From Theory To Practice:Design A Transitional Care Network Platform For The Elderly With Chronic Diseases

BackgroundChina is facing great challenges about aging tendency of population and high incidence of elderly chronic disease. Network media as a new way of information services, for its initiative and effectiveness, was gradually gained the acceptance of the most users. How to combine the modern technology with scientific and effective health management models to achieve a new transitional care model with high economic and social benefits is what we think about. The illness experience and health empowerment of patients should be considered in the effective health management or transitional care models. Compared to professional medical personnel, chronic patients have a better understand about their own lives and specific disease rules, and a clearer feeling of needs physiologically and psychologically, so that the patient’s own was the primary caregiver. To improve self-management ability, fully understanding the own life experiences and discovering the patient’s own inner capacity should be involved in elderly chronic patients with transitional care models as well as understanding the patient’s cognitive-adapt processes of disease. Due to the different cultural background, there are diverse explanations of patient’s disease cognitive. In area of health management, the disease cognitive and response model of elderly patients with chronic disease and transitional care network approach remain to be further studied in China.According to the International Diabetes Federation (IFD)2011statistics, the global number of diabetes was366million, and estimated that in2030the number will grow to552million. Diabetes mortality rate is very high; there will be one people in every ten seconds die due to diabetes-related causes. Diabetes is one of the most prevalent non-communicable diseases. In2010, adult diabetes prevalence rate is9.7%, the total number of patients has more than90million, and China is now home to the most cases worldwide. Diabetes is a heavy burden to patients, their families and Social medical institutions. It is a very important and meaningful task to help patients and their families facing the correct and proper management of diabetes. Therefore, this research chooses elderly diabetic patients as our target subject, to provide an initial experience and data for the future research of other chronic diseases.ObjectiveThe purpose of this study is to explore the relationship between disease cognitive, coping strategies and self-efficacy in elderly patients with diabetes, understand the adapt process of patients, build and develop theory framework of nursing intervention mode and diabetes adaptation model which is suitable for Chinese elderly patients, that provides a theoretical basis for the further development of transitional care model for elderly patients with diabetes and other chronic disease. Meanwhile, combining the theory and practice, we hope to design a transitional care network platform which was suitable for elderly patients with chronic disease, extend the health care from hospital to community, and strengthen the patient’s capacity of self-management. The research issues include:What the perception of the disease in elderly patients with diabetes? Have the perception of disease effect on process of adaptation and response to the disease? What is the role of self-efficacy in the process? Have patient’s potential been mobilized to make a positive adjustment in the self-management process? Are there any factors would affect the patient’s perception of the disease? How to help patients achieve adaptation to the disease? How to introduce the care theoretical model to the network information technology?MethodThe study consists of three parts.1. Theoretical framework and research hypothesisThe study based on the Roy’s adaptation model, combined the Leventhal’s common sense model and Bandura’s theory of self-efficacy to build an adaptation model of elderly diabetics, and the research hypothesis was also confirmed as well as research variables.2. The relationship between illness perception, self-efficacy, coping strategies and health conditions.Total250samples were collected through convenience sampling questionnaire from diabetic outpatients and endocrinology in certain grade-three general hospital in Guangzhou, illness perception, self-efficacy, coping strategies and health conditions were investigated and the relationship was explored by diabetes patients basic information table, by the assessment tools of Brief Illness Perception Questionnaire(Brief-IPQ), Self-Efficacy for Managing Chronic Disease6-Item Scale (SECD6), Medical Coping Modes Questionnaire (MCMQ), The Summary of Diabetes Self-Care Activities Measure (SDSCA) and EQ-5D-5L. The study validated and revised the hypothesis and proposed some suggestions about the effectively transitional care model for patients with diabetes according to research results.3. Preliminary establishment of transitional care network platform of elderly chronic disease.To design and establish A transitional care service network platform based on nursing conception model proposed by this study, referenced successful model of transitional care in other countries.Results1. Theoretical framework and research hypothesisCommon sense model and self-efficacy, both theories emphasize personal