Concept of Shared Decision Making

Introduction

The concept of Shared decision-making (SDM) plays an important role in patient health outcomes. SDM refers to when patients and health care professionals work together. This means that, patients are put at the centre of making critical decisions concerning their treatment and care. Additionally, the various available choices for an individual are discussed which enable the patients reach decision together with the health and social care professional (Slade, 2017). Furthermore, studies show that patients who have long term conditions and who are actively involved in their care have better outcome compared to those who are passive participants in the process of SDM. Likewise, it is essential in the efficacy for commissioners as it reduces unwarranted discrepancies in clinical practice (Coulter and Collins, 2011). This paper will discuss shared decision making in health care while discussing the long term conditions and community nursing in managing these condition. The assay is based on case scenario of Mr Jameson to achieve its learning outcomes. The paper is very important in advancing knowledge in SDM and long term condition management as well as the role of community nurses and matrons among other specialist in the community.

Background

Following a recent visit Mr Jameson was given a diary by the diabetic nurse to keep record of his diet and weight. Keeping a diary allows for a comprehensive view of how certain meals or foods affects blood glucose levels. Furthermore, keeping a dietary diary aids patients with diabetes self-manage their condition better. There are different types of diaries to suit each individual lifestyle or preferences, like using mobile Apps or computer software or just keeping a physical book/ journal (Davies, 2014). This indicates that in the case of Mr Jameson (Appendix 1), because of his high BM and overall negligent of managing his condition keeping a diary is vital. Studies suggest that, proper diabetes and blood pressure management is very critical. For instance, with poor management, diabetes and blood pressure damage blood vessels, kidney, as well as the nerves (Dehlendorf et al., 2017). Currently many people are suffering from various long term conditions (LTC) just like the case of Mr Jameson. LTC refers to health disorders which cannot be cured though their complications and symptoms can be controlled with treatment. Such conditions includes diabetes, asthma, arthritis and high blood pressure (Dehlendorf et al., 2017).

The Chronic Care Model is an organizational approach for taking care of individual with long term conditions. It emphasises the importance of establishing a health care system that prompts a more proactive approach that focuses on aiding patients with self-management. Unlike the reactive approach, in which service responds mainly when people fall ill. Lastly this approach also enables patients to actively be involved in making decisions (Coulter et al. 2013). Therefore, given the advantages of the model, this can be most effective approach to manage Mr Jameson case.

The bio psychosocial perspective aims to provide a more comprehensive framework contrary to the biomedical model which only considers the biological and more scientific determinates of health. The bio psychosocial model encompasses more holistic and integrated view. This includes the biological aspect which concerns the anatomical, structural and molecular substance of disease, in addition the effects of the biological functioning. The psychological structure of the model deals with psychodynamic factors, such as experience and reaction to illness, essentially it indicates how individuals cope psychologically with illness. Lastly the social aspect pertains to how environmental, cultural and familial factors influence coping and experience of illness (Dogar, 2007). In the case of Mr Jameson is biological needs include lowering and maintain adequate glycaemic control, this is to avoid any further complications. His latest results presents HbA1c 9%, blood glucose 17mmol/l and blood pressure 190/90.

The World Health Organization (2011) recommends that HbA1c for diabetic ideally should be 6.5% (48mmol/moll) or below. Hba1c indicates average plasma glucose over a period previous 8-12 weeks, and is often used as a diagnostic tool for diabetes. In the aspect of psychological needs Mr Jameson’s wife reports that he has been depressed lately, and when at home is inactive. He also indulges in fried food and have a tendency to over eat.

Discussion

Following a recent visit to the clinic Mr. Jameson Hba1c was 9%, blood glucose level was 17mmol/l and BP of 190/100mmHg.

With such cases, a primary care manager would need to take charge in the care planning. For instance, community matron (CM) are tasked with managing the care of individual with LCT with the objective of reducing and preventing unnecessary hospital admissions and reducing length of stay in hospital. Furthermore, the role of the CM also includes improving outcomes for patients, in which they adapt an integration of all elements of care. Moreover, they facilitate important information which is relevant to people with LTC. CM is also responsible for reviewing and prescribing medication. Lastly, working collaboratively with other relevant agencies and coordinating those inputs is an essential role of the CM (Bentley, 2014). The role of CM was initially introduced by government to tackle the increasing number of patients with multiple complex LCT and social care needs, evidently there is an ambiguity regarding the effectiveness of CM role in reducing acute hospital admissions (Kazmierski and King, 2015). Reducing the length of stay in hospitals in the UK is priority due to increased length of stay from hospital admission when compared to other European countries (Turner, 2015)

