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Define primary healthcare.
A cost effective, efficient, care approach to preventing and managing health risks, enhancing quality of life, and affecting enduring change with person-centered care to address wellbeing.
Define chronic illness.
A persistent/long-lasting health condition that progresses over time, usually lasting over 3 months. The social/economic consequences impact an individual’s quality of life.
What is the difference between a chronic illness and disease?
An illness involves the human experience, how it is perceived, lived with and responded to (holistic effects on all aspects of life).
A disease refers to the condition’s pathophysiology.
Name 5 primary healthcare providers.
GPs, pharmacists, dentists, podiatrists, physiotherapists, dieticians, and psychologists.
Name 5 chronic conditions.
Asthma, diabetes, cancer, back pain, mental health conditions, osteoporosis, and COPD.
What are the 4 principles of primary care?
Chronic illness/disability affects all dimensions of a person’s life
Care must be holistic and culturally sensitive
Care must be relevant to the person and their family/support network
Providers must teach patients about contributing risk factors
Define equity.
The quality of being fair and impartial, absence of unjust, avoidable, or remediable differences among groups of people.
Define collaborative partnerships.
Partnership between providers, patients and their families in shared decision-making, coordination, and cooperation for collaborative practice.
Define access.
Access to a service, provider or institution. It gives people a chance or the ease with which consumers and communities can use services related to their needs.
Define evidence-based.
A care approach integrating the best available research evidence with clinical expertise and patient values.
Define accountability.
The process of holding people responsible, with an honest/open approach.
Define shared responsibility.
An approach where responsibilities for health goals are shared among community stakeholders (eg. doctors, nurses, patients and their family/support network).
Define sustainability.
Allocating resources well, developing a healthcare plan with longevity.
Define person-centered care.
Care practice where patients actively participate in their treatment, focuses on their needs and ensures their preferences/values guide clinical decisions, respectful care.
Define health literacy.
The skills, knowledge, motivation, and capacity of a person to access, understand, appraise, and apply information to make effective informed health decisions.
Define self-management.
The ability of individuals and their support networks to promote and maintain health and prevent disease, or cope with an illness/disability.
Define empowerment.
Facilitates self-directed behaviour change by encouraging a focus on strengths. It helps patients build capacities to gain access, networks and/or a voice to gain control over health decisions, needs to be internally motivated.
How does higher health literacy benefit patients and the healthcare system?
It supports individual medication compliance, consistent personal monitoring, higher self-care levels, reduces costs, improves quality of life, engages with preventative measures.
How does lower health literacy affect patients and the healthcare system?
It leads to poor health, emergent care, frequent hospitalisations, increased difficulty with management, non-compliance, higher costs and a lower quality of life.
Define health education.
A combination of learning experiences designed to help individuals and communities improve their health by increasing knowledge and influencing their attitudes.
What are the principles of chronic care?
Sustainability
Equity
Access
Shared responsibility
Collaborative partnership
Accountability and transparency
Person centered
Evidence based
(Acronym - SEASCAPE).
Describe the Nurse’s role in chronic illness management.
They identify risks early, support behaviour modifications, optimise evidence-based care, facilitate self-management, manage disease, prevent transition from impairment to disability, and encourage active health participation.
What are some factors affecting patient learning?
Current education, financial circumstances, language, attention span, motivation to learn, family and community support, emotional factors and general health condition.
What are the different stages of change?
Pre contemplation, contemplation, preparation, action, maintenance, relapse. They reflect a person’s readiness to make changes to health behaviour.
Define pre contemplation.
The patient is not open to change, the behaviour outweighs its burdens, wants to continue.
The nurse wants to minimise harm, collect info/form relationships, act non-judgementally.
Define contemplation.
The patient still enjoys the behaviour, may experience some adverse consequences.
The nurse facilitates patients arriving at their own decision, will meet some resistance.
Define preparation.
The patient realises costs outweigh burdens, takes small steps to change, needs options.
The nurse provides small amounts of education, encourages change and small steps.
Define action.
The patient enacts change, modifies behaviour, experiences some grief with changes.
The nurse gives them time/space, celebrates wins, positive reinforcement, risk of relapse.
Define maintenance.
The patient successfully quits, sustained change, emotional/physical detachment.
The nurse helps patient consolidate changes, gives strategies to prevent relapses.
Define relapse.
The patient returns to previous undesirable behaviours more than once.
The nurse assists in renewing contemplation/action phases, don’t demoralise patients.
What are the 5 A’s for behaviour change?
Assess, advise, agree, assist and arrange. They help people with chronic conditions undergo lifestyle changes and access preventative healthcare.
