N3CN3 FINAL PAPER 2026 COMPLETE
RESPONSE SET GRADED A+
◉ What is chronic disease. Answer: illnesses that are prolonged, do
not resolve spontaneously, and are rarely cured completely
◉ What is the prevalance increase of chronic disease driven by.
Answer: - increasing obesity
- smoking
- growing number of older people
◉ CDM. Answer: chronic disease management
◉ why is a horizontal system approach weak for chronic disease?.
Answer: involves patients being transferred between primary care
and specialist hospital services but the lack of service integration
has often been weak
- as a result of the focus on the needs of the organizations rather
than the patients
◉ quality chasm. Answer: Gap between current healthcare quality
and potential.
,◉ Chronic Disease Management patient involvement. Answer: -
successful outcomes in CDM are dependent on patients performing a
range of complex self-care behaviours
- emphasis on self-care places patient at the centre of the care
system
- led to the empowerment model
◉ empowerment model (chronic disease). Answer: emphasizes
patient choice, shared decision making, and the psychosocial aspects
of care delivery
◉ CDM: Vertical integration. Answer: - recognizes that patients with
differing levels of severity or disease progression will need different
approaches to care
- one of the most widely adopted models is Kaiser Permanente's
model
◉ Kaiser Permanente's Model. Answer: Level 1: "Self-care support"
(70-80% of patients) which focuses on screening, education and
patient empowerment
Level 2: "Assisted care" (15% of patients) which focuses on high risk
patients needing active clinical management
,Level 3: "intensive management" (5% of patients) which focuses on
high risk patients with complex needs, often accompanied by
multiple-pathology
◉ CDM: Care system integration. Answer: care system integration
aspires to make better use of the resources through horizontal
integration of care providers and systems
◉ Wagner's Chronic Care Model. Answer: - community resources
and policies
- health care organization
- self-management support
- delivery system design
- decision support
- clinical information systems
◉ Nurses contribution to CDM. Answer: - horizontally (managing
patients through and between care systems)
- Vertically (Providing preventative health care, providing self-care
support and education, identifying problems and complications;
managing problems and optimising therapies, and providign case
management in more complex cases)
◉ 3 contribution of nurses in CDM. Answer: 1. Nurse-led care
, 2. Nurse-led and nurse delivered care
3. Nurse delivered care
◉ Nurse led care. Answer: the nurse identifies the needs and then
organizes a care package or refers to others; independent nursing
practice
◉ Nurse-led and nurse delivered care. Answer: the nurse identifies
the needs and manages the problem herself; independent nursing
practice
◉ Nurse delivered care. Answer: the nurse provides care under the
direction of others, a more advanced nurse or a doctor; dependent
nursing practice
◉ Research found roles of a nurse in CDM: Patient activities:.
Answer: - assessment
- health promotion
- clinical interventions
◉ Assessment (CDM) (6 groups). Answer: - Case-finding and
screening
- Supporting diagnosis
- allocation to care
RESPONSE SET GRADED A+
◉ What is chronic disease. Answer: illnesses that are prolonged, do
not resolve spontaneously, and are rarely cured completely
◉ What is the prevalance increase of chronic disease driven by.
Answer: - increasing obesity
- smoking
- growing number of older people
◉ CDM. Answer: chronic disease management
◉ why is a horizontal system approach weak for chronic disease?.
Answer: involves patients being transferred between primary care
and specialist hospital services but the lack of service integration
has often been weak
- as a result of the focus on the needs of the organizations rather
than the patients
◉ quality chasm. Answer: Gap between current healthcare quality
and potential.
,◉ Chronic Disease Management patient involvement. Answer: -
successful outcomes in CDM are dependent on patients performing a
range of complex self-care behaviours
- emphasis on self-care places patient at the centre of the care
system
- led to the empowerment model
◉ empowerment model (chronic disease). Answer: emphasizes
patient choice, shared decision making, and the psychosocial aspects
of care delivery
◉ CDM: Vertical integration. Answer: - recognizes that patients with
differing levels of severity or disease progression will need different
approaches to care
- one of the most widely adopted models is Kaiser Permanente's
model
◉ Kaiser Permanente's Model. Answer: Level 1: "Self-care support"
(70-80% of patients) which focuses on screening, education and
patient empowerment
Level 2: "Assisted care" (15% of patients) which focuses on high risk
patients needing active clinical management
,Level 3: "intensive management" (5% of patients) which focuses on
high risk patients with complex needs, often accompanied by
multiple-pathology
◉ CDM: Care system integration. Answer: care system integration
aspires to make better use of the resources through horizontal
integration of care providers and systems
◉ Wagner's Chronic Care Model. Answer: - community resources
and policies
- health care organization
- self-management support
- delivery system design
- decision support
- clinical information systems
◉ Nurses contribution to CDM. Answer: - horizontally (managing
patients through and between care systems)
- Vertically (Providing preventative health care, providing self-care
support and education, identifying problems and complications;
managing problems and optimising therapies, and providign case
management in more complex cases)
◉ 3 contribution of nurses in CDM. Answer: 1. Nurse-led care
, 2. Nurse-led and nurse delivered care
3. Nurse delivered care
◉ Nurse led care. Answer: the nurse identifies the needs and then
organizes a care package or refers to others; independent nursing
practice
◉ Nurse-led and nurse delivered care. Answer: the nurse identifies
the needs and manages the problem herself; independent nursing
practice
◉ Nurse delivered care. Answer: the nurse provides care under the
direction of others, a more advanced nurse or a doctor; dependent
nursing practice
◉ Research found roles of a nurse in CDM: Patient activities:.
Answer: - assessment
- health promotion
- clinical interventions
◉ Assessment (CDM) (6 groups). Answer: - Case-finding and
screening
- Supporting diagnosis
- allocation to care
