Hypertension is also regarded as a significant public health issue. It is among the leading causes of morbidity and mortality across the world. The condition mortality rate is six percent of the whole population. This means that an estimated 7.6 million individuals die from hypertension. If the disease is not treated, it can shorten life and be a primary risk factor for coronary heart disease and renal diseases, among others. In order to ensure high blood pressure is kept within the normal range, both pharmacological and non-pharmacological methods are used, and adherence to treatment is key. Across the globe, among the critical factors that prevent effective control of blood pressure above 25 percent is a lack of adherence to treatment among patients. Failure to adhere to treatment may start with avoiding treatment and failure to take prescriptions. Other factors that indicate non-adherence in hypertensive patients include failure to attend clinic appointments, unhealthy behaviors such as smoking, lack of exercise, excessive calorie consumption, and high fat and sodium diet.
Treatment for high blood pressure takes an extended period. Therefore, it is essential to ensure that patients with hypertension can cope with their condition by teaching them how they can adapt. Since treatment for high blood pressure is continuous, developing and maintaining a healthy lifestyle needs case management, support, and a professional’s advice. Effectiveness in case management does not only improve adherence to treatment and lifestyle changes but control of the condition, its symptoms, and reduced number of emergency room visits. In addition, case management effectiveness reduces hospitalization, physical and psychological impact, and improved quality of life. Today, chronic illnesses have increased, and this calls for a need to control them. Management of chronic diseases does not only entail treating the disease but equipping and supporting the patient in different ways.
Delegate your assignment to our experts and they will do the rest.
When dealing with patients suffering from high blood pressure, the nurse has to become a case manager because nurses are usually close to patients. Many studies have investigated the effects of lifestyle changes, training offered by nurses to patients with hypertension, case management, and adherence to treatment and found them an effective way of managing the condition. The current paper proposes a case management plan for patients with hypertension, identifies its goals, key stakeholders required in approval and implementation of the program, and the outcomes of the recommended case management plan.
Recommended Case Management Plan
The case management process is a holistic method in the management of a patient’s condition involving his/her support system (Mullahy, 2016). The proposed plan is adaptive to the practice environment of a case manager and the healthcare facility. This case management plan consists of nine stages, namely screening, assessment, risk stratification, planning, implementation, follow-up, care transition, communication after the transition, and evaluation. The process of case management is cyclical and iterative; hence stages can be revisited as required until the expected outcomes are realized (Cohen & Cesta, 2005). The phases of the proposed case management plan are as discussed below:
Phase One: Screening
In this phase, the case manager will visit the patient’s home to conduct an assessment of the patient’s needs. The case manager will then create a list of the patient’s health issues related to hypertension. The information gathered at this point will be essential while making a care plan for the patient. Screening focuses on the evaluation of critical information on a person’s health condition to identify the need for case management services (Yun et al., 2014). The primary purpose of screening is to determine if the patient can benefit from case management services. As a result, early intervention will be promoted, and the desired outcomes realized.
Phase Two: Assessment
The information to be collected for the hypertensive patients’ assessment include health participation, knowledge of hypertension self-care practices, health conditions, use of services, socioeconomic status, home environment, support network, health insurance plan, cognitive and physical function, and the willingness to accept change. The case manager may use two major strategies in collecting a patient’s information. The first strategy is face-to-face interaction with the patient, the patient’s support system, and physicians involved in the patient’s care. The second strategy is the collection of information by assessing different records such as the patient’s health records and employer, among others, as would be required (Mckay, 2005).
Phase Three: Risk Stratification
Risk stratification involves categorizing a client in one of the risk groups. These groups are low, moderate and high risk. The purpose of satisfying is to help identify the appropriate type of intervention based on a patient’s condition and needs. Stratification allows the case manager to execute targeted risk group interventions that improve a patient’s outcomes (Mullahy, 2016). Among the factors to be considered are other health conditions besides hypertension, medication, use of substances/alcohol, blood pressure level, physical activity level, nutrition, mental health, support system, and socioeconomic status, among others.
Three groups will be used to stratify hypertension patients. Risk group one will include patients with no risk factors and a lack of target damage to organs or the presence of cardiovascular illness. The second risk group will consist of hypertensive patients with at least one risk factor without organ damage or identified cardiovascular conditions. Diabetes is not included in this group. The risk factors in the second group included smoking, the presence of dyslipidemia, patients above the age of sixty years for males, postmenopausal females, and a family history of heart disease. The final group will comprise of patients with diabetes as well as a cardiovascular disease with proof of organ damage. Conditions qualifying for group three include diabetes, left ventricular hypertrophy, angina, stroke, congestive heart failure, nephropathy, myocardial infarction, and retinopathy, among other conditions qualifying as target organ damage (Yun et al., 2014).
Phase Four: Planning
The planning stage involves the identification of goals and objectives for care. Also, interventions and services to be provided are identified in this phase. The services and treatment to be given are based on the identified needs during a patient assessment at the beginning of the case management process (Mullahy, 2016). Also, the patient’s risk group is considered when planning. In this phase, the case manager will develop a personalized case management plan for each patient in consideration of a patient’s input, physicians and other healthcare staff taking care of the patient, approval, and his/her support network. The plan should be action-inclined, particular on period, and multidisciplinary (Yun et al., 2014). The case manager will address the patient’s needs for individual care and care throughout the continuum. The desired outcomes of the plan will also be identified at this point. The expected outcomes should be both measurable and attainable in a set period (Yun et al., 2014). In addition, evidence-based practices and guidelines would be essential in taking care of patients.
