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Let's Be Frank
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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

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