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By Min Lee, Managing Director
In Mauritius, 25% of our population will be above 60 years old within the next decade.
There is also a high prevalence of chronic diseases like diabetes (22%) and hypertension (28%).
Why does this matter?
As we age, our healthcare needs are no longer episodic - where we can go in and out of a clinic and recover. The moment we have a chronic illness, multiple illnesses, and frailty that naturally arise because of age, we start requiring a continuum of care - this means continuous health monitoring, sometimes across multiple domains of health requiring different specialists. This also means having to dynamically adjust medications and interventions to increase our overall health-span.
An Unfortunate Example
Mr Rajan is widowed and lives alone. At 85 years old, he has been diabetic for 20 years. He also has high blood pressure, and osteoarthritis in his knees which makes it difficult to walk long distances. For the past few weeks, he has been feeling exhausted, and does not have the energy to cook. He loses weight quickly, which throws his diabetes out of balance. And as a result, he takes more painkillers to relieve the pain in his knee, and also pills to help him to sleep at night.
One morning, he falls when attempting to get out of bed. Thankfully, his neighbours hear him after an hour, and they call for an ambulance. Mr Rajan fractured his hip, and also shows very low blood sugar, dehydration, and malnutrition. In the medical field, we know that hip fractures in the elderly are often a death sentence, unless there is serious and proper rehabilitation and functional training immediately after the operation.
This story is unfortunately no exception, but a holistic view of care could have avoided such a rapid deterioration in health on so many domains.
For a start, a nurse navigator could have helped Mr Rajan manage his diabetes, monitor his blood pressure, weight, and hydration, and adjust his medications with his doctors, with an effective plan for pain relief to avoid over-medication. A diabetes-friendly meal delivery plan could have made it easy for him to eat healthy and nutritious meals to prevent weight loss. A physiotherapist could have helped relieve his knee pain with hot and cold compressions, and also create a plan for building strength and balance. A personal assistant could have spent time with him regularly not only to help with errands, but to also go for outings, have fun, and have meaningful conversations to fight against social isolation.
A Holistic Care Model, led by Nurse Navigators
This is why we introduced the crucial role of a nurse navigator who serves as the client advocate. Our nurse navigators work closely with a multidisciplinary team of doctors and/or allied health professionals, and consult closely with family members, to provide comprehensive care to our loved ones, monitoring and reporting on outcome measures. They are observant, and are the first to sense if interventions are needed. They then work across boundaries and with multiple health specialists to ensure our loved ones receive the appropriate and timely care needed.
Our nurse navigators also go further, to educate and empower families about diseases, treatments, preventive measures, translating any medical jargon into easy terms that clients can understand. They regularly update the care plans, and can also train family caregivers or paid caregivers to deliver the care plans, monitoring outcomes through the KazaCare mobile application.
In addition, we also actively train our Nurse Navigators to champion health and wellness outcomes that go beyond clinical measures, to also include physical, mental, environmental, and spiritual wellbeing, and use quality of life as the ultimate goal in designing their care plans.
This is a key role in providing healthcare outside of a hospital environment to extend care at home, especially for our loved ones who may have complex illnesses or are frail.
Most importantly, we know that many of our elders are cared for by family caregivers or even a neighbour or friend. Our nurse navigators are also available as a standalone service to complement the caregiving team that you already have. We hope that our model of care will provide more families with additional relief and peace of mind.
7/9/2021 02:06:03 pm
Excellent initiative Min ... I wish you the very best. This is a service that the country badly needs.
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