First priority for Mr Jameson would be adequate glycaemic control. In the 1990s Wagner et al developed the Chronic Care Model (CCM) with the intention to act as a patient-centred, evidence-based and proactive approach and achieve a more comprehensive health care system for individual with chronic diseases. The model is comprised of six main components, made up of health system of a health organization (HSHO), self-management support (SMS) decision support (DS), delivery system design (DSD), community-including organizations and resources for patients (CORP) as well as clinical information systems (CIS),

Moreover, Wagner suggest that in order to enhance patient’s confidence, skills and to allow patients to gain complete control of the management of their illness, there must be an interaction between patients and health care providers. The interaction objective is to put in place a care delivery system with well-developed process and catalyst which allows for changes in the care delivery system (Yeoh et al. 2017).

Self-management is an important key element of the Chronic Care Model (CCM) with premise of empowering patients by way of education, counselling and providing training for patients. Furthermore, some studies indicate that SMS when utilized effectively can assist with the improvement of clinical outcomes, better quality of life and lower costs. However, it requires both health providers and patients to share responsibility (Yeaoh, et al. 2017).

The Roper-Logan-Tierney (RLT) nursing model can be divided into: model of nursing and model of living. The premise of the model is set out so that it can be applied in specialized areas in nursing practice respectively. In the model of living there are 12 core activities of daily living activities identified. However, for the purpose of the case scenario the only activities pertaining Mr Jameson will be examined, although one activity cannot be undertaken on the exclusion of another.

The activity which are very essential in controlling or maintain a good glycaemic level for Mr Jameson would be ‘eating and drinking’. According to this model this activity depends on various factors, such as accessibility and affordability to healthy food options. Therefore, special consideration should be made when addressing scenario (Holland and Jenkins, 2019). Nutritional therapy is considered to be a crucial element of the effective management of diabetes mellitus, along with achieving successful glycaemic control, including reducing long term tissue damage. Diabetes UK outlines nutritional guidelines relevant to people with Type 2 diabetes (T2D). It is recommended that a dietician who is registered and with relevant nutritional expertise participate in delivery of nutritional care, it’s equally significant that all multidisciplinary members can delivery evidence-based nutritional advice (Dyson et al, 2011).

The Diabetes UK recommendation (2019) highlights four elements of glycaemic control in T2D, this include weight loss by at least 5% in the overweight population, thus reducing calorie intake while increasing energy expenditure. Secondly, healthy diet such as the Mediterranean-style diet. Thirdly providing education that assists with identifying carbohydrate intake, with aim of reducing the total amount of carbohydrate intake. Lastly, vigorous physical activity of at least 150mins every week, in the course of three days per week are also recommended.

Limitations on studies based on dietary approach implies there is no one specific dietary style, in the long term management of T2D therefore, should be based on factors such as overall nutritional quality of the diet as well as the individual preference. In addition to any risk of harm and clinical benefit should be take into consideration. However, a meta-analysis of RCTs states that, a Mediterranean-style diet can lower HbA1C as much as 5mmmolmol (0.47%). Similarly, another meta-analysis of RCTs asserts that a 5% or more weight loss can reduce HbA1C substantially by 7mmmol/mol (0.6%) (Evert et al., 2019).

It’s of great importance for Mr Jameson to be offered structured diabetes education programme as such programme has been proven to be clinically effective and beneficial as it concerns with improving glycaemic control, weight loss, quality of life and reducing cardiovascular risks. (Diabetes UK, 2018).

This means that Mr Jameson would be referred to such programme, DESMOND (Diabetes Education and Self-management for Ongoing and newly diagnosed). According to UK National Diabetes audit 2014-15 for England and Wales states that only 5.3% of those 75% patients with type 2 diabetes whom have been offered attended. Nonetheless, DESMON is a NICE approved structured education programme, which consist of 6 hours face-to-face educational sessions which are delivered in group format (Chatterjee et al. 2017).

Second priority to meet Mr Jameson biological need would be managing his hypertension. The primary course of treatment has been monotherapy treatment. With the new guidelines set by the European society and European society of cardiology now recommends two antihypertensive drugs as the most effective line of treatment to lower elevated BP, thus controlling BP. The guidelines also stipulate in cases which that isn’t achieved three or more antihypertensive drug strategy should be implemented (Mancia, 2018). Mr Jameson has been prescribed in accordance with such guidelines two antihypertensive drugs.

