Cognitively aware chronic disease management

Overview of Practice Nurse Model of Dementia Care: Domains of cognitively aware chronic disease management care planning

If a cognitive impairment is suspected by the PN or GP, or volunteered by the person or Support Person (if available), assessment and chronic disease management care planning is then considered in the context of cognitive impairment. The Support Person and a discussion on future planning is included in this process. 

Cognitively aware chronic disease management is person centred, strength-based care planning. During assessment prioritise information about individual preferences, needs, values, routines, sources of joy and personal meaning [1] and build upon the individual’s strengthens and abilities.

The ‘domains of chronic disease management care planning’ diagram shows assessment and care planning domains; broad area of health and wellbeing which are interdependent.  The extent to which each domain is assessed will vary according to the person and their needs.  Not all this information described in the diagram needs to be covered in one consultation.  Assessment and care planning is an on-going process.  Additional domains may be assessed over time as the nurse-patient relationship develops, or as circumstances require.

Summary of “Domains of cognitively aware chronic disease management care planning” (Gibson & Yates, 2018)

Fazio, S., Pace, D., Flinner, J., Kallmyer, B. (2018). The Fundamentals of Person-Centered Care for Individuals with Dementia. Gerontologist. Vol. 58, No. S1, S10–S19