Part A - Chronic Care Model
About the case selected
The subject of the chosen case study is Andrew Hills, a Langwarrin resident who is 32 years old. He suffers a number of chronic illnesses that significantly affect his health and need for in-home care.
Andrew has previously experienced bronchiectasis, where can cause sputum generation of mucus, dyspnoeal, and sporadic flare-ups. His physical capabilities are limited by this condition, which typically results in fatigue and chest pain. In addition, he has inflammatory bowel illness, which exacerbates his ongoing medical issues. According to Grudniewicz et al. (2023), Andrew was just diagnosed with brain cancer that had progressed to his lungs. His medical condition has been worse since receiving this diagnosis, and he now has a six-week prognosis. His illness has worsened to the point where he coughs up blood and has to take several medications to control the symptoms, including opioids, steroid inhalers, and painkillers. As his illness worsened, Andrew's independence and quality of life at home were significantly impacted. He needs medical care and supported care to carry out everyday tasks because he is no longer able to work. Despite having at least some assistance from his sister, his social background further complicates matters because he lives alone and is estranged from his parent's. He needs medical care and supported care to carry out everyday tasks because he is no longer able to work. Despite having at least some assistance from his sister, his social background further complicates matters because he lives alone and is estranged from his parents.
Struggling with complex case study analysis? Download free, expert-written case study samples from the Best Assignment Writing Service Australia.
The challenges of managing multiple chronic illnesses including cancer that's terminal at home are highlighted by Andrew's case.
Two specific components of Wagner’s Chronic Care Model
Two important components of the Wagner Chronic Care Model that apply to Andrew's situation are managing one's own assistance and delivery design of the system.
Self-management support empowers patients to take control of their condition's management. In the case of Andrew, with bronchiectasis, inflammatory bowel disease, and metastatic brain cancer that provide him with complex care requirements, structured self-management approaches can help him cope with his condition in the home context. Research has demonstrated that self-management strategies, including education on symptom assessment, medication adherence, and lifestyle modification, improve the health outcomes of individuals with chronic illnesses (Pomey et al., 2024). Andrew may experience greater autonomy and fewer needless hospitalizations as a result of the tailored instruction centred on palliative care, respiratory symptom treatment, and his sister's participation in the cooperative process of making decisions.
The system of distribution is designed with collaborative, proactive, and integrated treatment in mind. Andrew is particularly susceptible because of his disjointed support system and lack of family participation. Research has demonstrated that interdisciplinary care teams improve consumer satisfaction in chronic conditions by streamlining the treatment process and facilitating communication (Wagner et al., 2020). An early connection between nursing, palliative services, breathing assistance, and malignancies can remove care discrepancies and promote continuity in Andrew's situation. The following framework underpins his treatment in order to address his medical requirements and quality-of-life goals while taking into account his mental, psychological, and psychological well-being (Apuzzo et al., 2024).
Part B- Two community-based tools
Community Palliative Care Services
Description
Palliative care services refer to specialized community-based assistance for individuals with serious, life-threatening illnesses, as provided by organizations like Palliative Care Victoria. Palliative care is a holistic approach that addresses physical, emotional, and social needs. The services include symptom management support to control pain, nausea, breathlessness, and other symptoms), nursing visits, psychological assistance, and access to allied health professionals (such as physiotherapists or social workers. Care delivery is coordinated with general practitioners and specialists to ensure continuity.
Promotion of Health Literacy and Consumer Participation
Palliative care teams educate patients and families to self-manage symptoms such as pain, breathlessness, and fatigue. Education in this context involves providing easy-to-understand information and practical guidance for managing these symptoms. This approach enhances health literacy by empowering families to make informed decisions regarding home-based care. Additionally, palliative care models encourage consumer involvement by including patients and their families in advance-care planning and goal setting, and by strictly honouring their preferences regarding care, as outlined by Palliative Care Australia (2020).
"Students navigating patient management protocols and clinical case studies can also refer to Nursing Assignment Help for subject-related academic guidance."