Fig.1. bio-psycho social table of need

Fig.2. bio-psycho social table of need of Mr Jameson

Nonetheless, non-adherence to prescribed drugs amongst patients with long-term condition is very common. One study suggests that adherence to hypertensive drugs are related to patient’s factors. Based on one pharmacy refill records indicated that there is a link between adherence to medication and achieving control (Borzecki, et al. 2005). Factors such as doubts of efficacy of drug, asymptomatic condition prompting patients to stop taking medication, costs, low health literacy and perception of condition all contribute to poor adherence to medication (Tan et al. 2017). Lastly, patients of African ethnic origin when compared to Caucasians patients have higher rates of the onset of hypertension. In turn higher rates in hypertension is associated with higher risk of stroke, end-stage renal disease and congestive heart failure. The reasons remain unclear for the racial disparities in levels of high blood pressure and related risks associated with hypertension amongst those of African origin (Lackland, 2014).

Home monitoring prompts better adherence of treatment as well as leading to lower BP in comparison to standard care. Further, home monitoring guide’s therapy and achieves better management of blood pressure and sees better patient satisfaction. Lastly, home monitoring can assist in identifying resistant antihypertensive treatment (Mcgrath, 2015).

In order to optimise the management of a long-term condition such as diabetes mellitus, shared-decision making (SDM) have been the most effective approach in the management of such condition. SDM has been defined as been a collaborative decision-making between clinicians and patients. As it’s evidence-based by adapting the best available evidence, in which patient’s treatment can be optimise as it weighs benefits and harms in the treatment options. Further, the SDM aids the effectiveness decision-making process. This means patient’s involvement would consider their preferences along with the clinicians input to set personalised targets. The study conducted by Ouden et al. (2017) concluded that, the goal setting with a clinician could be a useful in aiding of treatment adherence, and the proportion of patient’s to successfully reach all their treatment goals.

Similarly, Healey et al. (2015) asserts that quality of health are essentially important determinant and health service costs due to the global increase in the prevalence of LTCs. NHS outcomes framework domain 2 adopted the House of Care framework in order to enhance quality of life for individuals with long-term conditions. Additionally, people with long-term condition often also have co-morbidities, people with multiple LTCs have decreased quality of life and clinical outcomes in addition to longer hospital stays.

Therefore, in the management of Mr Jameson DM and depression, tele health would to be incorporated in his care management. Tele-health emerged in the early 1900s and it’s system which facilitates the process of information sharing between the health care provider and patients. Tele-health involves a wide range of medical modalities, including different methods of delivering multiple ranges of technological advanced equipment. Tele-health has seen increased usage by nurses and nurse-practitioner in practice in consultations, remote patient monitoring and patient education.

In the case of Mr Jameson tele-health consultation would mean getting relevant information in the assessment of his conditions, management of problem via telephone or provide relevant referral to the appropriate service. Adopting tele-health could potentially reduce or eliminate geographical distance which could be a barrier for patients to receive treatment and care. In particular, in rural areas this would be beneficial, as otherwise those people would have limited access to health care. On the other hand, tele-health poses data protection and ethical issues as patient information, etc are transmitted via this technology. However, tele-health sees cost reduction and improved health outcome (Neville, 2018).

Similarly, Tregenza (2019) argues that tele-health facilities early detection of potential deterioration thus promoting timely intervention. Furthermore, any out of the ordinary readings of patient’s health aid in preparing CM for intervention prior to face-face consultation. Along the same line, Tregenza (2019) also highlights the NHS long term plan (NHS England 2019) which acknowledges the complexity of the management of patient needs in primary care, with promised resources and funding in the effort to improve care in the community whiles at the same time promoting self-care.

However, CM faces several challenges in the community such as hostility of some patients and members of community, lack of resources, lack of enabling technology among other challenges. For instance, with the advancement of technology, the Electronic record keeping is very critical for CM for easy retrieval and follow up of patients (Brodney et al., 2016). This means that, with such data software, the CM work can be very effective. Similarly, studies suggest that, there is lack of enough nurses in community care (Healey et al. (2015). Moreover, it has affected ability of patients to be managed close/at home hence changing how nurses operate and the whole community nursing.