experience, pre-construction of self, individual response to illness and treatment, and that the patients’beliefs are more influential in their recovery than the severity of the illness. Where the theories are most divergent is their application to therapeutic interventions, which reflect the different sources of influence that each theory emphasizes. Based on their similarities and differences it is possible to integrate the two theories into a conceptual care model.Illness representation offers a general perspective of an individual’s initial interpretation of their illness, as the representation components are largely formed before their experience of the illness and have been shown to have a predictive value in terms of short-term patient responses; self-efficacy explores how a patient perceives their own ability to adopt and maintain health behaviors require in the treatment of their condition, and has been shown to have a predictive value in terms of long-term patient responses. Therefore, there is a chronological sequence to the focus that each theory adopts and if there is a relationship between the two then it should follow this chronology. The chronic disease adaptation model put forward by this study proposes that illness perception components predict self-efficacy. This sequence appears theoretically logical, as the illness perception model tends to predict the intention of health behavior change rather than the actual behavior change, while Bandura’s self-efficacy research is based on predicting actual long-term behavior change.These time scales provide a chronological framework for the integrated design of care interventions, suggesting the direction of the relationship-the illness representation components influence the long-term perception of the patient’s self-efficacy-creating a more holistic regime to manage both the patients’initial conceptualization of their condition and to develop their perceived ability to cope with their condition and its treatment over the longer term. By incorporating both illness perception and self-efficacy into a single conceptual care model, an explicit framework has been provided for further research.2. The relationship between illness perception, self-efficacy, coping strategies and health conditions.The questionnaires were issued for250, recycled246. The valid questionnaires are233. Effective recovery ratings are93.2%.233individuals who have type2(n=216,92.7%), type1(n=4,1.7%) and other types (n=13,5.6%) diabetes mellitus participated in this study. Participants’age range from60～91, the average age was69.03±7.86years. On average, length of diagnosis with diabetes was114.42±93.25months.In the different dimension of illness representation of elderly diabetes, timeline, cure/control and consequences has higher scores, meanwhile identity, coherence, and emotional representation has lower scores. Suggest that most patients think the diabetes mellitus is long-term and controllable; diabetes has certain influence to life. Their perceived degree of understanding of diabetes was normal. In terms of understanding of the etiology, most patients think diet, daily lifestyle and genetics is the major cause of diabetes, but there is also some wrong understanding of the etiology in patients.Different demographic and disease characteristics will have an impact on different aspects of diseases depicted. U test showed that female patients have higher emotional representation score than male patients (P<0.01); the patient without partner have higher emotional representation score than patients have a partner (P <0.05); patients without job have higher timeline, consequences and emotional representation score than patients with job (P<0.01). Spearman correlation analysis showed that age was positively correlated with consequences and was negatively correlated with personal control (P<0.01) and treatment control (P<0.05); Education level was positively correlated with emotional representation (P<0.05); Economic burden was positively correlated with; Duration of diabetes was positively correlated with timeline (P<0.05) and emotional representation (P<0.01), and was negatively correlated with personal control (P<0.01); Number of complications was positively correlated with identity, consequences and emotional representation (P<0.01), was negatively correlated with personal control (P<0.01); Treatment modalities was positively correlated with identity (P<0.01), consequences(P<0.01), treatment control(P<0.05) and coherence (P<0.01), was negatively correlated with personal control (P<0.05). Regression analysis showed that the patient’s disease is characterized mainly affected by age, education, work status, economic burden, duration of disease, complications, and treatment modalities.The results show that there is a significant relationship between the patients’ illness representations, self-efficacy and coping strategies. Illness representations can affect the selection of coping strategies, self-efficacy plays an intermediary role between the illness representations and coping strategies depicted. Spearman correlation analysis showed that facing was negatively correlated with consequences strategies personal control, treatment control and self-efficacy (P<0.01); Avoidance was positively correlated with consequences (P<0.05), and was negatively correlated with personal control, treatment control and self-efficacy (P<0.05or P<0.01); Yielding