Alfrina Hany, S.Kp, M.Ng (AC)Diberikan pada mata kuliah Keperawatan Kronis Jurusan Keperawatan FKUB

20 & 24 Agustus 2018

Model Keperawatan Kronis

Model Keperawatan Kronis

Suatu model yang mungkin paling tepat untuk merawat pasien dengan penyakit kronis.

Fokus model ini adalah terbentuknya interaksi yang produktif antara pasien yang

mengalami penyakit kronis dengan tim lintas profesi yang pro aktif.

Titik berat pelayanan ini lebih mengutamakan pada pelayanan di luar rumah sakit

Model Keperawatan Kronis Direkomendasikan ada 6 elemen yg mjd sentral penting untuk meningkatkan pelayanan

keperawatan kronis.

Elemen tersebut adalah :

1.Community

2. Health systems

3.Self management support

4.Decision support

5.Delivery system redesign

6.Clinical information systems

Keterkaitan antar elemen dapat terlihat pada gambar di

bawah ini :

Outcomes vs Interaction

Improved outcomes/hasil yang meningkat (status kesehatan yang lebih baik dan

kepuasan pasien) berasal dari interaksi yang produktif antara pasien dan tim kesehatan.

Agar interaksi bisa produktif maka interaksi tersebut harus dibentuk dalam 4 area yaitu :

Self management support : bagaimana kita membantu pasien untuk hidup dengan kondisinya

Delivery system redesign : WHO is there and WHAT do they do to contribute to good

quality care

Desicion support : promote clinical care that is consistent with scientific evidence and patient

preferences (yg terbaik utk pasien dan bisa terus dilakukan)

Clinical information systems : bagaimana kita mendapatkan dan menggunakan informasi

untuk perawatan pasien

Organisasi Kesehatan & Komunitas

Keempat aspek perawatan ini berada di tingkatan layanan dimana dipengaruhi oleh

organisasi kesehatan dan sistem kesehatan yang berada di dalam komunitas

Sumber daya dan kebijakan di komunitas juga akan mempengaruhi jenis pelayanan yang

akan diberikan.

Essential Element of Good Chronic Illness

Care

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Informed,

Activated

Patient

Productive

Interactions

Prepared

Practice Team

Interaksi bisa dengan bertemu langsung, bisa melalui telpon ataupun melalui pesan.

Produktif artinya perawatan pasien dengan kondisi kronis dilakukan secara

sistematis dan kebutuhan pasien terpenuhi

What characterizes an “informed,

activated patient”?

They have the motivation,

information, skills, and confidence

necessary to effectively make decisions

about their health and manage it.

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Informed,

Activated

Patient

Prepared

Practice Team

At the time of the interaction they have the

patient information, decision support, and

resources necessary to deliver high-quality

care.

What characterizes a“prepared”

practice team?

• Mengkaji kemampuan manajemen diri & kepercayaan diri pasien

berdasarkan status kesehatannya shg bisa menjadi self manager yg baik

• Menyesuaikan manajemen perawatan dengan langkah - langkah di SOP

• Active, follow-up secara berkelelanjutan.

Informed,

ActivatedPatient

Productive

Interactions

Prepared

Practice

Team

How would I recognize a

productive interaction?

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Self-Management Support

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Empower and prepare patients to manage their health and health care.

Emphasize the patient’s central role in managing their health. Providers reinforce the

patient's active and central role in managing their illness.

Use effective self-management support strategies that include assessment, goal-

setting, action planning, problem-solving, and follow-up.

Evidence now strongly suggests that to achieve optimal outcomes in most chronic

illness, we must improve the patients ability and interest in managing their own

condition.

The strategy to support self-management (the 5A’s):

Assessment includes not only knowledge but beliefs and behavior. (Knowledge

isn’t enough to change behavior. We need to understand more about what

patients value and what they do.)

Advice needs to be linked to scientific evidence, not provider biases.

Agree on goals that are important to patients and actions to reach them.

The 5A's :

Assist by identifying barriers and problem-solving to deal with them.

Arrange a specific follow-up plan including utilizing internal and community

resources to provide ongoing self-management support to patients.

Contoh

Astma Action Plan memandirikan pasien asma dalam mengidentifikasi kondisi

dirinya dan apa yang harus dilakukan saat di rumah

Delivery System Design

(This is about HOW we interact with patients)

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Define roles and distribute tasks among team members.

Use planned interactions to support evidence-based care. Planned interactions have an agenda, like a routine physical visit. Planned visits

can be either 1:1 or in groups.

Provide clinical case management services for high risk patients. Patients with complex needs, or engaged in an acute transition or exacerbation,

often benefit from more intensive attention. The use of a clinical case or care manager, usually a nurse or a pharmacist, has been shown to be effective

Delivery System Design Ensure regular follow-up.

Follow-up is not left to chance. Better outcomes in chronic illness care are due to proactive follow-up by the health care team. In chronic illness, it is Follow-up, Follow-up, Follow-up.

Give care that patients understand and that fits their culture.

Patients should be routinely asked to “teach back” to check comprehension and if they are comfortable with the plan. Providers need to check in with patients to make sure that the interaction style is compatible with their cultural norms, values, and beliefs.

Decision Support

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Embed evidence-based guidelines into daily clinical practice.

We need to not only possess guidelines, but we must get them off the shelf or the

computer screen and use them in decision making.

Integrate specialist expertise and primary care.

Use proven provider education methods.

Share guidelines and information with patients.

Another thing we can do is to inform patients of guidelines pertinent to their care so

they understand why a particular test, procedure, or screening is being performed.

Clinical Information Systems

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The crucial factor in improving chronic illness care is aclinical database that has the critical information that oneneeds to have a productive interaction (a registry)

Organize patient and population data to facilitate efficientand effective care.

Health Care Organization

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Create a culture, organization, and mechanisms that promote safe & high-qualitycare.

Visibly support improvement at all levels, starting with senior leaders.

Promote effective improvement strategies aimed at comprehensive system change.

Encourage open and systematic handling of problems.

Provide incentives based on quality of care.

Develop agreements for care coordination. Develop agreements that facilitate care coordination within and across organizations. Work

with local hospitals, and social service agencies in an open and coordinated manner

Community Resources and Policies

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There are many important resources and services for patients that are not part of most

medical systems: peer support groups, exercise programs, nurse educators, or dieticians

Encourage patients to participate in effective community programs. This means you need to

first know what and where they are.

Form partnerships with community organizations to support and develop interventions

that fill gaps in needed services.

Advocate for policies to improve patient care such as insurance coverage for diabetes

supplies.

Examples of service delivery components of the Chronic Care

Model

www.improvingchroniccare.org

Access resources at:

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Praktikum

Kelas dibagi menjadi 6 kelompok

Masing-masing kelompok memilih sub elemen model yang dikehendaki dan

berdiskusi terlebih dahulu

Kelompok mengaplikasikan sub elemen model tersebut dengan membuat role play

Kelompok mendapatkan masukan dari kelompok lain

TERIMA KASIH