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Preliminary Care Coordination Plan for Type 2 Diabetes in the Elderly

Type 2 diabetes mellitus is one of the most prevalent chronic diseases affecting the world’s population and specifically the elderly. This chronic disease becomes common with age and leads to many health complications. A comprehensive care coordination plan that focuses on the physical, psychosocial and cultural factors should be employed in the management of type 2 diabetes in older adults. The following is an initial care coordination strategy for the management of type 2 diabetes in elderly patient within a community care setting using available community resources for safety and efficiency of care.

Some of the complications of the type 2 diabetes include cardiovascular disease, neuropathy, retinopathy, and nephropathy. Such complications can greatly affect an elderly person’s capacity to perform ADLs and remain self-sufficient. The treatment of type 2 diabetes in the elderly entails close monitoring of blood glucose levels, blood pressure, and lipid profiles to reduce and control these complications. Also, prescribed exercise regimes based on the person’s physical mobility status will enable the improvement of glycemic control and general well-being (American Diabetes Association, 2022).

Another essential factor that should be considered when treating diabetes in the elderly is medication. The problem of polypharmacy or taking of multiple medications is prevalent among elderly patients and results in drug-drug interactions and increased risk of hypoglycemia. It is recommended to perform medication reconciliation and optimization at least quarterly to reduce complexity and adverse effects. Moreover, devices and technologies like continuous glucose monitors and insulin pumps can support self-management and yield better results (Davis et al. , 2022).

Many elderly people with type 2 diabetes experience psychosocial problems such as emotional distress, anxiety, and depression. Living with a chronic condition means that the individual is faced with the responsibility of having to manage the illness and this brings about helplessness and isolation. The continuum of care requires mental health through counseling, support groups, and stress management intervention. The integration of mental health services into primary care visits is effective because it means that the emotional aspect of a person’s health is not ignored (Regier et al., 2022).

Another essential component of diabetes care in the elderly is social support. This support comes from the family, other caregivers or other organizations as they help in making sure that patients stick to their treatment regimens and follow the necessary changes in their lifestyles. Involving family and caregivers in the care process may also enhance compliance and outcomes. Also, local activities, such as volunteer work or exercise, can prevent loneliness and enhance psychological well-being.

Culture plays a crucial role in the care of elderly patients with type 2 diabetes. For example, the choices of foods and cultural beliefs about treatment could affect the compliance with doctors’ advice. It is crucial to take into account these cultural factors in order to provide care coordination. This entails educating the patient in their preferred language, recommending appropriate diets and lifestyle changes and involving local leaders to encourage patients to adhere to the recommended treatments (Office of Minority Health, n.d.).

Different cultures have different needs and expectations and therefore, healthcare providers need to be culturally competent. Cultural competence in this training enables the providers to offer individualized care that is culturally sensitive, leading to improved health. Working with organizations that specialize in the cultural groups in question can also help improve care coordination.

It is, therefore, necessary to set appropriate goals for elderly patients with type 2 diabetes that is understandable, reasonable, and quantifiable. Enhancing disease surveillance and management is one of the major goals. This entails following up and having periodic tests on blood sugar levels, blood pressure, and cholesterol in order to have the disease well controlled. If patients engage in telehealth services, then there can be constant check and balance to make interventions and modifications.

Enhancing patient education and self-care is another important goal. Education of the elderly patients on the disease and how they can manage it through medication, diet and exercises enables them to take full responsibility for their care. That is why it is important to establish programs which can help patients to manage themselves in the future.

Of importance is to include mental health services as part of the diabetes care. Such patients would therefore require routine mental health assessment during primary care visits. Referral procedures to other mental health practitioners and support groups help patients to have the right care for their state of mind.

Another goal is also to promote for culturally appropriate care. Educating healthcare workers and working with community representatives in addressing culture-related issues may go a long way in enhancing patient understanding and compliance to recommended treatment paradigms.