Phase Five: Implementation
Implementation involves the execution of case management tasks and interventions required to accomplish the patient’s identified case management goals (Mullahy, 2016). In this phase, the case manager will bring together and integrate all the services and services required to meet the patient’s needs. The case manager will identify case management services according to the patient’s condition. The care will be provided through home visits by the case manager or phone calls. Home visits will enable the case manager to offer services such as counseling and education to his/her patient directly. Guidance and education on essential aspects of hypertension management such as weight control, counseling on moderation in alcohol consumption, quitting smoking, and appropriate physical activity levels will be offered.
The case manager will offer guidance on the appropriate use of medical services, counseling on diet, medication, and how to manage complications associated with hypertension. Moreover, case managers will provide education on family support and how to take blood pressure, among other activities, as identified based on the patient’s needs and risk category. Case managers will constantly share important information with patients and their support systems. Also, the information will be shared with other healthcare staff working with the case manager, the patient’s payor, and all other relevant individuals.
Phase Six: Follow-up
During follow-up, the case manager will review, evaluate, monitor, and reassess the patient’s health, needs, ability to take care of oneself, adherence to treatment, and lifestyle changes. In addition, the patient’s treatment plan and outcomes will be evaluated. The main objective is to assess how effective and appropriate the case management plan is (Mullahy, 2016). The case manager, at this point, will gather adequate and relevant information, share it with the patient, support network, and healthcare staff involved in offering care, among others. The case manager will identify any need to make revisions or modifications to the patient’s care plan.
Phase Seven: Transition
Transition involves moving the patient across case management services based on the patient’s health status and required services. The case manager will prepare the patient and the support network for discharge, transfer to a different facility, or transition to another level of care. To ensure a safe transition, the case manager has to ensure that there is adequate communication with important individuals in the next stage of care or the support system (Cohen & Cesta, 2005). In addition, the case manager will educate the patient on care after transition and the required follow-up.
Phase Eight: Communication after Transition
This phase will involve communication with the patient or the support network to determine how the patient is progressing after transitioning. The case manager in this phase is required to inquire about services offered to the patient and medications, among other issues related to the patient’s health/condition (Mullahy, 2016). The case manager will conduct follow-up on different issues identified during communication after transition and seek ways to address them. Based on the identified issues, the case manager may involve other staff to identify a solution. Moreover, the case manager will be required to give feedback collected to key stakeholders, such as care providers and health insurance firms.
Phase Nine: Evaluation
During the evaluation, the case manager will measure the outcomes of the patient’s case management plan for hypertension and the impact of the plan on the patient’s health condition. Different outcomes, such as clinical, physiological, and treatment management, among others, are evaluated (Cohen & Cesta, 2005). The case manager will produce a results report for the patient.
Stakeholders
Stakeholders’ support is essential in ensuring the success of a case management plan. Stakeholders ought to be involved in every step of the case management process to create support, get suggestions, and take part in the assessment. The involvement of stakeholders in each phase can solicit buy-ins, success, and development of long-term support of a plan ( Rosery, H., & Schonfelder, 2018) . The stakeholders and individuals needed to support the plan in the organization include patients suffering from hypertension, a patient’s support network, and different healthcare systems such as care providers and payors. It is important to include all the interdisciplinary group members for the plan to receive implementation support.
Goals
Patients will adhere to treatment, and the lifestyle changes made to control blood pressure.
The patients will be able to control the symptoms related to hypertension
The number of emergency visits made by high blood pressure patients will significantly reduce
Patients will have reduced or no need for hospitalization.
The physiological and psychological impact of treatment will improve.
Patients will have an improved quality of life
Conditions such as heart disease, stroke and renal disease, among other diseases related to hypertension, will be prevented.
Conclusion
Hypertension is one of the leading causes of death across the world. Hypertensive patients require multiple lifestyle changes in an attempt to manage the condition. They ought to understand how to live with the disease and its symptoms as well as the inconveniences that accompany it. To ensure that hypertensive patients adhere to treatment and have appropriate care, it is crucial to inform them of the required lifestyle changes that should be made. As a result, healthcare professionals such as nurses have an immense responsibility because they are required to collaborate with different healthcare professionals such as doctors and nutritionists. Case management for hypertension patients is a collaborative process that involves assessing, planning, facilitating, coordinating care, evaluating, and advocating for different services and treatments to meet a patient’s health needs. The case management plan will impact patient’s knowledge as well as different psychosocial factors such as support networks which lead to improved personal care behaviors. The case manager will provide supportive services such as education and counseling to both patients and their families to ensure effective behavior change in health practices and the use of health care services. Changes in lifestyle and individual care behaviors among hypertensive patients are linked to short term results, which consequently impact the long term health of patients and their use of medical services.
References
Cohen, E. L., & Cesta, T. G. (2005). Nursing case management: From essentials to advanced practice applications . Elsevier Health Sciences.
McKay, S. (2005). A collaborative process between disease management and case management. Lippincott’s Case Management , 10 (6), 310-312. https://doi.org/10.1097/00129234-200511000-00013
Mullahy, C. M. (2016). The case manager’s handbook . Jones & Bartlett Publishers.
Rosery, H., & Schönfelder, T. (2018). Healthcare system stakeholders. White Paper on Joint Replacement , 91-104. https://doi.org/10.1007/978-3-662-55918-5_4
Yun, S., Lee, I., Kim, J. H., & Ko, Y. (2014). Effectiveness of community-based case management for patients with hypertension. Journal of Korean Academy of Community Health Nursing , 25 (3), 159. https://doi.org/10.12799/jkachn.2014.25.3.159
