Home Care Case Managers' Integrated Care of Older Adults With Multiple Chronic Conditions

Abstract

Variations in HCCM practice may impact the delivery of case management standards when caring for older adults with MCCs. This has implications for the comprehensiveness and consistency of HCCM practice, as well as interdisciplinary health professional and the client's awareness of the HCCM role when providing integrated care to older adults with MCCs within home settings. The greatest facilitators and barriers to integrated care are those case management standards and clinical and professional integrated care functions that focus on partnerships, collective and shared responsibility and accountability, coordinated person centered of care for clients, and ensuring engagement and partnership in self-management. This indicates the need for development of case management policies and programs that support the work of HCCMs in the delivery of seamless and collaborative case management and integrated care functions that foster collaboration and partnership-building efforts. The development of a new case management and integrated care conceptual framework that includes case management standards, professional and clinical integrated care functions would guide HCCM integrated care practice, policy and research to support client and family-centered care, and foster shared values for sustainable partnerships across care settings.

Paljon palveluja tarvitsevien asiakkaiden yksilöity sosiaali- ja terveyspalvelujen yhteen kokoaminen

“…Yksilöidyn palvelusuunnitelman merkitys on nähty tärkeäksi paljon palveluja tarvitsevia asiakkaita koskevissa tutkimuksissa (esim. Wassmer ym., 2008;Shah ym., 2011;Sinervo ym., 2016;de Carvalho ym., 2017;Baird & Fraser, 2018;van der Heide ym., 2018). Tutkimuksen seurantaaikana yhteisiä palvelusuunnitelmia tehtiin 56 ja koko 15 kuukauden kokeiluaikana vain 84 (Oulun kaupunki, 2017).…”

“…Sote-integraatiota rakennettaessa yhteistä palvelusuunnitelmaa voidaan käyttää paljon palveluja tarvitsevien asiakkaiden sote-palveluja yhteen kokoavana tekijänä (Veras ym., 2014;Wodchis ym., 2015;de Carvalho ym., 2017;Baird & Fraser, 2018;van der Heide ym., 2018). Myös kansallisessa sote-uudistuksessa on puhuttu yhteisestä asiakassuunnitelmasta, johon kootaan kaikki asiakkaan tarvitsemat palvelut (Sipilän hallituksen esitys valinnanvapauslainsäädännöksi 8.3.2018).…”

Developing a depression care model for the hill tribes: a family and community-based participatory research

“…This framework has inspired various interventions and has been applied in several countries with diverse healthcare systems and socioeconomic contexts [12]. Many studies showed that it was suitable and effective for patients with chronic illness in the community [13,14], such as patients with diabetes mellitus (DM) [15] and severe mental disorders [16]. It is applicable for chronic physical and mental illness as there are commonalities between both, regarding their shared determinants and consequences, and common healthcare strategies for their prevention and management [17].…”

“…It is applicable for chronic physical and mental illness as there are commonalities between both, regarding their shared determinants and consequences, and common healthcare strategies for their prevention and management [17]. In the ICCC application, some nurse case managers successfully applied this framework for chronic older patients in Canada, as it focused on encouraging people in the community to assess, plan, and care for patients together [13]. CBPR, a collaborative approach, involves stakeholders in every research stage (problem identi cation, data collection, implementation, analysis, and dissemination of the results).…”

Developing a Depression Care Model for the Hill Tribes: A Family- and Community-Based Participatory Research

“…It is applicable to both chronic physical and mental illnesses due to commonalities in their determinants, consequences, and shared healthcare strategies for prevention and management [ 17 ]. In the context of the ICCC application, some nurse case managers in Canada have successfully applied this framework to care for elderly chronic patients, emphasizing community involvement in assessing, planning, and providing care [ 15 ]. Furthermore, CBPR is action-oriented and aimed at supporting and enhancing strategic actions for community transformation and social change [ 18 ].…”