Community Resources for Continuum of Care

Disease Management Programs

Disease management programs, which patients can access through their local hospitals and clinics, include regular health check-ups, informative sessions, and individualized plans. For instance, the Chronic Disease Self-Management Program (CDSMP) is a prominent intervention that uses workshops and peer support to assist patients (Hevey et al., 2020). These programs assist patients to achieve competencies in the management and prevention of the diseases.

Support groups provide vital emotional and social support, which are significant in the daily management of type 2 diabetes in the elderly population. Through support groups such as the online support groups and the local support groups, patients increase their morale as they hear and learn from other patients facing similar challenges (American Diabetes Association, 2022). These groups offer company and often lead to a great decrease of loneliness and/or depression.

Federally qualified health centers or community health centers as they are commonly known are crucial in the delivery of care to the uninsured and underprivileged. These are centers that provide primary, mental, and chronic health conditions, among others. Many of them are on a sliding fee scale to ensure that people who have no insurance can afford the charges (National Association of Community Health Centers, n.d.). One of the strengths of community health centers is their ability to address all aspects of diabetes care within one facility.

Mobile hospitals and telemedicine are some of the modern approaches that help to address the shortage of health care centers. They reach out to areas where access to formal health care is limited with services like screening, inoculation, and information on health. These clinics are most useful in the rural areas or any area that is not well covered in terms of health facilities. Telehealth services allow for remote care, constant check-ups, and consults with specialists without the need for physical travel, which is convenient for patients (Health Resources & Services Administration, 2024). These services are easily accessible, convenient, and supplement the continuum of care for diabetes management.

Coordination of care in the elderly, specifically in type 2 diabetes management, needs to incorporate physical, psychosocial, and cultural care domains. Thus, it is possible to conclude that by setting particular goals and utilizing the available community resources, the healthcare providers can create the necessary safety for the proper continuum of care. The combination of telehealth and mobile clinics will be instrumental in addressing various challenges and enhancing the quality of life for elderly patients with T2D. From the care coordination perspective, one can improve the quality of life of the diagnosed individuals, as well as decrease the toll on the health care facilities.

References

American Diabetes Association. (2022). Standards of medical care in diabetes—2022.
Diabetes Care, 45(Supplement 1), S1-S264.

Davis, J., Fischl, A. H., Beck, J., Browning, L., Carter, A., Condon, J. E., … & Villalobos, S. (2022). 2022 National standards for diabetes self-management education and support. 
The science of diabetes self-management and care, 
48(1), 44-59.

Health Resources & Services Administration. (2024). Telehealth Resource Center Program. Retrieved from
https://www.hrsa.gov/telehealth/telehealth-resource-centers#:~:text=The%20Telehealth%20Resource%20Center%20(TRC,Regional%20TRC%20in%20your%20state.

Hevey, D., Wilson O’Raghallaigh, J., O’Doherty, V., Lonergan, K., & Marese Heffernan; Victoria Lunt; SineadMulhern; Damien Lowry; Niamh Larkin; Kathy McSharry; David Evans; Jackie Morris Roe; Mike Kelly; Peter Pardoe, Harry Ward; Sean Kinsella. (2020). Pre-post effectiveness evaluation of Chronic Disease Self-Management Program (CDSMP) participation on health, well-being and health service utilization. 
Chronic illness, 
16(2), 146-158.

National Association of Community Health Centers. (n.d.). What is a Community Health Center? Retrieved from
https://www.nachc.org/community-health-centers/what-is-a-health-center/

Office of Minority Health. (n.d.). Culturally and linguistically appropriate services. Retrieved from
https://minorityhealth.hhs.gov/cultural-and-linguistic-competency

Regier, D. A., Goldberg, I. D., & Taube, C. A. (2022). The de facto US mental health services system: a public health perspective. In 
Mental Health Care and Social Policy (pp. 105-126). Routledge.