was positively correlated with consequences and emotional representation(P <0.05or P<0.01), and was negatively correlated with identity, personal control and self-efficacy(P<0.05or P<0.01). Test of the intermediary role of self-efficacy showed that self-efficacy completely mediated the associations of consequences, personal control, emotional representation and facing strategy (mediating effect=-0.112,0.222,0.149, effect ratio=0.147,0.965,0.296), and partially mediated the associations of treatment control and facing strategy (mediation effect=-0.091, effect ratio=0.653).Self-efficacy partially mediated the associations of consequences, treatment control and avoidance strategy (mediating effect=0.043,-0.072, effect ratio=0.288,0.531). Self-efficacy partially mediated the associations of emotional representation and Yielding strategy (mediation effect=0.021, effect ratio=0.054).These results verified our initial conceptual model proposed in the first part, and an explicit framework has been provided for further research and its effectiveness can be intervention research designed for extendant care..3. Preliminary establishment of a transitional care network platform for patients with elderly chronic disease.The holographic intervention model proposed in this study is applied to the network platform to achieve applying the theoretical model into transitional care practice. Network holographic care intervention achieves interaction between medical staff and patients through three aspects:file management, follow-up management and communication. Four functional modules was designed including user login and registration, patient file management, individual patient center and Health Plaza, which involve in the patient’s perception-coping process with the adaptation process, to improve the patient’s self-efficacy, and ultimately to improve patient self-awareness of the disease and help patients develop positive coping strategies to improve patient self-management ability.DiscussIn this study, we use adaptation model as a framework, combined with common sense model and self-efficacy theory, present and preliminary test the adaptive mode of elderly diabetes. We verified the impact of patients’perception-coping process on self-management and health behavior. We partially revealed its inner processes of adaption of elderly diabetes, which provides a theoretical basis for clinical self-care intervention of patients with diabetes and other similar chronic disease.Based on the results, we made the following key recommendations:①Assessment patients’illness perception starting from the evaluation of patients’ illness representations, which refers to the meaning of their disease portrayed by patients. We can obtain new understanding of the disease from the patients’perspective by portraying disease by illness representations.②Pay attention to the different characteristics of patients’ illness perception demand. The study showed that different illness perception in patients with different characteristics. So in clinical care, we should be concerned about the illness perception characteristics in patients with different characteristics, in order to take individualized health education, improve the quality of nursing intervention.③Pay attention to the role of self-efficacy. This study demonstrated that self-efficacy plays a completely or partially intermediary role in illness perception and the choice of coping strategies among elderly patients with diabetes. Self-efficacy and coping strategies are closely related. Enhance self-efficacy in elderly patients with diabetes, on the one hand, should focus on improving diabetes-related perception level, to strengthen health education for patients with cognitive weak point; On the other hand, should to focus on improving patient health beliefs, in order to enhance patients’ confidence in self-management activities.④This study proposes a theoretical model to provide theoretical guidance for developing clinical care and transitional care programs for diabetes or other chronic diseases.In this study, the practice of using Holographic Care Model in network platform design process prove that the attempt that make theoretical model from theory to practice is feasible.ConclusionIn this study, we hypothesize a new adaptation model for elderly diabetic patients through theoretical studies and preliminary validate the prototype of theoretical model, present theoretical perception-coping adaptation model in elderly diabetic patients. In the theoretical model, the process of adaptation to the patient’s disease is a perception-coping process, general information will affect the patient’s perception of the disease, and patients with different illness representation take different strategies to coping with the disease, thus affecting the self-management behaviors and health status of the patient. Patient health outcomes are feedback to illness perception. Self-efficacy is expected to play a mediation role in the illness perception and coping strategy to the disease adaption process. Based on this model, we propose a Holographic Care Model for elderly patients with diabetes, emphasis a comprehensive on patient perception-coping of the adaptation process. Finally, we try to use Holographic Care Model in transitional care network platform, settled in practice, optimizing transitional care services for the elderly with chronic diseases.