. The intake of any form of alcohol or smoking is to be mentioned by the nurse to Ann to be totally prohibited in her condition. This is because alcohol intake affects the already damaged kidney in the CKD patient to show inefficiency to work and become damaged to make the person opt for kidney transplantation (Donald et al., 2018). Since Ann is already adversely affected by CKD and is under dialysis, the nurse is to educate her about the importance of avoiding alcohol in absolute manner to prevent total kidney damage which is adverse for her health.

In the UK, alcohol intake is common among the individual and in gatherings. In case Ann faces hindrance cope with alcohol cessation, the nurse is to refer her to alcohol cessation program to help her learn self-management techniques in avoiding alcohol intake if done by her in the CKD condition. The nurse is to educate Ann regarding the way she is to maintain a good glycemic control on her own. This is because enhanced glycemic control in CKD patient leads to slow exacerbation in CKD (NHS, 2019). Moreover, the nurse is to educate Ann regarding the simple exercises such a walking and running to be performed and the way they are beneficial for her in controlling progression of CKD. The role of nurse in supporting self-management of CKD by Ann is to educate the individual regarding the way to follow the diet chart provided by the dietician. This is because it would make Ann aware of the way mentioned dietary specifications are to be easily included in everyday life activities to lead an enhanced life with controlled CKD.

The above discussion mentions that health inequalities are raised due to low income, poor social status, hindered education and living condition among people. The health inequality impact the adults with long-term condition (LTC) to face early death, delayed diagnosis of disease, hindered healthcare and others. The current case study regarding Ann mentioned that she has presence of enhanced supportive physical working environment in regarding to her CKD condition as no strenuous acts are to be performed at the work due to which returning to work would be good for her health to remain engaged socially. Moreover, returning to work would help Ann to have enhanced income and earning to be able to effective manage the cost of care for dialysis and additional health services. However, increased burden of care is seen on Ann’s daughter Tara as she is only one presence for Ann to provide care. In this condition, the nurse caring for Ann is to arrange renal social worker would help Ann is adjusting her life with CKD to live without assistance from others. In multidisciplinary care setting for Ann, the dieticians, physical trainer and social workers are to be involved. The role of nurse in promoting self-care for Ann is to educate her regarding the way and importance of keeping the blood pressure low, way diet chart is to be followed, need of avoiding alcohol and others to ensure her be self-efficient in controlling and managing CKD to live a healthy life.

References

• Assari, S., 2017. Combined racial and gender differences in the long-term predictive role of education on depressive symptoms and chronic medical conditions. Journal of Racial and Ethnic Health Disparities, 4(3), pp.385-396.
• Brydsten, A., Hammarström, A. and San Sebastian, M., 2018. Health inequalities between employed and unemployed in northern Sweden: a decomposition analysis of social determinants for mental health. International journal for equity in health, 17(1), p.59.
• Chang, T.I., Zheng, Y., Montez-Rath, M.E. and Winkelmayer, W.C., 2016. Antihypertensive medication use in older patients transitioning from chronic kidney disease to end-stage renal disease on dialysis. Clinical Journal of the American Society of Nephrology, 11(8), pp.1401-1412.
• Corcillo, A., Pivin, E., Lalubin, F., Pitteloud, N., Burnier, M. and Zanchi, A., 2017. Glycaemic, blood pressure and lipid goal attainment and chronic kidney disease stage of type 2 diabetic patients treated in primary care practices. Swiss medical weekly, 147. pp.30-56.
• Donald, M., Kahlon, B.K., Beanlands, H., Straus, S., Ronksley, P., Herrington, G., Tong, A., Grill, A., Waldvogel, B., Large, C.A. and Large, C.L., 2018. Self-management interventions for adults with chronic kidney disease: a scoping review. BMJ open, 8(3).pp.89-111.
• dos Santos Pereira, B., da Silva Fernandes, N., de Melo, N.P., Abrita, R., dos Santos Grincenkov, F.R. and da Silva Fernandes, N.M., 2017. Beyond quality of life: a cross sectional study on the mental health of patients with chronic kidney disease undergoing dialysis and their caregivers. Health and quality of life outcomes, 15(1), p.74.
• Fukushima, R.L.M., Micali, P.N., Carmo, E.G.D., Orlandi, F.D.S. and Costa, J.L.R., 2019. Cognitive abilities and physical activity in chronic kidney disease patients undergoing hemodialysis. Dementia & neuropsychologia, 13(3), pp.329-334.
• Gollie, J.M., Harris-Love, M.O., Patel, S.S. and Argani, S., 2018. Chronic kidney disease: considerations for monitoring skeletal muscle health and prescribing resistance exercise. Clinical Kidney Journal, 11(6), pp.822-831.
• Grill, A.K. and Brimble, S., 2018. Approach to the detection and management of chronic kidney disease: what primary care providers need to know. Canadian Family Physician, 64(10), pp.728-735.
• Havas, K., Douglas, C. and Bonner, A., 2017. Person-centred care in chronic kidney disease: a cross-sectional study of patients’ desires for self-management support. BMC nephrology, 18(1), p.17.
• Hoebel, J., Maske, U.E., Zeeb, H. and Lampert, T., 2017. Social inequalities and depressive symptoms in adults: the role of objective and subjective socioeconomic status. PloS one, 12(1), p.e0169764.
• kidneycareuk.org 2019, Facts and Stats: Chronic Kidney Disease, Available at: https://www.kidneycareuk.org/news-and-campaigns/facts-and-stats/ [Accessed on: 6 November 2020]
• kidneycareuk.org 2019a, Counselling and support service: Chronic Kidney Disease, https://www.kidneycareuk.org/get-support/counselling-and-support-service/
• Ko, G.J., Obi, Y., Tortoricci, A.R. and Kalantar-Zadeh, K., 2017. Dietary protein intake and chronic kidney disease. Current opinion in clinical nutrition and metabolic care, 20(1), p.77.
• Lin, M.Y., Liu, M.F., Hsu, L.F. and Tsai, P.S., 2017. Effects of self-management on chronic kidney disease: a meta-analysis. International journal of nursing studies, 74, pp.128-137.
• local.gov.uk 2010, Marmot Review report – 'Fair Society, Healthy Lives, Available at: https://www.local.gov.uk/marmot-review-report-fair-society-healthy-lives#:~:text=The%20Marmot%20Review%20into%20health,can%20lead%20to%20health%20inequalities. [Accessed on: 6 November 2020]
• Mafra, D., Gidlund, E.K., Borges, N.A., Magliano, D.A.C., Lindholm, B., Stenvinkel, P. and von Walden, F., 2018. Bioactive food and exercise in chronic kidney disease: Targeting the mitochondria. European Journal of Clinical Investigation, 48(11), p.e13020.