Potential Benefits
In the case of Andrew, palliative care services can help to relieve his unpleasant symptoms, provide emotional support, and enhance his end-of-life quality. His sister, who is a key support, would benefit from respite care and professional advice in the area of caregiving. It is proven that community palliative care helps to avoid unnecessary hospitalization and provides a comfortable and dignified environment at home (Cuchet et al., 2024).
Alignment with Person-Centred Care and Chronic Disease Models
These services are in line with person-centred care in that they are customized to the values and preferences of Andrew, even though interdisciplinary care, according to the Chronic Care Model, is also incorporated. They too maintain the NSQHS Comprehensive Care Standard through safety, respect, and continuity.
Lung Foundation Australia Support Programs
Description
Lung Foundation Australia provides national programs to those living with chronic respiratory diseases, including bronchiectasis. Programs consist of educational information, phone support lines, peer-support groups, and individualized exercise and pulmonary rehabilitation programs.
Health Literacy and Consumer Promotion
Patients' and carers' health literacy is enhanced since the Foundation offers patient-friendly information available on disease progression, medications, and self-management. Peer-support groups are another effective approach in promoting consumer participation, where people can share their experiences and strategies, promote empowerment and social connectedness (Marlin_Admin, 2025).
Potential Benefits
In the case of Andrew, the program may enhance his education on managing the symptoms of bronchiectasis, anxiety, and treatment adherence. In the case of his sister, the carer networks would give her emotional support and some practical advice on how she could help Andrew in his daily life. Social isolation that is typical in chronic disease management is also reduced by such programs (Greenhalgh et al., 2017).
Person-Centred Care Congruency and Chronic Disease Models
These supports resonate with person-centred care, as they are seeing the lived experience of Andrew and giving priority to Andrew as the decision maker. They are also suggestive of the National Strategic Framework on Chronic Conditions through patient engagement, self-management, and cross-setting of healthcare arrangements.
Part C - Self Management Care Plan
SMART Goals
| SMART Goal | Justification for the Goal | The Nurse’s Role in Helping the Patient Achieve the Goal |
|---|---|---|
|
Goal 1: Within the next four weeks, Andrew will practice twice-daily airway clearance using his nebuliser and inhalers as prescribed, achieving a reduction in coughing episodes and improved ease of breathing at home. |
Andrew's breathing ability is hampered by tumours in the lungs and chronic pneumonia, two conditions which are specifically addressed by this objective. Good ventilation of the airways improves management of symptoms, lowers the risk of infection, and minimizes mucus accumulation (Chaudhuri et al., 2021). Additionally, it supports data suggesting regular self-management techniques increase the capacity for breathing and reduce hospitalizations for individuals with long-term respiratory disorders (Osadnik et al., 2020). Although discomfort treatment can enhance convenience and sleep duration, Andrew maintained some freedom by concentrating on manageable daily routines. Given that Andrew's disease has progressed to the point where his energy is restricted, an accurate and quantifiable timeline guarantees that the measure taken is manageable and not stressful. His confidence in handling respiratory problems inside the house is also increased by promoting commitment to this objective. |
By teaching proper inhalation and nebulizer procedures, the healthcare professional plays a crucial role in maximizing therapy efficacy. Frequent videoconferencing check-ins and visits to the residence might track symptom modifications, address obstacles, and strengthen adherence. Additionally, the nurse and physical therapist can work together to implement posture techniques and breathing exercises that maximize clearing of airways (Caneiras et al., 2022). In order to lessen caregiver stress, the nurse also helps Andrew's sister by training her how to help with treatment regimens. In order to maintain patient-centered treatment, inspirational interviewing can help Andrew stick to his routine even when he is exhausted. |
|
Goal 2: Over the next six weeks, Andrew will participate in one weekly virtual or community-based palliative care support session, aimed at enhancing emotional well-being and reducing caregiver strain for his sister. |
