Topic Learning Outcomes

LO1: Determine the ethical, legal, political, and sociological factors that create barriers to care for clients with chronic and complex health needs.

LO2: Examine primary health care and chronic disease management models, and the role of the nurse within the interprofessional healthcare team in integrating care with a view to prevent avoidable hospitalisations.

LO3: Critique local and national approaches to health promotion and services available in the community for people with chronic and complex health needs.

CASE STUDY

Address: Surland St, Blackwood
Age: 72
Background: Mark Seymour is a retired mechanic living in suburban Adelaide. He presents with increasing breathlessness, fatigue, and reduced mobility.

Chronic Health Conditions

• Chronic Obstructive Pulmonary Disease (COPD)

• Type 2 Diabetes

• Hypertension

• Osteoarthritis

Living Situation

Mark owns a two-bedroom unit in a block of 20 properties. The home is single-storey but lacks accessibility features.

Family and Social Support

• Daughter – Melissa (45): Lives nearby, visits weekly for shopping and cleaning.

• Son – David (40): Lives interstate, maintains phone contact.

• Neighbour: Has a close relationship and occasionally assists with errands.

• Receives a part aged pension, holds a Health Care Card and Seniors Card.

• No Commonwealth-funded services currently and is unsure of eligibility.

Health and Wellbeing Concerns

• Recent 4 kg weight loss due to low appetite and fatigue.

• Increasing joint pain and impaired mobility.

• Requires potential home modifications (bathroom adjustments, ramp).

• Feels isolated and frustrated with declining independence.

• Avoids medical appointments, prefers managing health at home.

Care Goals

Mark would like support with:

• Maintaining independence at home.

• Understanding available support services (concerned about cost; struggles with online information).

• Improving mobility and pain management.

• Increasing community engagement to support mental wellbeing.

• Reducing worry about being perceived as “useless” due to declining physical health.

Assessment Instructions

You are the Registered Nurse in the local GP practice. Using the case study, address the following tasks.

Task 1

Discuss how social isolation may act as a barrier to Mark accessing appropriate person-centred care, and how this may potentially lead to hospitalisation.

Task 2

Focusing on Mark’s self-identified care needs:

1. Identify one (1) Commonwealth Funding Support Mark is eligible for.

2. Identify one (1) other Government Support Service he is eligible for.

3. Provide rationales explaining why the services identified are person-centred, and how they support Mark’s ability to self-manage at home.

Task 3

Using the 2017 NSFCC (Part 2, Objective 2.1) as your foundation:

• Discuss the role of the Registered Nurse in improving Mark’s capacity for self-management.

• Include specific examples.

• Integrate relevant NMBA Registered Nurse Standards for Practice (sub-standards).

• Link your discussion to the Fundamentals of Care (FOC) framework.

Task 4 

Select one (1) of Mark’s person-centred care needs.
Identify and discuss one current local or national health promotion initiative that could help him retain independence and avoid hospitalisation.

Presentation Guidelines

• Word count: 1800 words ± 10%

• Use headings: Task 1, Task 2, Task 3, Task 4

• No introduction or conclusion required.

• Submit as Word document (.doc/.docx)

• Line spacing: 1.15 – 1.5

• Font: Arial or Calibri, size 11 or 12

• Use professional nursing terminology; avoid acronyms, abbreviations, and jargon.

• Use Australian English.

• Include a footer with Student FAN.

Brief summary of assessment requirements

You are the Registered Nurse (RN) at a local GP practice and must prepare an 1800-word case study response (±10%) using the Mark Seymour scenario. Use headings Task 1–Task 4 and Australian English. No introduction or conclusion required. Reference in APA 7 and include a footer with student FAN. Follow presentation guidelines (Word format, Arial/Calibri 11–12, 1.15–1.5 spacing).

Core requirements (what to cover):

• Task 1 (≈400 words): Explain how social isolation acts as a barrier to person-centred care for Mark and how it may lead to hospitalisation (safety, delayed help seeking, poor self-management, mental health, nutrition, medication adherence).

• Task 2 (≈600 words): Name one Commonwealth funding support Mark is eligible for and one other government service; provide clear person-centred rationales showing how each supports self-management at home (e.g., home support, allied health, home modifications, transport).

• Task 3 (≈400 words): Using 2017 NSFCC Part 2 Objective 2.1, discuss the RN’s role in improving Mark’s self-management. Integrate NMBA RN Standards for Practice (relevant sub-standards) and link to the Fundamentals of Care (FOC).

• Task 4 (≈400 words): Choose one of Mark’s person-centred needs (e.g., mobility/home modifications, community engagement, pain management) and discuss a current local or national health promotion initiative that could help him remain independent and avoid hospitalisation.

• Maintain professional terminology, justify recommendations with evidence-based reasoning, and ensure all references are accessible.

Key pointers to include in each Task 

Task 1

• Define social isolation and show how it affects access (transport, info literacy, reluctance to attend appointments).

• Link isolation to risks: worsening COPD, falls, uncontrolled diabetes, medication mismanagement, malnutrition, depression → hospitalisation.

• Include brief person-centred examples specific to Mark (e.g., avoids appointments; limited internet skills).

Task 2

• Identify one Commonwealth support (e.g., Commonwealth Home Support Programme / Home Care Package assess eligibility) describe scope (domestic assistance, personal care, minor home mods, allied health referral).

• Identify one other government/local service (e.g., council home modification grants, My Aged Care navigation, community transport, local allied health).

• Give person-centred rationales (affordability, tailored assessments, promoting independence, enabling safe mobility, reducing admissions).

Task 3

• Summarise NSFCC Objective 2.1 and apply to Mark (integrated care planning, shared decision-making).

• Map RN actions to NMBA sub-standards (assessment, planning, communication, coordinating referrals, evaluating outcomes).

• Link to Fundamentals of Care domains (physical, psychosocial, relational) with practical examples (e.g., teach inhaler technique, arrange mobility aids, coordinate allied health, provide anticipatory care plan).

Task 4

• Choose one need (e.g., improving mobility and home safety).

• Name one initiative (e.g., local falls prevention program / national healthy ageing program / community rehabilitation) and explain how it supports independence and reduces hospitalisation risk.

• Show expected outcomes and how success would be measured.

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