Topic Learning Outcomes

LO1: Determine the ethical, legal, political, and sociological factors that create barriers to care for clients with chronic and complex health needs.

LO2: Examine primary health care and chronic disease management models, and the role of the nurse within the interprofessional healthcare team in integrating care with a view to prevent avoidable hospitalisations.

LO3: Critique local and national approaches to health promotion and services available in the community for people with chronic and complex health needs.

CASE STUDY

Address: Surland St, Blackwood
Age: 72
Background: Mark Seymour is a retired mechanic living in suburban Adelaide. He presents with increasing breathlessness, fatigue, and reduced mobility.

Chronic Health Conditions

• Chronic Obstructive Pulmonary Disease (COPD)
• Type 2 Diabetes
• Hypertension
• Osteoarthritis

Living Situation

Mark owns a two-bedroom unit in a block of 20 properties. The home is single-storey but lacks accessibility features.

Family and Social Support

• Daughter – Melissa (45): Lives nearby, visits weekly for shopping and cleaning.
• Son – David (40): Lives interstate, maintains phone contact.
• Neighbour: Has a close relationship and occasionally assists with errands.
• Receives a part aged pension, holds a Health Care Card and Seniors Card.
• No Commonwealth-funded services currently and is unsure of eligibility.

Health and Wellbeing Concerns

• Recent 4 kg weight loss due to low appetite and fatigue.
• Increasing joint pain and impaired mobility.
• Requires potential home modifications (bathroom adjustments, ramp).
• Feels isolated and frustrated with declining independence.
• Avoids medical appointments, prefers managing health at home.

Care Goals

Mark would like support with:

• Maintaining independence at home.
• Understanding available support services (concerned about cost; struggles with online information).
• Improving mobility and pain management.
• Increasing community engagement to support mental wellbeing.
• Reducing worry about being perceived as “useless” due to declining physical health.

Assessment Instructions

You are the Registered Nurse in the local GP practice. Using the case study, address the following tasks.

Task 1

Discuss how social isolation may act as a barrier to Mark accessing appropriate person-centred care, and how this may potentially lead to hospitalisation.

Task 2

Focusing on Mark’s self-identified care needs:

1. Identify one (1) Commonwealth Funding Support Mark is eligible for.
2. Identify one (1) other Government Support Service he is eligible for.
3. Provide rationales explaining why the services identified are person-centred, and how they support Mark’s ability to self-manage at home.

Task 3

Using the 2017 NSFCC (Part 2, Objective 2.1) as your foundation:

• Discuss the role of the Registered Nurse in improving Mark’s capacity for self-management.
• Include specific examples.
• Integrate relevant NMBA Registered Nurse Standards for Practice (sub-standards).
• Link your discussion to the Fundamentals of Care (FOC) framework.

Task 4 

Select one (1) of Mark’s person-centred care needs.
Identify and discuss one current local or national health promotion initiative that could help him retain independence and avoid hospitalisation.

Presentation Guidelines

• Word count: 1800 words ± 10%
• Use headings: Task 1, Task 2, Task 3, Task 4
• No introduction or conclusion required.
• Submit as Word document (.doc/.docx)
• Line spacing: 1.15 – 1.5
• Font: Arial or Calibri, size 11 or 12
• Use professional nursing terminology; avoid acronyms, abbreviations, and jargon.
• Use Australian English.
• Include a footer with Student FAN.