The balance between continuous delivery of quality health services and affordability is often delicate, with the risk of the balance tipping over. Payers for medical services are always seeking effective ways of reducing costs, improving the effectiveness of interventions (Clark, 2015). Providers also attempt to find ways to offer the maximum standard of care within the available resources while ensuring appropriate reimbursement. Most importantly, patients seek continuity of care, easy access to proper healthcare needs without facing financial ruin. All these needs bring us to a universal integrator: the case manager. Professional case management involves consistent quality care, which is client and culturally-centered with effective use of available financial resources (Clark, 2015). The number of patients on treatment for heart failure is bound to increase for aging populations due to medical advances reducing the mortality for ischemic heart disease (Khunti et al., 2007). Coupled with the complexities of care for patients with heart failure, it is essential to engage population health managers for such patients.
As a population health nurse, my role would be to use evidence-based guidelines to ensure optimum care for heart failure patients. To begin population management, it is crucial to create a database of information for all patients on the program (Annema et al., 2009). This would involve screening the patients referred to determine the appropriateness of the process. One of the qualifications would be a patient 65 years and above with a confirmed diagnosis of congestive heart failure on treatment. It is essential to ensure patients meet minimum criteria to determine the suitability of services offered (Hendricks et al., 2014). In the initial plans, once a patient is identified, the client and caregivers ought to be informed of their selection, followed by the obtainment of a consent for case management services. Communication with clients and families at the beginning of case management is vital to ensure maximal cooperation is achieved.
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An assessment of the patients then follows client identification and information. An evaluation could involve gathering of patient-specific data for inclusion in a patient database. A vital part of the assessment would be the functional capacity of different patients based on professional guidelines such as the New York Heart Association classification for heart failure (Hendricks et al., 2014). This classification identifies patients based on the presence of dyspnea. It ranges from patients with standard functionality with dyspnea on exertion to the extreme of patients with dyspnoea at rest (Hendricks et al., 2014). The determination of patient functionality provides a guideline for the development of a patient-specific plan of care. Information to be collected would include; pre-existing comorbidities, mental health issues, complications experienced, investigations conducted, and medication. The creation of a database individualizes patient care plans for a population health nurse.
Part of the assessment would include an evaluation of the patient's relationship situation to determine the availability of support for follow-up. More important is the determination of a client's willingness to take part in the case management program. During this assessment, I would be required to be professional, open-ended, and motivating to ensure that clients feel comfortable and confident in my services. A complete evaluation would also include assessment of substance use, and the patient’s financial situation to determine care financing. Generally, the evaluation aims at collecting as much information as possible to help in the formulation of a plan of care while building the confidence for the successful implementation of care.
Once all the information is collected through a thorough assessment, the development of a plan of care is vital. The plan of care is a structured and dynamic tool that documents opportunities, interventions, and expected goals of care. A plan of care for this group of patients would involve the development of preventive measures, methods of health promotion and treatment services tailored for the Clients. A plan for preventive measures would include education on lifestyle changes as a way of secondary prevention of the disease. This information would be passed on to all clients under my care. Lifestyle changes would include nutritional advice, tailored exercise, and salt restriction (Karunathilake et al., 2018). Adults with high blood lipids ought to consume more whole grains, poultry, vegetables, and fish while avoiding food such as sweetened beverages and red meat (Karunathilake et al., 2018). Health promotion measures would also involve lifestyle adjustments to promote wellbeing. It is essential to consider the resources available for each patient and the barriers to access to these resources, such as food. In the teaching and implementation of preventive and health promotion measures, passing information to caregivers is crucial since they contribute heavily to implementation.
A critical component of the plan of care for patients with congestive heart failure is medical care, especially medication that controls heart failure and prevents further complications. The formulation of this plan would involve a physician's input, based on their assessment of the patient and the patient's treatment history. I would input in the database the medication each of the clients is on and whether the drug has successfully controlled symptoms. This would be important in determining adjustments and the need for further care. A database would contain anti-failure medication, preventive measures such as medication for dyslipidemia and hypertension. These medications are classified under preventive measures since they prevent the decompensation or progression of heart failure. It would also contain definitive treatment for these patients.
Implementation of the plan would involve the client, caregivers, health professionals, providers, payers, and the community based on available resources and cultural background of the individual patients. It would start with teaching preventive and health promotion measures, carried out by a qualified nurse in the community. Teaching of these measures also needs the participation of caregivers to help in implementation (Clark, 2015). Once the measures are taught, the next step would be to take note of the patients' drug durations and ensure they are replenished within their budgets. Replenishing mediation ensures continuity in care and prevents the worsening of heart failure since stopping the medication could lead to decompensated heart failure (Brook, 1998). This will involve communication with the provider, payers, and family to ensure a seamless supply of drugs. Critical in implementation is the input of physicians whose role is monitoring, prescription, and follow-up of patients. With the physician, follow-up for these patients will be planned and communicated to the payer, provider, and caregivers in advance.
The arrangement of emergency hospital visits will involve organizing healthcare financing with patients and family members to avoid a lack of funding. It will also include educating the patient on the procedure of seeking emergency services to avoid confusion. All the plan elements will be continuously monitored and adjusted to fit the patients' needs at any particular time. Any changes and adjustments will be communicated to the clients, caregivers, nurses, physicians, providers, and payers. Collaboration and communication with these players help ensure the provision of quality health services in an organized manner within the cultural scope and financial limits of all patients.
Population health management is vital in ensuring continuity of care for patients who need care beyond the hospital. This will ensure the reduction of hospital visits, reduction of confusion when seeking health services, and confidence-building in patients' ability to take charge of their health. As a population health nurse managing patients with heart failure, it is essential to consider patients' general and individual needs. These needs, gathered from communication with the clients, caregivers, and health professionals, will form a database that will guide plan formulation. Implementation of the plan needs cooperation between different stakeholders to ensure seamlessness in the provision of quality healthcare. It is vital that during this implementation, the patient is placed at the center of it all for better outcomes.
References
Annema, C., Luttik, M. L., & Jaarsma, T. (2009). Do patients with heart failure need a case manager?. Journal of Cardiovascular Nursing , 24 (2), 127-131.
Brook, R. D., & Greenland, P. (1998). Role of secondary prevention in congestive heart failure due to coronary artery disease. Coronary artery disease , 9 (10), 653-658.
Clark, M. J. (2015). Population and community health nursing . Pearson.
Hendricks, V., Schmidt, S., Vogt, A., Gysan, D., Latz, V., Schwang, I., Griebenow, R., & Riedel, R. (2014). Case management program for patients with chronic heart failure: effectiveness in terms of mortality, hospital admissions and costs. Deutsches Arzteblatt international , 111 (15), 264–270. https://doi.org/10.3238/arztebl.2014.0264
Karunathilake, S. P., & Ganegoda, G. U. (2018). Secondary prevention of cardiovascular diseases and application of technology for early diagnosis. BioMed research international , 2018 .
Khunti, K., Stone, M., Paul, S., Baines, J., Gisborne, L., Farooqi, A., Luan, X., & Squire, I. (2007). Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial. Heart (British Cardiac Society) , 93 (11), 1398–1405. https://doi.org/10.1136/hrt.2006.106955
