CHRONIC DISEASES AND GERIATRICS

SERVICE DESCRIPTION

Chronic diseases may be inherited, but many lifestyle and environmental factors such as smoking, inappropriate diet, sedentary lifestyle and heavy alcohol consumption are known to increase risks. These are to some extent within the control of a well-informed individual but there are often other factors such as poverty, under-nutrition in utero and in infancy, genetic predisposition, over which the individual has little control.

Besides early diagnosis, management and harm reduction there are opportunities at every stage for prevention and for promoting healthy behaviour.

Priority chronic diseases are hypertension, diabetes type 2, asthma, epilepsy, stroke, renal disease and obstructive lung disease.

NORMS
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  1. Increase by 50% the proportion of clinics providing comprehensive services for persons with chronic diseases.

  2. Assess patient satisfaction and quality of care 6 monthly by a supervisor who also evaluates the degree of community involvement in care planning.

  3. Reduce the number of people with BMI greater than 30.

  4. Minimise patient travel by prescribing supplies of drugs to last 1-3 months.
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STANDARDS
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  1. References, prints and educational materials

1.1 Copy of National Guideline on Primary Prevention of Chronic Diseases of Lifestyle.
1.2 Management protocols on Type II diabetes at primary health care level.
1.3 Health promotion and educational materials relating to chronic diseases of lifestyle, ageing and cancer in local languages.

  1. Equipment and Sspecial Facilities

2.1 Working sphygmomanometer with range of cuffs, and stethoscope.
2.2 Urine test strips for glucose, protein and ketones.
2.3 Blood glucose testing equipment.
2.4 Snellen Chart.
2.5 Clinics have easy access for the aged, those in wheelchairs and those with arthritis.

  1. Medicines and Supplies

3.1 Arrangements are made by the clinic to minimise patient travel by prescribing supplies of drugs to last 1-3 months.

  1. Competence of Health Staff

4.1 Every clinic has a staff member who has skills to prevent, diagnose and manage chronic conditions including geriatrics, nutrition, genetics, mental health and reproductive health.
4.2 Patients are able to see the same nurse for repeat visits and a system of recall on cards or calendars is used to ensure continuity of care.
4.3 Staff are able to provide counselling and motivation on disease acceptance, continuity of care and compliance.
4.4 Staff are able to establish in patients a feeling of always being welcome even though they keep coming frequently over the years.
4.5 All staff show respect and concern for the elderly and the disabled.
4.6 Staff have the skills and attitude to protect and promote the rights of patients with regard to a full knowledge of health status, participation in decisions, access to own health records and becoming a partner in own health care.
4.7 Staff know that the prevalence of diabetics in South Africa is high (10% in Indian community and 5 - 6% in black community) and are able, using epidemiological skills, to estimate how many cases there are in the clinic catchment areas and are alert to identify them early.
4.8 Staff are receptive to periodic visits from doctors or district surgeons/medical officers and use the visits to review chronic disease patients.

  1. Referrals

5.1 All patients are referred to the next level of care when their diagnosis and needs fall beyond the scope of competence as recommended by the protocols.
5.2 Staff know where to phone the nearest hospital/doctor for advice.
5.3 Detailed information is kept on the frequency of follow-up visits 1 -3 monthly and yearly for detailed examination by doctor.
5.4 Patients suspected of having diabetes are referred to hospital for diagnosis.

  1. Patient Education

6.1 After diagnosis patients and caretakers are supported and their capacity developed regarding self care, self-monitoring, compliance, prevention of complications and management of the disease.
6.2 Education activities are sensitive to the cultural and economic realities of the patient and home.

  1. Records

7.1 Patient register of chronic conditions and treatment record.
7.2 Patient carried cards.
7.3 Home-based care records.

  1. Community Based Services

8.1 Staff work with any district NGO and CBO dealing with chronic conditions.
8.2 After analysis of the chronic disease register attempts are made to provide education in the community on modifiable risk factors, healthy food plans, less salt (iodised), weight control, sport and exercise, substance abuse especially alcohol, smoke (tobacco, smoke in houses), UV protection for albinos, early recognition of symptoms and periodic check-ups.
8.3 Educational activities are culturally and linguistically appropriate.

  1. Collaboration

9.1 Staff collaborate with other departments and sectors whose activities have a bearing on chronic diseases.
9.2 Staff facilitate the initiation of clubs and special groups for people with chronic diseases.
9.3 Clinic staff approach the catchment area population through community health committees, NGOs, CBOs, youth groups and the church to reduce common risk factors operating in the community.

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