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2010/1 Module Catalogue
 Module Code: NUR3036 Module Title: CHRONIC DISEASE MANAGEMENT
Module Provider: Health & Social Care Short Name: CDM3
Level: HE3 Module Co-ordinator: STEVENS D Ms (HSC)
Number of credits: 20 Number of ECTS credits: 10
Module Availability
Semester 2
Assessment Pattern
Summative: Analytic study of a patient or patient group (2500 words)

Students will present an analytical study of patient/ patient group and the way in which their chronic disease health and social needs are managed. The study will conclude with recommendations for practice.

Students will be expected to:

• Demonstrate knowledge and systematic understanding of the key issues in the management of long term conditions.
• Evaluation of relevant organisational, educational and clinical models to support practice
• Application of these theories to the work environment
• Discuss ways in which the care of this group of patients maybe developed or improved

Evidence from practice may be used to support the case study and presented as an appendix to the main body of the work.
Module Overview
Module Aims
The aim of this module is to enhance the student’s understanding and knowledge of the concepts and principles of chronic disease management and develop strategies to empower people to develop knowledge and skills to self care and develop strategies to facilitate appropriate service referrals.
Learning Outcomes
At the end of this module, the student should be able to:

Subject knowledge and understanding
• Critically explore and evaluate existing models of delivery of care for long term conditions
• Demonstrate knowledge and understanding of the global and national context of the management of long term conditions
• Evaluate understanding and beliefs of illness and disease across the life span
• Develop an in-depth understanding of the impact of cognitive and behavioural factors on people in relation to long term conditions
• Critically evaluate referral pathways for long term conditions.
• Develop an appreciation of the legal and ethical parameters of chronic disease management

Cognitive/ intellectual skills
• Demonstrate a critical understanding of the evidence base underpinning chronic disease management
• Critical evaluate information management systems and their importance in long term care
• Analyse guidelines, care pathways, roles and responsibilities in shared care

Practical skills
• Develop autonomy in skills for leadership, project management and practice organisation to arrange appropriate service delivery for chronic conditions
• Carry out risk assessment and stratification for a range of chronic diseases
• Develop advanced communication skills

Key/Transferable skills
• Develop an understanding of models of education and empowerment and use this to advance understanding of the importance of self-care in long term conditions.
• Demonstrate high level communication skills and strategies to work across boundaries within a multi-professional team
• Develop skills of reflection through case and family analysis
Module Content
Advanced Communication skills
Public health and the epidemiology of long term conditions
Political and service delivery systems affecting management
Information systems, disease registers, recall systems
Multi-agency care and the role of guidelines and care pathways in primary care
Leadership skills and team work in health care
Characteristics of specialist and generalist practitioners
Organisational systems analysis
Models of empowerment and patient education
Models of rehabilitation
Legal and ethical issues in chronic disease management
The expert patient
Effective self care
Risk assessment and stratification in chronic conditions e.g. in diabetes, cardiovascular, renal, respiratory and mental health
Risk assessment tools
Clinical decision making in the context of chronic disease management
Methods of Teaching/Learning
Taught: 48 hours
Self-directed/ workbased learning: 152 hours
Selected Texts/Journals
Audit Commission (2004). Older People – Indpendence and Well-being: the Challenge for Public Services. Audit Commission. London

Corben S, Rosen (2005) – Self Management of Long term Conditions: Patients Perspective on the way ahead. Kings Fund, London

Department of Health (2002) Screening/Case finding: A practical aid to implementation in primary care

Department of Health (2004) Improving Chronic Disease Management Department of Health.

Department of Health (2005b) The National Service Frameworks for Long-term Conditions 265109, HMSO, London

Department of Health (2005c) Supporting People with Long-term Conditions to Self-Care 3853, HMSO, London

Department of Health (2006b) Supporting People with Long-term Conditions to Self-Care a Guide to Developing Local Strategies and Good Practice, 5411, HMSO, London

Department of Health (2006). A New Ambition for Old Age; implementing the NSF for Older People. Department of Health. London.

Department of Health (2008a) Cares at the Heart of 21st Century Families and Communities: A Caring System on your Side, a Life of your Own, 286149, HMSO, London

Department of Health (2008b) High Quality Care for All: NHS Next Stage Review Final Report, HMSO, London

Department of Health (2008). Healthcare Services for Older People. Department of Health. London.

Department of Health (2008) End of Life Care Strategy: promoting high quality care for adults at the end of life. Department of Health. London.

Disease Management (2001) New generation of predictive modelling tools emerging. Disease Management 6[22]

Dixon J. et al (2004) Managing chronic disease: What can we learn from the US experience? London: King’s Fund

Freeman R. (2000) The Politics of Health in Europe (European Policy Research Unit S.) Manchester University Press.

Institute of Medicine (2001) Crossing the Quality Chasm: a new health system for the 21st Century National Academy Press, Washington DC

Iles V. & Sutherland K. (2001) Managing Change in the NHS : Organisational Change – available on

Kernick D. (Ed) (2004) Complexity & Healthcare Organization : A view from the street Radcliffe , Oxford.

Kemshall, H. and Littlechild, R. (eds) (2000) User involvement and participation in social care : research informing practice London : Jessica Kingsley.

Kings Fund (2006) Combined Predictive Modeul Final Report, Kings Fund, London

Managing Chronic Diseases BMJ Themed Issue 19 March 2005 (Vol 330, No 7492)

Metcalfe J (2005) The Management of Patients with Long Term Conditions, Nursing Standard 19 (45) July 10 p23-60

McHugh, G, Charmers, K, Luker, K. (2007) Caring for Patients with COPD and their Families in the Community, British Journal of Community Nursing, 12(5) 219-22

Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives:

Peckham, S and Exworthy, M. (2003) Primary care in the UK : policy, organisation and management Basingstoke : Palgrave Macmillan

Pollack A. (2004) NHS PLC: The privatisation of our healthcare Verso Books

Singh, D. (2005) Transforming Chronic Care. Evidence about Improving Care for People with Long Term Conditions, University of Birmingham Health Services Management Centre

Stevenson J. Spencer L. (2002) Developing intermediate care : a guide for health and social
service professionals London : King's Fund

Rollmick, S, Miller, WR. (1995) What is Motivational Interviewing, Behavioural and Cognitive Psychology 23: 325-34

Wakley G. & Chambers R. (Eds) (2005) Chronic Disease Management in Primary Care: Quality and Outcomes Radclifffe, Oxford

Wanless D. (2002) Securing our Future Health: Taking a Long-Term View Final Report HM Treasury

Webster C .(2002) The National Health Service : a political history Oxford University Press

World Health Organisation (2002) Innovative Care for Chronic Conditions: Building Blocks for Action. Ref Type: Generic

Zimmerman, B., Lindberg, C. and Plsek, P. (1998) Edgeware, VHA inc, Irving, Texas

Journals and websites

Health Service Journal
Critical Social Policy

Department of Health (2009) Living well with Dementia, a National Dementia Stratagy

Supporting People With Long Term Conditions Homepage

NatPact Documents

Long Term Conditions on NHS Networks

Primary Care CDM
(click on Primary Care and select the Chronic Disease Management link).

Our Healthier Nation
(click on People and Communities and select Expert Patients).

Kaiser Permanente

Kings Fund Reading Lists

Last Updated
29TH JULY 2010