EXECUTIVE OVERVIEW
We plan to increase access to care in the rural, underserved region of Ghana by implementing a sustainable model of care to address and assist in the management of chronic diseases and maternal mortality.
Chronic illness can bring significant disability and early death and affect every aspect of life-how one eats, works, and loves. Having a long-term illness can demand profound life changes. Managing symptoms, changing diet, taking medications, and interacting with the medical care system are but a few of the tasks entailed.
One successful multidimensional approach to caring for patients with chronic illness within primary care is “the chronic care model”. This model includes system changes designed to provide both patient and provider with support for disease management. Examples include linking patients with community resources; accessible guidelines to inform provider’s clinical decisions, and clinical information systems that foster integrated care and track actual disease management.
Establish trust with the current clinics serving the populace allowing us to mediate care along with them.
Engage partners: Partners can help overcome resource limitations, provide referrals, assist with outreach, and in some cases, offer financial support, provide access to known and trusted community members, such as service coordinators at senior housing sites, local public health personnel.
Transportation access is a significant problem in rural areas that can affect participation. In concert with our partners, we will try to develop some form of transportation system which will ease the burden off those destitute individuals with no means to afford them.
Constant communication with leaders and participants is important for maintaining connections.
Ongoing outreach and promotional messages are vital.
Tasks, Objectives & Goals
Chronic disease management through primary care:
Address knowledge gaps in chronic disease
Hypertension –
Educate patients on diet
Consequences/Sequelae of hypertension
Utilizing a blood pressure cuff
Pharmacotherapy for hypertension
Diabetes Mellitus
Educate patients on the etiology of diabetes
Monitoring to include regular blood sugar checks, utilizing the equipment
Biannual/annual exams: Ophthalmology, Podiatry
Laboratory data: a1c, TSH, lipid panel, CMP, vitamin D, B12
Pharmacotherapy
Educate on the consequences of uncontrolled disease
Chronic Kidney Disease
Chronic heart failure
Cerebrovascular disease
Obesity
Maternal mortality through diligent prenatal, antennal and post natal care:
Screening for concomitant disease such as DMII, HTN, Obesity, family health history, pre-eclampsia
Screen for STDs, TORCH
Pelvic/Pap smears
Ultrasound
Prenatal vitamins/Vaccinations
Amniocentesis/chorionic villus sampling
Increase Obstetric care by obtaining more providers to include nurses, midwives, and physicians
Education of the staff
Bimonthly live and or recorded lecture series from different specialists to be arranged according to availability
Establish a network with current clinics in the rural areas
Renovate the infrastructure
Increase provider to patient ratio
Improve diagnostic ability by introducing novel technological tools
Transportation
Currently there is no effective transportation to higher level of care and patients have to pay out of pocket
Establish connections with the local ambulance services in the area to build a constant supply