Chronic condition self management: Working in partnership toward appropriate models for age and culturally diverse clients
Clinical Practice Consultant, Asthma Care Coordinator, State Wide Paediatrics, Department of Health South Australia, North Adelaide SA
Senior Lecturer and Child Protection Consultant, Division of Health Sciences, School of Nursing and Midwifery, University of South Australia, City East Campus, Adelaide SA
with Jenna A Paterson
University of South Australia
PP: 169 - 178
Chronic conditions place a significant burden on the Australian health care system, and this burden continues to increase. This article examines the concepts of chronic illness and chronic condition self management (CCSM), particularly in the context of asthma. It explores the implementation of, and barriers to, CCSM in the modern health care system with a focus on CCSM in children and adolescents, and the differences that need to be recognized when dealing with Indigenous Australian children.
chronic condition, chronic condition self management, children and adolescents; asthma
It is estimated that just over seventy per cent of Australians have a chronic condition and this is likely to increase ten per cent by 2020 (Jordan & Osborne, 2007). Comparing this group to people without a chronic condition they place a greater demand on resources and an already over burdened health care system (Cunningham et al., 2008; Newland & Zwar, 2006). Asthma is one such chronic condition (Newland & Zwar, 2006) and is identified as a national (Saini et al., 2008) and state health priority due to its impact on communities and care resources (Department of Health South Australia, 2007). One in nine children is diagnosed with asthma. Unlike some other chronic conditions, it is not preventable but managed with a focus on symptoms, co-morbidity reduction (Couzos & Davis, 2005) and reduced demands on health care intervention (Cunningham et al., 2008; Newland & Zwar, 2006). How can chronic conditions, such as asthma, be better managed before they overwhelm the Australian health care system? Are there solutions and are these achievable within present health systems and care frameworks? This paper will define chronic condition, identify barriers to health care delivery changes for persons with chronic conditions, and explore chronic condition self management (CCSM) children and adolescents with chronic conditions.
What is chronic condition?
The literature defines chronic condition in adults as lasting longer than six months (Jordon et al., 2008) and the chance of developing a chronic condition increases with age (Newman, 2008). No such definition exists for children and adolescents with a chronic condition however children with 'special health care needs' are defined as at risk of a chronic condition and as requiring care beyond the general paediatric population (Sawyer, 2007; Sawyer & Aroni, 2005). Thus the concept of chronic condition in children and adolescents differs from that in adults and therefore planned management needs to differ between these groups. Chronic conditions place significant burdens on family units and as these children mature the burden increases for families, health professionals and health care systems (Sawyer & Aroni, 2005). A report by Sawyer (2007:622) found that 'one in five children and adolescents have special health care needs and one in ten children do not live a full and active life because of the limitations and/or disabilities from their chronic conditions.' If the focus of self management is not broadened to include children and adolescents, current funding for this strategy will quickly be re-directed toward other projects.
Barriers to change in health care delivery
The final report of the South Australian Generational Health Review (Government of South Australia, 2003:1) found that for the health industry to be sustainable into the future a shift in paradigm is required from acute care to primary care focus with its emphasis on early detection and prevention of disease. There are contrasting thoughts regarding the impact of this shift for people with chronic conditions. Matheson et al. (2006) studied the management of airway disease in a large cohort of Australians and identified it vital that persons with chronic conditions be managed in acute care areas where specialist professionals are better equipped with expert knowledge. Other researchers believe that better health outcomes are achieved in the primary health care setting (Jordon et al., 2008; Newman, 2008; Wilson et al., 2007) where expert knowledge is also available but perhaps under-recognized and under-utilized.
Asthma is not preventable but early intervention improves clinical outcomes (Kumar & Clark, 2005). Therefore the expertise of a respiratory specialist may be required initially for clinical diagnosis with continued management having a community multidisciplinary and "partnership in care" approach (Bateman et al., 2008). The majority of people with chronic conditions are seen in primary health settings, predominately by general medical practitioners (GP) (Harris et al., 2008). As a result of this the Australian Government has invested heavily in health care programs targeted at CCSM in this area (Osborne, 2008). However, a barrier to the success of these programs is GP's lack of engagement in these programs resulting in low numbers of clients being referred and hence reduced program viability in GP practices (Jordan & Osborne, 2007). Likewise Newman (2008) states that for chronic management programs to be integrated into routine health care they must attract GP support. In contrast, GPs state they are underpaid and time poor and therefore not able to engage with and support these programs (Goeman et al., 2005). So, whilst there is a Government focus to assist with CCSM approaches in primary health care settings such as general practices, GPs believe the funding is not sufficient to support such programs and they have no time to engage in these models of client care. If this is the case, it is vital to equip practice nurses to be involved and assist such client groups with self management processes to achieve and maintain better quality of life (Weng et al., 2007). Community or out of hospital nurses are an integral inclusion in the primary health care team when managing asthma in children, especially in adolescents (De Benedictis & Bush, 2007). Furthermore nurse-led asthma home visiting programs have been used to identify asthma triggers in poorly controlled symptoms (Bracken et al, 2009).
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