Define assessing behaviour change.
Assess beliefs, behaviours, knowledge, health literacy and readiness for change.
Define advising behaviour change.
Advise regarding health risks, benefits of change, tailor information to individuals.
Define agreeing with behaviour change.
Set collaborative SMART goals, develop thorough plans and monitor progress.
Define assisting with behaviour change.
Identify personal barriers, motivational interviewing, teach the patient some techniques.
Define arranging behaviour change.
Plan follow ups, provide self-management support, collaborate with the MDT.
Define comorbidity.
Having 2+ chronic conditions at the same time, where one condition is the focus and others are viewed in relation to the first condition. It mainly occurs from overlapping risk factors or conditions arising from complications of the other.
Define multi-morbidity.
Having 2+ unrelated chronic conditions where one does not have priority over another. Hypertension, depression, and chronic pain are the main contributors to the prevalence of multi-morbidities.
Describe 4 complications of managing co-morbidities.
A reduced quality of life
Impaired daily function
Decreased quality of physical and mental health
Shortened lifespan
What are 2 complications of managing multi-morbidities?
Putting focus on a single condition
Higher risk of interactions between medications for different conditions
What are some things that chronic illness patients experience?
Fragmented system (HCPs work in isolation from each other)
Uncoordinated care
Difficulty finding/accessing necessary services
Service duplication with absent/delayed services
Low uptake of digital health and technology by HCPs
Feelings of disempowerment, frustration, and disengagement
What are some areas for improvement in chronic illness management?
Change healthcare focus from episodic to ongoing, regular care
Policies supporting chronic condition management
Integrated healthcare system, information sharing across providers
Integrate across settings (inpatient, outpatient, pharmacy, community)
Intersectorial collaboration, further HCP training
Emphasis on the patient’s role, encourage educated patients
Support patients and families, emphasise prevention
What are the WHOs 6 key principles for chronic conditions?
Evidence-based practice, population health approach, focus on prevention, quality focus, integration, flexibility, and adaptability.
What are the 3 levels of the WHOs chronic conditions framework?
Macro (intersectorial collaboration between government sectors)
Meso (healthcare organisations and communities)
Micro (patient interaction, need for empowement)
Define burden of disease.
It measures the impact of living with illness/injury and dying prematurely, using disability-adjusted life years (DALYs). 1 DALY is 1 year of healthy life lost to an illness/death —> The more DALYs the greater the burden of disease.
What are some behavioural and metabolic risk factors?
High cholesterol, high BP, high BGL, and obesity.
What are the 4 key modifiable risk factors?
Smoking
Nutrition
Alcohol
Physical inactivity
What are the 10 most prevalent chronic conditions?
Mental/behavioural conditions, back pain, arthritis, asthma, diabetes, CVA/stroke, osteoporosis, COPD, cancer and chronic kidney disease.
Define determinants of health.
The condition in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.
Individuals (biological traits/behaviours)
Environmental (housing, climate, location)
Social (education, income, social life)
Define motivational interviewing.
A strategy encouraging behavioural change by offering non-judgemental information, strategies, and resolving mixed feelings towards change. It empowers problem-solving, encourages goal setting and choices, and doesn’t impose restrictions on patients.
What are some limitations of motivational interviewing?
Underlying mental health conditions, lack of motivation, low therapeutic communication, time constraints, training deficiencies, and few group treatment opportunities.
What are the 4 steps to motivational interviewing?
Engaging, focusing, evoking, and planning change
Describe engaging and focusing on change.
Engaging - Let them lead conversation, build rapport, open ended questions, safe space.
Focusing - Identify what’s important to them, if/why they want to change, choose a goal together, either direct, guide, or follow the patient towards change.
Describe evoking and planning change.
Evoking - Support/encourage, don’t challenge negative thoughts, give advice if asked for it.
Planning - Guide in creating a plan, encourage “commitment talk”, help create SMART goals.
Define protective factors.
Factors associated with a lower likelihood of bad outcomes, reduces a risk factor’s impact (eg. good mental/spiritual/emotional health, positive attitudes, good self-esteem, family and community support, consistent routines, and good conflict resolution skills).
Define patient activation.
A patient’s willingness to acquire knowledge, skills, and confidence for managing health.
What are the 4 levels of patient activation?
Disengaged and overwhelmed (no confidence, low knowledge, poor adherence)
Partial awareness but struggling (some knowledge, large gaps, can set simple goals)
Taking action (builds management skills, goal-oriented, strives for good behaviours)
Maintains behaviours, pushing further (has new behaviours, maintaining them is key)
Describe people with a high patient activation score.
