Care Management Model for Older Adults with Chronic Diseases in Community

Abstract

           Many Thai older adults are living longer but with increasing levels of disability from chronic illnesses in the community. Registered nurses play a vital role in providing care management for older adults with complex chronic diseases, frailty, and comorbidities. This article studied on the definition and conceptual framework of the following: 1) identification of members who need care management, 2) comprehensive needs assessment, 3) care plan development, 4) implementation of care plan, 5) analysis of the effectiveness and appropriateness of care plan, 6) modification of care plan based on the analysis, and 7) monitoring of the outcomes. This study also demonstrated the successful key of care management in community as follows: 1) appropriate patient selection, 2) person-to-person encounters, 3) trained care managers with low caseloads, 4) multidisciplinary teams including physicians, 5) informal family caregivers, and 6) use of coaching technique, and applying the care management model to older adults with complex chronic diseases in the community. This article contributes to understanding care management concepts and identifying an action guideline for providing care management that has improved the quality and reduce the costs in health care services.