Given Andrew's impending prognosis and the emotional toll that his prognosis has taken, this objective is crucial. Individuals with cancer that is advanced who participate in hospice care group discussions report increased mental stamina, less isolation from others, and improved quality of life (Kavalieratos et al., 2021). Additionally, it gives his sister access to coping mechanisms, which lessens the strain on caregivers and encourages collaborative decision-making. The six-week period accommodates his deteriorating health while allowing him quantifiable involvement. This objective tackles holistic care, acknowledging that emotional and psychological assistance are just as important as medical care. Peer and community support programs have been shown to dramatically increase patient satisfaction and decrease unplanned hospitalization at the conclusion of life (Wheatley et al., 2021). |
By taking into account Andrew's weariness and mobility issues, the nurse can provide accessibility and assist with enrollment in suitable neighborhood or internet-based assistance programs. The nurse can assess his level of involvement during subsequent appointments and promote introspective dialogue to help him work through his feelings. Additionally, nurses promote family involvement by helping Andrew's sister obtain support services and respite opportunities. In order to address psychological issues and provide continuity of treatment, the nurse facilitates conversation among Andrew, his household, and the professionals who provide palliative care. A person-centred approach is demonstrated by encouragement, assurance, and adaptability in modifying the number and duration of meetings to Andrew's health situation (Fitch & Maamoun, 2020). |
Part D - Interprofessional Education
Interprofessional Collaboration
In order to effectively manage Andrew's complicated medical issues, interprofessional collaboration is crucial. Physiotherapists, behavioural scientists, speech therapists, physicians, nurses, and other medicine experts' varied contributions were showcased at the IPE event. For Andrew's bronchial asthma and lung cancer metastases, when preserving functional ability and comfort is crucial, Richard (7:59) clarified that physiotherapist focuses greater on dealing with symptoms than cure. Dixie (20:22) highlighted the psychological aspect, pointing out that patients can manage terminal illnesses with the aid of behavioural and cognitive assistance. Psychological assistance could help Andrew deal with his anxiety and build emotional fortitude. Lewis emphasized the value of speech pathologists in treating breathing-related swallowing and interpersonal difficulties that might surface as his illness worsens (22:13; 23:15). The registered nurse’s advocacy function, which keeps the consumer's voice at the forefront of care decisions, was explained by Amy (26:50). In chronically along with hospice care settings, evidence demonstrates that collaboration among professionals optimizes efficiency, decreases dispersed support, and enhances patient experiences (Willumsen et al., 2021). For Andrew, this kind of collaboration guarantees comprehensive care that incorporates social, psychological, and physical requirements.
Patient-Centred Care
The importance of patient-centered care in chronic illness was reaffirmed at the conference. Given Andrew's situation, which includes his dependence on his sister and his separation from his parents, consideration for his own values and preferences is necessary. Amy (26:50) emphasized how nurses uphold patient autonomy and encourage positive transformation, guaranteeing that treatment is in line with patients' priorities. Since Andrew has a terminal diagnosis, the values of patient-centred care—dignity, respect, and partnership—are crucial. Research indicates that person-centred approaches enhance adherence towards methods of self-management, medical satisfaction, and overall quality of life. Customizing interventions for Andrew, such as incorporating his sister in arranging and delivering personal care at home that promotes independence, guarantees that his objectives stay at the forefront. This supports care that is customized for each patient's unique situation, which is in line with the NSQHS Integrated Care Standard.
Communication and Shared Decision-Making
Throughout the course, communication and group decision-making came up frequently. According to Lewis (22:13), communication difficulties worsen when speaking and swallowing are impacted by respiratory impairment(Joseph-Williams et al., 2021). Techniques like active listening, the use of visual aids, and simpler language could enhance communication between Andrew, his family, and the team. Additionally, Dixie (20:22) emphasized the importance of addressing behavioural types, which promotes meaningful communication and patient involvement. Nurses must support informed choices and communicate effectively and respectfully in accordance with NMBA Standard 2 (Nursing and Midwifery Board of Australia, 2016).