More likely to undergo screening, vaccinations, check-ups, have healthy behaviours, treatment adherence, and normal BMI, BGL, BP and cholesterol levels.
Describe people with a low patient activation score.
Less likely to be actively involved or know about their treatment plan, more likely to have unmet needs, delay appointments, abnormal clinical indicators, and more re-admissions.
What is a brief intervention?
It sparks motivation to change, only effective if done multiple times with the 5 As.
Define the OARS model for good communication.
Open ended questions (increased participation and engagement)
Affirm (strengths and progress made)
Reflect (help people see a way forward based on personal circumstances)
Summarize (confirm understanding)
Describe the role of the nurse in motivational interviewing.
Assess skills (readiness for change, support systems, management abilities)
Behaviour change skills (help with goal setting, problem solving, developing plans)
Organizational strategies (work with MDT, use resources, apply evidence to practice)
What are the chronic illness management programs?
Medicare benefits schedule, pharmaceutical benefits scheme, national disability insurance scheme, and the national health and medical research council (NHMRC).
Describe the Medicare Benefits Scheme.
A list of approved subsidised medical services (appointments, procedures, tests). The government pays providers for services needed for appropriate treatment, and the scheduled fee is what’s considered appropriate for the service.
Describe the Pharmaceutical Benefits Scheme (PBS).
Provides subsidised medications, must be prescribed by doctors. NPs, optometrists, and dentists have some prescribing rights.
Describe the National Disability Insurance Scheme (NDIS).
Targeted support to improve outcomes for people with disabilities and families, focused on personal support/early intervention, connects people with transport, health, education, housing, and workforce services.
Describe the NSW Health ACI Rehabilitation for Chronic Conditions Framework.
Aims to improve access to evidence-based rehab programs for people with chronic conditions, guides providers on delivering safe care, resource availability, target populations, and geographical remoteness (in response to service shortages).
Define Primary Health Networks.
Aims to increase efficiency/effectiveness in patient services to improve care coordination, especially for those at risk of poor health outcomes. It’s federally funded to manage regions through grants (depends on region performance), so regions in need can get coordinated healthcare where/when needed. There are 10 networks in NSW, not correlating with LHDs.
Describe the importance of primary health networks.
They support access to healthcare, helps avoid unnecessary hospitalisations, improves population health, ensures services connect/share information, gives HCPs a clear picture of a patient’s health/treatment needs, and builds a strong primary healthcare system.
What is the purpose of a primary health network?
It works with hospitals, aboriginal medical services, AH providers, training coordinators, state government, aged care providers, and private health insurers to lower effort and resource duplication, create better coordination and secure info sharing, and less hospital pressure.
Define social determinants of health.
Non medical factors influencing health outcomes. The conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping daily life conditions. They may include social exclusion, stress, work, unemployment, addiction, food, and transport.
What is considered rural and regional Australia?
All of Australia outside of the ACT, Sydney, Melbourne, Perth, Gold Coast, Brisbane, Wollongong, Central Coast, and Newcastle. They have higher hospitalisation, death and injury rates, poor access to/lower likelihood of using primary healthcare services than people in metro areas.
What are some modifiable risk factors regarding people in regional areas?
Individuals are more likely to smoke or drink alcohol at higher levels than people in urban areas. Occupational hazards (manual jobs, exposure to toxins) and machinery put people at a higher physical health risk.
What are some principles of primary healthcare?
Equity
Empowerment
Access
Community participation
Health literacy
Cultural sensitivity
Health promotion
Intersectorial collaboration
Cultural safety
Appropriate technology
(Acronym - EEACH CHICA)
Define eHealth Technology.
A cost effective method, secure use of information and communication technology to support health fields including healthcare services, surveillance, health literature, education, knowledge, and research.
Describe telehealth versus telemedicine technology.
The use of electronic information and communication technologies to support long-distance clinical healthcare, patient/professional education, public health, and administration. Telehealth is a broader term than telemedicine.
What are some resources available to people in rural locations?
Central Australian Rural Practitioners Association (CARPA)
The Primary Clinical Care Manual (PCCM)
Chronic Conditions Manual (CCM)
They help HCPs in regional and remote locations with the prevention and management of common general and chronic conditions.
Define non-modifiable risk factors.
Determinants that cannot be controlled or changed to impact health status, including gender, race, family history and advancing age.
Describe the purpose of the Integrated Care for Patients with Chronic Conditions Framework of 2019.
It replaces the chronic care model in NSW, and includes elements of population health promotion so broad prevention efforts, recognition of social determinants and enhanced community participation can be integrated into the work of service teams to manage chronic diseases. It involves selecting the right people, engaging patients/carers, collaborative relationships, and appropriate technology to support care plans and information sharing.