Moreover, Duncan (2019) explains that integrated health and social care models that are gaining province and are adopted from the Netherland; Buurtzorg model and Embrace. Several elements emerged from the WHO system of integrated care in relation to multi-morbidity such service delivery, information and research and leadership and governance. Additionally, Struckmann et al. (2018) highlighted five key elements of integrated care ‘coordination of services, person-centred care’, self-management, holistic assessment, integration and collaboration’. With one of the enabling factors being use of electronic information systems. Hence the implantation of tele-health in Mr Jameson care plan.

According to Huang et al. (2015) there is a correlation between T2D and depression in that, they argue the onset of depression stems from negative emotional response triggered by failure to adequately maintain good glycaemic levels. Moreover, studies indicate that poor glycaemic control as well as low compliance with therapies.

Likewise, there is link between depression and T2D with patients whom have increased risks associated with cardiovascular disease, renal impairment and retinopathy. Thus affecting elements of daily and social life, as well as health related quality of life. Huang et al (2015) study conclude that implementing Cognitive Behavioural therapy and Motivational enhancement therapy which was to investigate if the employing such therapies could improve significantly HbA1c, fasting glucose and BMI 90 days after intervention, as well as decrease in depression symptoms, which found clinically and statistically significant improvements. Thus referring client such services.

Mr Jameson would also benefit from visual screen, as one of leading complication of T2D is retinopathy in addition to causing early retinal neurodegeneration leading to various visual deficits (Tsai et al. 2016). Likewise, Cairncross, Steinberg and Labuschagne (2017) asserts that visual screening should be offered in primary care as that would contribute to early detection of eye pathology in a timely manner. As that would reduce the risk of glaucoma, cataracts and diabetic retinopathy as those complications are commonly prevalent in the diabetic population. Failure to adequate offer such service could lead to poor vision, vision impairment. Therefore, Mr Jameson should be referred to an ophthalmologist.

Mr Jameson was given a diary by the diabetic nurse. He would require the input of Nutritionist in which he would receive help with food options, thus aiding patients ‘achieve health goals. Similarly, a dietician if necessary can prescribe dietary treatment for those people that require. In the case of Mr Jameson as he is overweight referral to a dietician would mean optimizing food and nutritional intake, weight loss, behaviour change and work collaboratively within the MDT for efficacy. Nevertheless, putting to consideration cultural differences and implementing effective personalised holistic-care all depend how well the health care provider degree of cultural sensitivity and awareness (Stojanovaska, Naemiratch, Apostolopoulos, 2017).

For the case of Mr Jameson there are several specialist who need to be included in his condition management. For instance, to manage hyperglycaemia, he requires to be referred to a diabetes specialist nurse (DSN). Studies suggest that, such specialist are central to individual care as well as outcomes including self-care management. (Tsai et al. 2016). DSNs therefore reduce length of stay in hospital. Therefore, in the case of Mr Jameson’s the main role of DSN would be helping him manage hyperglycaemia, improving his health care and making him confident in managing his condition (Gilday et al., 2018) Moreover, due to the emotional and psychological impact associated with diabetes and high blood pressure and challenges associated with them, another specialist needed is a Community Psychiatric Nurse. This is an individuals who effectively carry out recovery and supportive activities to individuals experiencing continual and acute mental illness (Baltzell et al., 2017). His role in Mr Jameson’s is to assess his clinical care needs and develop, implement, and review the program of care to promote increased quality health care services. This would benefit him in coping with psychological challenges associated with high blood pressure and diabetes. Lastly, due to the effects of diabetes and its effects on sight, referring Mr Jameson to an optician would be very important to check his eyesight.

Kaiser Permanente’s is prominent due to its efforts in integrating services. The organization is supported by population risk stratification which much emphasis in preventing and managing diseases (Cherry & Jacob, 2016). Mr Jameson is having a long term condition, although, with respect to psychological and emotional need, his condition should shift to level one individual due to the complexity.

Conclusion

The concept of Shared decision-making (SDM) plays an important role in patient health outcomes. SDM refers to when patients and health care professionals work together. This means that, patients are put at the centre of making critical decisions concerning their treatment and care. As per the case of Mr Jameson, it is evident that, shared decision making is very critical especially in managing long term conditions. However, it is significant to note that, due to the complexity of the long term conditions, more health care professionals are needed to take care of LTC patients.

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References

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