References
- Apuzzo, L., Iodice, M., Gambella, M., Scarpa, A., & Burrai, F. (2024). Chronic Care Model – a secondary publication. International Journal of General Practice Nursing, 2(1), 15–22. https://doi.org/10.26689/ijgpn.v2i1.6265
- Caneiras, C., Figueiredo, C., & Pina, J. (2022). Pulmonary rehabilitation and physiotherapy approaches in chronic respiratory diseases. Pulmonology, 28(5), 330–339. https://doi.org/10.1016/j.pulmoe.2022.05.002
- Chaudhuri, N., Whyte, M. K. B., & Hurst, J. R. (2021). Managing bronchiectasis in adults. BMJ, 373, n1440. https://doi.org/10.1136/bmj.n1440
- Cuchet, I., Dambrun, M., Bedhomme, S., Savanovitch, C., Roussel, H. V., & Maneval, A. (2024). The roles of French community pharmacists in palliative home care. BMC Palliative Care, 23(1). https://doi.org/10.1186/s12904-024-01406-6
- Fitch, M. I., & Maamoun, J. (2020). Supportive care needs of patients with advanced cancer: A systematic review. Journal of Clinical Nursing, 29(11–12), 1744–1761. https://doi.org/10.1111/jocn.15239
- Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A’Court, C., Hinder, S., Fahy, N., Procter, R., & Shaw, S. (2017). Beyond adoption: A new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. Journal of Medical Internet Research, 19(11), e367. https://doi.org/10.2196/jmir.8775
- Grudniewicz, A., Gray, C. S., Boeckxstaens, P., De Maeseneer, J., & Mold, J. (2023). Operationalizing the Chronic Care Model with goal-oriented care. Patient, 16(6), 569–578. https://doi.org/10.1007/s40271-023-00645-8
- Joseph-Williams, N., Elwyn, G., & Edwards, A. (2021). Shared decision-making in chronic illness: A systematic review. Patient Education and Counseling, 104(5), 903–915. https://doi.org/10.1016/j.pec.2020.12.019
- Kavalieratos, D., Gelfman, L. P., & Dionne-Odom, J. N. (2021). Palliative care in chronic illness: Improving quality of life and reducing burden. Annual Review of Medicine, 72, 45–59. https://doi.org/10.1146/annurev-med-042319-114640
- Marlin_Admin. (2025, September 10). Lung Foundation Australia: Together we’re making a difference. Lung Foundation Australia. https://lungfoundation.com.au/
- Nursing and Midwifery Board of Australia. (2016). Registered nurse standards for practice. https://www.nursingmidwiferyboard.gov.au
- Osadnik, C. R., McDonald, C. F., & Holland, A. E. (2020). Airway clearance techniques in bronchiectasis and COPD. Respirology, 25(9), 933–942. https://doi.org/10.1111/resp.13813
- Palliative Care Australia. (n.d.). Palliative Care Australia. https://palliativecare.org.au/
- Pomey, M., Schaad, B., Lasserre‐Moutet, A., Böhme, P., & Jackson, M. (2024). Towards a new integrated model for taking into account the experiential knowledge of people with chronic diseases, integrating mediation, therapeutic education and partnership: The Expanded Chronic Care Patient–Professional Partnership Model. Health Expectations, 27(5). https://doi.org/10.1111/hex.70054
- Santana, M. J., Manalili, K., Jolley, R. J., Zelinsky, S., Quan, H., & Lu, M. (2019). How to practice person-centred care: A conceptual framework. Health Expectations, 22(3), 271–284. https://doi.org/10.1111/hex.12803
- Wheatley, V. J., Baker, J., & Toft, K. (2021). The role of community-based palliative care in supporting patients with chronic disease. BMC Palliative Care, 20(1), 65. https://doi.org/10.1186/s12904-021-00758-9
- Willumsen, E., Ahgren, B., & Ødegård, A. (2021). A conceptual framework for interprofessional collaboration. Journal of Interprofessional Care, 35(1), 33–40. https://doi.org/10.1080/13561820.2020.1791809
10 Years | Ph.D. in Nursing