Define capability development.
Individual growth in knowledge, skills, and experience, including skills based training, knowledge based education and experience, relationship building, management tools and a focus on workplace environment/motivation.
Define shared care plans.
Used for patients with illnesses and conditions where coordination across multiple services is complex. It supports better communication between patients and health teams, more transparency, self-management, goal setting, quality of care, and continuous shared decision making.
Define care navigation.
Facilitates service access for patients, carers and families for defined episodes of care to improve timeliness and suitability of care, reduce barriers to access, lowers follow up failures, and lowers unplanned admissions.
Define health inequity.
Systematic differences and avoidable gaps in health outcomes, appearing because of differences in health status and resource distribution among population groups.
Define vulnerability.
The degree to which certain populations are unable to anticipate, cope with, resist, and recover from the impact of disease/disasters, affected by age, gender, ethnicity, exposure to trauma, socioeconomic status, experience of incarceration, and homelessness/unsafe accommodation.
Define vulnerable populations.
Groups of people with a disproportionate burden of disease from barriers to accessing healthcare, causing life expectancy and health outcome differences. They can include ATSI people, CALD people, LGBTQ+ people, those with low socioeconomic status, elderly, children, women and refugees.
Define culture.
A set of guidelines inherited as a member of society, telling them how to view the world and behave in relation to other people, either social, political, or historical. It expresses preferred mindsets, involves language, defines relationships, roles, rights and obligations.
Define culture and health.
It influences mindset, actions, ethics, beliefs, and social interactions. Involves ethnicity, clothing, mannerisms, body language, education, customs, practices, diet, norms, and communication. Stereotyping shows a lack of sensitivity, racism, discrimination, and prejudice.
Define assimilation, integration, rejection and marginalisation.
Assimilation is abandoning culture, integration is blending culture, rejection is replacing culture, and marginalisation is non-acceptance of culture.
Define stigma.
Negative set of beliefs, perceptions or attitudes held towards particular people/groups, based on traits like race, gender, behaviour, disability. It lowers the likelihood of vulnerable groups engaging with healthcare services.
Define direct and indirect discrimination.
Direct discrimination is when someone is treated less favourably than another person because of their background or personal traits. Indirect discrimination is when an unreasonable condition, law, or policy applies to all but disadvantages some people because of a shared personal characteristic.
Define cultural competence and cultural awareness.
Cultural awareness is attentiveness to culture relevant to patient assessment, recognising inherent power structures. Cultural competence is sensitivity to, and skills in providing appropriate care for people.
Define cultural sensitivity and cultural safety.
Cultural sensitivity is self reflection, recognition and respect for differences. Trust, respect and acceptance is fostered within patient-nurse relationships. Cultural safety includes practices promoting an environment protecting the authenticity and acceptability of diversity by acknowledging diversity, providing culturally appropriate care, empowerment and advocacy training.
Define cultural knowledge and ethnocentrism.
The understanding of different cultures enough to notice differences (eg. diet, religion, health beliefs). Ethnocentrism is the tendency to view the world through one’s own cultural lens, constructs and beliefs.
Define verbal communication and non verbal communication practices.
Avoid colloquialisms, sarcasm and slang. Use open and closed questions, pictures, gestures, translators, contact interpreters if needed. Consider body language, eye contact, facial expressions, and different concepts of personal space.
What are some barriers impacting illness management?
Transient HCPs, lack of trust, low levels of HCP cultural safety, lower likelihood of accessing preventative care, separation from country and family when required to travel to urban areas for specialist treatment.
What are protective factors for ATSI people?
Cultural identity, participation in cultural activities, access to traditional lands, connection to family and kinship.
Define disempowerment.
Talking more than listening, making assumptions, judgemental body language, providing only options suitable for the nurse, making decisions without consulting patients. Includes white colonisation, Stolen Generations, displacement/dispossession of land, cashless welfare cards, paternalism, lack of involvement in decision making and health literacy levels.
Describe the social and emotional wellbeing model of health for ATSI people.
It acknowledges connection to land, culture, spirituality, family, and community as contributors to wellbeing. It also considers experiences of grief, loss, trauma, suicidal ideation, identity issues, racism, social disadvantage, and cultural dislocation.
What is the ATSI definition of health?
Not just physical wellbeing, but encompassing the social, emotional, and cultural wellbeing of the whole community, in which each person can achieve their full potential as a human being which brings about the total wellbeing of their community.
Define primary prevention.
Reduces risk factors, health assessments, health promotion, immunisation, child growth and development.
