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Disease Management:
Riding the New Wave of Care

By Rose Lucas, RN

(Page 2 of 2)
To understand DM and its premise, one has to have an appreciation for the adult learners. The methodology of an adult learner incorporates the value system of the individuals: if adults donít find value in what DM is teaching, they wonít implement the health management practices we nurses will want to teach them. It is the challenge of the DM nurse to try and help individuals understand why it is important to take their medications, or go to the doctor on a regular basis. This can be an important aspect for caregivers, for at times the role of being the educator/caregiver is rejected by the very person they are caring for. That ďother voiceĒ can be invaluable in reiterating the teachings the caregiver had previously shared.
This takes the skill of a seasoned nurse to recognize if less or more education is needed from a call.  The magic happens in DM when goals are met during a call with the help of the DM program. Documenting this positive outcome demonstrates the success of a DM program. Initial calls take the most time, allowing for the patientís individuality in health care and emotional needs. Once your loved one becomes an established patient, fortified with educational materials on their health care needs, the DM programs call once every two to three months to maintain the health maintenance goals. If there has been a recent hospitalization, restorative health goals are incorporated by the DM program. The nurse makes a call once a week until the individual is stable. The reevaluation of the goals every time there is an interaction with the DM nurse shows how the DM programs are interactive with the patientís health. DM programs should be always evolving and changing around the established needs.

Both the caregiver and their loved one deserve to be exposed to the philosophy of care that disease management can provide. The health care industry is stretched thin in resources, one of which is providing the time once spent teaching patients how to care for themselves when they get home. Individuals are more clinically fragile upon discharge than they were five years ago. The discharge teaching that was once comprehensive is now whittled down to a five-minute flow sheet. Family membersí abilities to comprehend is impaired by the anxiety and desire to get home. Once home, with the adrenaline rush that sustained everyone while in the hospital gone, both the caregiver and their loved one becomes frightened by the toll of the disease condition. Too often, it is when they are home that the questions and desire to learn more become apparent.  The preventative/ restorative plans of care gently implemented with a telephonic DM program in the comfort of oneís home may be literally what the doctor ordered to stay on the right track to health.


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