Identify a method that uses evidence-based data to support new or innovative ways to care for the aging population.
DNP 810 Topic Discussion Question Two

Identify a method that uses evidence-based data to support new or innovative ways to care for the aging population. What are the anticipated outcomes of employing this method and methods like it? How can the doctoral-prepared nurse apply this information in practice? Explain. Support your rationale with a minimum of two scholarly sources.

Traditional illness-centered health care models fall short when facing the CD challenges in our increasing aging population. As the World Health Organization already challenged the traditional view in its definition of health in 1948, nowadays health care trends try to go further. Some authors18 propose to define health as “the ability to adapt and to self-manage”, reflecting the current reality of older chronic patients. Current trends try to make health services more effective by being personalized and tailored to the patients’

DNP 810 Topic Discussion Question Two
DNP 810 Topic Discussion Question Two

needs, resources, and characteristics, based on early detection of risks and preventive treatment in the person’s environment. New ICT tools for ambulatory care are strongly contributing to the feasibility of home-based health care even in serious cases which just some years ago were restricted to intensive care units in hospitals.

But the application of these insights is hampered by the fragmentation of services in most health systems.21–23 The latest health care approaches are stressing the need to advance new frameworks for collaboration among social and health services in order to address the complex nature of CD progression in the older person, including biological, physiological, psychological, social, and contextual factors (eg, de Bruin et al and Burns et al24,25). Current health care trends do recognize such challenges and are progressing towards attaining the desired integration of health elements and services. A bibliographic review of evaluative research on innovative practices in the field allowed us to group them in the following current trends:

Early diagnosis and prevention,25,26 facilitated by new ICT tools.27–33 Multidimensional systems include noninvasive monitoring tools, gathering relevant patient’s biopsychosocial information within predictive applications to be used by the patients and health centers. E-health systems incorporate and process large amounts of real-time, multidimensional information from/to the patients’ home and natural settings, and from/to different areas and agencies in shared, interoperable, and synched big databases using cloud computing technology.5,19,20,33 Information recording and processing applications for smart wearable technologies (SWT), depth cameras, and knowledge management (KM) tools are more and more used in smartphones, tablets, and computers, including real-time information gathering and sharing tools, and patients and corporate portals for information interfaces and community participation. An ICT-supported KM approach may include collective intelligence processes, information-shared analysis, planning problem–solving, and actions to promote health and well-being, follow-up, and accountability.31–33 SWT, a noninvasive technology for remote, unobtrusive, and real-time recording of physiological data (heart rate, blood pressure, skin conductance, respiratory rate and volume, movement, and blood glucose) virtually without discomfort, allows a person to carry out their habitual daily activities while being monitored and guarded in their natural context.33 This technology opens tremendous possibilities for early detection and prevention of disease progression, relapses, and crises through the development of predictive tools including all the related biopsychosocial indices.
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Home-based, outreach health care. This approach works in the natural context where the problems and solutions are most present to preserve the well-being and autonomy of the patient. Cost-effectiveness studies19 comparing inpatient care vs home care revealed that patients in their own environment could manage their own autonomy and health longer and with higher satisfaction. More sustainable health autonomy and improved quality of life together with a reduction of costs by having the patient at home appear to provide a more cost-efficient approach than in-patient centralized care.19,20 Providing home-based services appears to improve symptoms; saves costs to health services; reduces hospitalization; preserves patients’ preferences, autonomy, and medication adherence; increases practitioners’ satisfaction; and makes better use of psychosocial support.1,34,35 Good examples are the home-based reablement (intense rehabilitation) practices, successfully expanded in different countries.36

Psychosocial health promotion, centered on the patients’ personal and social resources. The World Health Organization16 points out the need to include community health promotion strategies in health care systems. Searching for increased cost-efficiency and effectiveness, health care should enhance psychosocial resources of the patient and their communities. Community health managers (those agents in charge of the general health in a local community) represent a fundamental avenue for reaching all patients in a local area, promoting health communities (groups of patients with similar illness organizing themselves in mutual-support communities) intertwined with the local community, and enhancing personal and social resources on health and well-being to increase self-competence, cognitive and social skills, physical autonomy, illness acceptance, treatment compliance, and proactive involvement of the patient, that is, empowering the patient.1 Current examples in this direction are the home and community care managers, and even nonhealth professionals after a training program, significantly contributing to reduce dependency and improve quality of life in older patients.37

Genetic, psychosocial and real-time physiological predictive tools and algorithms regarding the patients’ health. Such tools and algorithms can be used for early detection, screening, and overarching preventive diagnosis, and can incorporate mathematical and statistical models.17,27–33,38–43

Integrated health care. This entails a set of procedures to merge services from different agencies and formal and informal resources in the relationship with the individual, family, and community. This approach is intended to tackle all main factors affecting a disease in a systemic and overarching manner,19–24,33 centered on improving the coordination among services and resources and the engagement of all stakeholders (including the patients and their communities) in decision-making, treatment, prevention, and health promotion.22,44 Aging persons with CD are perhaps the best example of cases with multifaceted and multilayered problems needing such a multidimensional approach to their care.

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