Currently there are many issues with the Mongolian health care system addressed in previous sections. From all of those problems, I chose this topic because it seemed most feasible to implement in Mongolia. Because of an existing personal contact with Mongolian cardiologists at the 1st central hospital in Ulaanbaatar, I will be able to implement the primary version of this HF disease management program and patient education in the Cardiology department. Local stakeholders are hospital management and leader cardiologists. They have showed their interest in implementing this evidence-based disease management plan and patient education. After further discussing with key stakeholders and champion cardiologists, we agreed to develop the most efficient and feasible model that can be adapted easily in Mongolian hospitals and further throughout the health care system.
In addition to applying this program in the “1st central hospital”, my plan is to do research based on pre and post intervention data accumulated from the hospital’s patient’s data archive. This will hopefully discover the effects of this program by comparing pre and post HF patient re- hospitalization data. The key measures would focus on improvements of re-hospitalization and patient’s quality of life triggered by the implementation of this program. In case of positive associations in the results of this program, we will have an opportunity to publish findings and propose it to the stakeholders at the Health of Ministry of Mongolia. If the program shows promising results we would partner with the Ministry and hopefully apply this program to other health care centers and hospitals, making it a part of national NCDs management program in the future.
36 Challenges
The possible challenges in implementation of this program are: lack of some local physician’s support, health care workers refusing to adapt the new approach, Mongolian geological characteristics, discrepancy of urban and rural areas, the inefficient health care system, gaps in socioeconomic status, inequality in patient’s education, and limited health care access.
The current traditional health system will be a huge barrier in adapting similar programs. Inefficient payment system, low salary of physicians, and lack of transparency in the hospitals’ environments will delay people striving for adapting new disease management programs at hospitals. In addition, local health providers might not agree with the proposed plan and refuse to participate in such innovative changes. Hopefully, support of hospital administration, champion doctors, and nurses will help this program to advance and be adapted successfully in health care settings of Mongolia. However, it is evident that the Mongolian health care system is no longer functioning effectively for neither for health workers nor the people therefore I strongly encourage health care reform when the timing is right.
The discrepancy existing between the rural and urban areas in Mongolia is large. It includes the discrepancies in: monthly earning, health access, education, economic, social and environmental factors. Because of these large gaps in discrepancies, this program will face some barriers in adapting this kind of programs. Nevertheless, an improvement of primary care access is necessary; the content of evidence-based proper health education packages must be developed and provided to HF patients regardless.
Clark et al. (2007) observed low obedience to doctor’s HF guidelines, issues with diagnostics, and issues with the implementation of interventions in rural communities compared
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to urban areas. It is evident that in rural areas with limited health care access and health discrepancies, it is much more difficult to provide efficient care to HF patients and to support self-management after discharge. Therefore, the HF disease management program and proper health education standards must be developed and applied in practice in Mongolia as soon as possible.
The health educational sessions should be developed on individual basis, depending on the patient’s literacy level, cognitive status, psychological state, culture, and access to social and financial resources. Patients should be screened for cognitive impairment and depression, because these can interfere with learning. Even though low literacy is not a problem for Mongolians, the discrepancy in social, economic and environmental factors is very large. Health providers should keep in mind that physical, cognitive, social, and environmental factors can affect the efficiency of educational sessions. Cognitive impairment is the most prevalent problem in HF patients and can affect significantly the patient’s ability to learn and retain information (Bennett & Sauvé, 2003 & Zuccalà et al., 2003).
Another well-known barrier to HF disease management program is depression, and it is astrong predictor of mortality for HF patients. According to an article written by Tiny Jaarsma, identification of depressive symptoms before enrollment in a disease management program might lead more effective use of the program because depressive patients might not benefit from a general program (Jaarsma et al., 2010). Unfortunately, the treatment for depression seems not to improve outcomes; therefore, patients with cognitive impairment and depression need more support and assistance of family member or caregivers at home (Lindenfeld et al., 2010). The depression and cognitive impairment is often encountered in low socio-economic areas; this might become a barrier for those HF patients who live in rural or lower income districts of
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Mongolia. Putting more resources towards and providing more assistance for this group of people will be a challenge for a country with limited resources.
HF patients often encounter several barriers that are the main reasons of patient’s unsuccessful self-management. Health providers should keep in mind that barriers in medication adherence are: high medication cost, transportation to the pharmacy or health clinics and confusion among prescribed drugs (S Stewart & Pearson, 1999). Barriers on sodium restriction adherence include time, cost, taste, others not eating low sodium food, interference with social- cultural norms or traditional food options, difficulty changing diet habits and etc… (Happ, Naylor, & Roe-Prior, 1997)
Conclusion
This paper discussed numerous evidences that support preventing and reducing mortality/morbidity of HF, CVDs and NCDs around the world, and especially in Mongolia. It is important for Mongolian health policy makers and health providers to be aware of patient needs and rising public health problems in Mongolia. Changing the entire health care system and developing totally different mechanisms to the ongoing system is not feasible today. It is important to look for the feasibility of any program or change. Therefore I believe that the most cost effective and feasible approach is to adopt an evidence-based HF disease management and patient education program in the health delivery system in Mongolia. All the interventions from the disease management program target the behavioral change and the elimination of risk factors that have been directly associated with the heart conditions. They also focus on delivering the necessary knowledge about a patient’s own health condition; making sure that they understand that it is a part of the treatment plan. Development of a disease management program might be a challenge, but it is a necessary change that many Mongolians need. The HF management
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program promotes patient’s self-management and self-management tools. It is difficult for a patient to deal with HF alone, and if some habits are not corrected HF patient lifespans will be shortened significantly, their quality of life drops, and health care cost will rise greatly. In conclusion, this paper is written to bring awareness among Mongolian health professionals and health policy makers about this hidden and very serious public health problem in Mongolia. In addition, I am proposing to develop and exercise the most appropriate, culturally adaptable and efficient HF disease management program and patient education in Mongolia, particularly in hospital settings.
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