Nursing Practice: Complex Integrated Care Essay

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Nursing Practice: Complex Integrated Care Essay

Question:

Describe the pathophysiology of the chosen complication.

Discuss the assessment and diagnostics of this complication.

Discuss the treatment and management of this complication.

Demonstrated ability to review the literature and select appropriate sources. Nursing Practice: Complex Integrated Care Essay.

Demonstrated ability to appraise and analyse the literature .

Answer:

Introduction

Diabetes Mellitus (DM) is a metabolic disorder. It is characterized by hyperglycemia that generates due to disequilibrium in insulin secretion and/or insulin action. The pathological hallmark of DM encompasses vasculature leading to microvascular and macrovascular complications. The microvascular complications like nephropathy and retinopathy accelerates the chance of developing macrovascular complications, which promotes atherosclerosis and eventually leads to the development of cardiovascular disease, peripheral vascular disease and stroke (Marieb & Hoehn, 2015). The following essay aims to highlight the pathophysiology associated with macrovascular complications of diabetes followed by assessment and diagnostic criteria. At the end, the essay will explore common treatment and management principles underlying macrovascular complications of diabetes. Nursing Practice: Complex Integrated Care Essay.

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Macrovascular Complications: Pathophysiology

According to Chilelli, Burlina and Lapolla (2013), the main pathological mechanism in macrovascular complications in DM mainly involves atherosclerosis. Atherosclerosis results from chronic injury or inflammation of the wall of arteries present in the coronary or peripheral vascular system. Inflammation the walls of the arteries cause oxidation of the lipids from low-density-lipoprotein particles under the action of angiotensin II. The oxidized lipid particles accumulate in the endothelial walls leading to narrowing (Bullock & Hales, 2016). The activation of the inflammatory pathway causes stimulation and proliferation of macrophage and attraction of T-lymphocyte at the site of inflammation. The activated T-lymphocyte induces proliferation of smooth muscle in the arterial walls and simultaneous collagen accumulation leading to thickening of arteries. The arterial inflammation leads to narrowing of the arterial walls throughout the body and thereby increasing the chance of cardiovascular accident (Chilelli, Burlina & Lapolla, 2013). Nursing Practice: Complex Integrated Care Essay.

Chawla, Chawla and Jaggi (2016) highlighted the pathophysiology underlying the inflammation in diabetes and subsequent development of macrovascular complications in details. According to Chawla, Chawla and Jaggi (2016), hyperglycemia provokes monocyte adhesion to the arterial cells. These monocyte adhserion triggers type 1 hypersensitivity reaction, promoting the accumulation of the primary mediators of hypersentivity and thereby causing thickening of the arteries. Increase blood glucose level activates matrix-degrading enzyme metalloproteinase, which cause plaque rupture and arterial remodelling leading toe thickening of the arteries. Diabetes also increases the secretion of the primary inflammatory mediators like C-reactive protein, plasminogen activator inhibitor and interleukine-6 that cause activation of macrophage and thereby leading to the development of inflammatory reaction under the influence of protein kinase C (PKC) pathway.

Constraints on NHS funding over the past seven years, combined with rising demand from a growing and ageing population, have put the NHS under enormous pressure. It has been clear for some time that simply working our current hospital-based model of care harder to meet rising demand is not the answer. Rather, the NHS needs to work differently by providing more care in people’s homes and the community and breaking down barriers between services.

Breaking down barriers means co-ordinating the work of general practices, community services and hospitals to meet the needs of people requiring care. This is particularly important for the growing numbers of people with several medical conditions who receive care and support from a variety of health and social care staff.

The NHS also needs to give greater priority to the prevention of ill health by working with local authorities and other agencies to tackle the wider determinants of health and wellbeing. Nursing Practice: Complex Integrated Care Essay. This means tackling risk factors such as obesity and redoubling efforts to reduce health inequalities. And it means fully engaging the public in changing lifestyles and behaviours that contribute to ill health and acting on the recommendations of the Marmot report and other reviews to improve population health.

The NHS five year forward view, published in 2014, set out a road map for achieving these objectives. Several areas of England have been working to put in place the new care models outlined in the Forward View, and every part of the country has developed sustainability and transformation plans (STPs) describing how they will implement the Forward View locally. Building on these developments, NHS England’s update on the Forward View, published in March 2017, made the following bold statement. Nursing Practice: Complex Integrated Care Essay.

Our aim is to use the next several years to make the biggest national move to integrated care of any major western country.

NHS England 2017, p 31

This aim is being pursued through the new care models, STPs and the evolution of some STPs into integrated care systems. These developments hold out the promise of a different way of working in the NHS with an emphasis on places, populations and systems.

