Chronic Disease Management

Running head: COMMUNITY ASSESSMENT REPORT 1
Community Assessment Report: Part IV
Student Name
Ameritech College of Healthcare

COMMUNITY ASSESSMENT REPORT 2
Part IV: Collaboration
Introduction:
Component: Collaboration with Community Healthcare Team Member
Community Health Member Top Three Priority Needs Describe Target (Vulnerable)
Population
Position: Physical activities need,
tobacco use, and the
management of chronic
conditions.
The elderly, aged 65 years
and above.Contact Information (Name
of Healthcare Organization)
Email:
Phone Number:
1. Develop a community diagnosis. Use the correct format: Health
Risk/problem/potential of/for (specific injury, illness, or potential of, complications of,
etc.) among (specific population) related to (supporting evidence of risk factors) as
evidenced by (contributing factors).
The health need addressed here is the management of chronic conditions among the elderly
(aged 65 and above) related to diabetes, chronic heart diseases, respiratory problems, and
arthritis as evidenced by high mortality rate amongst the elderly (Salzman, Collins, & Hajjar,
2012).
2. Identify 1 possible solution to address targeted need.
The management of chronic conditions can be addressed by identifying their morbidities and
the contributing factors ("COMPLEX CARE OF CHRONIC CONDITIONS IN THE
COMMUNITY: OLDER ADULTS AND CAREGIVERS NEEDS," 2015). This can help in
identification of the root cause of conditions like diabetes, arthritis, coronary heart disease,
asthma and take the necessary measures to avoid their onset.

COMMUNITY ASSESSMENT REPORT 3
3. Identify 1 primary, secondary, or tertiary intervention strategy to address targeted
need.
The management of chronic conditions needs can be done by using a lifestyle intervention in
the community settings and in the public health facilities. These interventions help the people
with chronic conditions to know how to live well with them, and help those without these
conditions know how to avoid them.
4. Develop 1 expected outcome in the form of a measurable objective – delineate who,
what, and when (outcome objective, process objective, management objectives).
I expected outcome in case of diabetes, which is a chronic condition common amongst the
elderly is for it to reduce weight within a span of 6 months by -16.7. This shall be possible
through exercises planned by the community diabetic team and the community health nurse.
5. Delineate 2 evaluation strategies (to determine if the intervention was successful).
One evaluation strategy involves measuring of the current chronic conditions state
outcome amongst the elderly, and compare it with the previous conditions before the
intervention strategy was employed. Another evaluation strategy is rating of diseases
where every condition should be rated in a chronic care model by obtaining reports
from community chronic health teams for the elderly.
6. Identify potential resources needed to address targeted need (list a minimum of 3).
Financial resource
Human resource
Space resource

COMMUNITY ASSESSMENT REPORT 4
Conclusions:
Managing chronic conditions is a long process that needs substantial planning. This is done by
collaboration between the patients, the community members and the health team to identify the
right measures of preventing the conditions to those who do not have, and managing it amongst
the sick. The implementation of this long term plan is faced by various challenges such as
financial constraints, that can be solved through financial supports from organizations, the health
sector and all other well-wishers.

COMMUNITY ASSESSMENT REPORT 5
References
COMPLEX CARE OF CHRONIC CONDITIONS IN THE COMMUNITY: OLDER ADULTS
AND CAREGIVERS NEEDS. (2015). The Gerontologist, 55(Suppl_2), 23-23.
doi:10.1093/geront/gnv651.05
Salzman, B., Collins, L., & Hajjar, E. R. (2012). Chronic Disease Management, An Issue of
Primary Care Clinics in Office Practice - E-Book. St. Louis, MO: Elsevier Health
Sciences.