Successful integrated care systems will take more control of funding and performance with less involvement by national bodies and regulators. They will also have the opportunity to demonstrate what the Forward View is seeking to achieve through organisations working in partnership rather than competing. Partnership working is not easy in the context of the Health and Social Care Act 2012 which was designed primarily to promote competition, but some areas are finding ways of overcoming the obstacles and are improving health and care for their populations.

The aim of this briefing is to explain what is happening in practice drawing on our work with the NHS and local government. We describe developments in the new care models and integrated care systems and ask whether they are resulting in cuts in services and the privatisation of services. We also discuss what needs to be done to build on progress to date. Nursing Practice: Complex Integrated Care Essay.

What are integrated care and population health?

Integrated care happens when NHS organisations work together to meet the needs of their local population. Some forms of integrated care involve local authorities and the third sector in working towards these objectives alongside NHS organisations. The most ambitious forms of integrated care aim to improve population health by tackling the causes of illness and the wider determinants of health.

Diagram showing the focus of population health systems

Developments in integrated care in England take different forms in different places. Nursing Practice: Complex Integrated Care Essay. A variety of terms are used to describe these developments and this can be confusing and potentially misleading. For the purposes of this briefing, the following definitions describe the three main forms of integrated care that we have observed in our work.

Integrated care systems (ICSs) have evolved from STPs and take the lead in planning and commissioning care for their populations and providing system leadership. They bring together NHS providers and commissioners and local authorities to work in partnership in improving health and care in their area.
Integrated care partnerships (ICPs) are alliances of NHS providers that work together to deliver care by agreeing to collaborate rather than compete. These providers include hospitals, community services, mental health services and GPs. Social care and independent and third sector providers may also be involved.
Accountable care organisations (ACOs) are established when commissioners award a long-term contract to a single organisation to provide a range of health and care services to a defined population following a competitive procurement. This organisation may subcontract with other providers to deliver the contract.

ICPs are at various stages of development across England and ICSs have been established in ten areas1, two of which – Greater Manchester and Surrey Heartlands – are part of the government’s devolution programme. ACOs are also currently under discussion in a small number of places and NHS England is developing a new contract to be used by commissioners wishing to go down this route.

1.The 10 ICS areas are: Blackpool and Fylde Coast; Berkshire West; Buckinghamshire; Dorset; Frimley Health; Bedfordshire, Luton and Milton Keynes; Nottingham and Nottinghamshire; South Yorkshire and Bassetlaw; Surrey Heartlands devolution area; and Greater Manchester devolution area. Four further areas have recently been selected to develop ICSs: Gloucestershire; Suffolk and North East Essex; West, North and East Cumbria; and West Yorkshire and Harrogate. Nursing Practice: Complex Integrated Care Essay.

What’s happening with new care models?

A variety of new care models has been put in place to better meet the changing needs of the population. Two of these care models, primary and acute care systems (PACS) and multispecialty community providers (MCPs), seek to integrate care and improve population health. PACS and MCPs take different forms in different places but share a focus on places and populations rather than organisations. Both are examples of what we describe as ICPs and they have emerged without the need for competitive procurement.

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In PACS, hospitals often take the lead in joining up acute services with GP, community, mental health and social care services. The emphasis in MCPs is on GPs working at scale to forge closer links with community, mental health and social care services. The distinction between PACS and MCPs is being blurred as different care models evolve and increasingly converge. Both are focusing on integrating care and working to improve population health in their areas.

An advanced example of a PACS can be found in Salford, part of the Greater Manchester devolution programme, where health and care services are working in partnership to meet the needs of a population of 230,000. Nursing Practice: Complex Integrated Care Essay. This work is led by Salford Royal NHS Foundation Trust which provides acute and community services, and adult social care services under a Section 75 agreement with Salford City Council. The trust collaborates closely with the mental health trust and work is under way to engage general practices in integrating care. The clinical commissioning group is collaborating with the local council to commission these services. The PACS in Northumberland is developing in a similar way.

An advanced example of an MCP is Encompass in east Kent where 13 general practices are collaborating to improve care for a population of 170,000. The MCP has five community hubs bringing together multidisciplinary teams of GPs, community nurses, social care workers, mental health professionals, pharmacists, health and social care co-ordinators and others. These teams manage the care of individuals who have been identified as being at high risk of hospital admission. Other initiatives include a database of voluntary and community services, a social prescribing service and drop-in dementia clinics. Early evidence suggests that these changes have led to year-on-year reductions in emergency admissions to hospitals. Nursing Practice: Complex Integrated Care Essay.