MODULE 3

COMMUNITY ORIENTED CARE

WEEK 1
Learner’s Guide
 • Download this slide to your own laptop
• Save by clicking “Save As” – chose location
to where you will save – edit the name to “
Instructions your last name – cluster #.pptx ”
• Read the handout for this module
• Read / watch the additional suggested
MODULE 3 reference materials
COMMUNITY ORIENTED CARE
• Provide your answer to the questions seen
in this slide
• Upload to this file to google classroom as
your output for this module
WEEK 1
Learner’s Guide
*** Do not forget to save your work at all
times
*** This slide set will serve as your output
presentation for this module
Links to the material

MODULE 3 Main learning material –

COMMUNITY ORIENTED CARE
HANDOUT for MODULE 1

WEEK 1
Learner’s Guide
 Section 1
❑ Review the case scenario from Patient-centered
OBJECTIVES Care and Family Focused modules
❑ Fill in the PFC matrix for patient-centered and
family-focused column (if not yet done previously)
Section 2
MODULE 3
COMMUNITY ORIENTED CARE ❑ Assess the community-oriented issues through the
use of:
❑ SCREEM table
❑ ECOMAP
WEEK 1 Section 3
Learner’s Guide
❑ Differentiate the identified issues whether it is a
problem on social determinants of health or for
building blocks of health systems
❑ Suggest an intervention plan for the case
 MODULE 3
COMMUNITY ORIENTED CARE
SECTION 1

[Activities]
❑ Recap of the previous scenario
❑ Filling of currently available data for PFC matrix
 RECAP OF THE CASE SCENARIO FROM
MODULE ON PATIENT-CENTERED CARE

This is a case of a 40 year-old, female, single parent, an

online seller who came in with chief complaint of weight
loss, polyuria and polyphagia for 2 months.
 ACTIVITY
Filling the PFC matrix with current data at hand
Fill the PFC matric table for the patient-centered and family-focused care aspect for this patient. Data should be lifted from the
previous modules (Modules 1 and 2).

PATIENT-CENTERED FAMILY-FOCUSED

Data at hand

Salient features

Diagnosis

Management/
intervention
 DATA AT HAND
Demographic Profile
A 40-year-old female online seller
Subjective Data:
Came in to consult for weight loss, polyuria,
and polyphagia.
She noted losing weight unintentionally for 2
months
Objective Data:
Laboratory results (from previous consult):
FBS 150mg/dl; HBAIC of 7%.
Physical examination:
BP 130/80; HR: 78/min; weight: 50 kg; Height:
5’ 5”, BMI: 18.31kg/m2
The systemic examination is essentially
normal
PSYCHOSOCIAL ISSUES:
The patient did not consult when she
experienced weight gain because everyone
seems to have it due to the pandemic.The
patient is a single parent with 2 children.
They are currently living with her parents.
She has no idea how to take care of her
health because she considers it her last
priority. She needs to earn to support the
needs of her kids.
SALIENT FEATURES
BIOMEDICAL HISTORY
The patient is a Diabetes Mellitus
Type 2 patient, the classic
presentation of weight loss, polyuria
and polyphagia.
Laboratory results suggest DMT2
with HbA1C of >/= to 6.5%, and
Fasting blood sugar of >126 mg/dl.
BMI of patient is 18.31kg/m2 pictures
the patient is underweight.
Diabetes
PSYCHOSOCIAL ISSUES
Mellitus
The patient has decrease level of
selfcare and health-seeking behavior
due to unconventional family set up.
The patient has decrease level of
selfcare and health-seeking behavior
due to decreased level of knowledge
in recognizing early signs of illness.
The patient has decrease level of
selfcare and health-seeking behavior
due to financial constraints.
DIAGNO MANAGEMENT/INTERVENTION
SIS
COMPREHENSIVE MEDICAL EVALUATION
A complete medical evaluation should be per-formed at the initial visit to:
Confirm the diagnosis and classify diabetes.
Evaluate for diabetes complications, potential co- morbid conditions, and overall
health status. Review previous treatment and risk factor management in people
with established diabetes. Begin engagement with the person with diabetes in the
formulation of a care management plan including initial goals of care.
Develop a plan for continuing care.
Lifestyle Behavior Change
Activity: >150 minutes/week of moderate-intensity physical activity.
Diet: A variety of eating patterns can be considered to
Type 2 prevent diabetes in individuals with prediabetes.
Pharmacologic Interventions
Metformin. Various pharmacologic agents have been evaluated for type 2 diabetes
prevention, and metformin has the strongest evidence base.
Vitamin B complex. Measurement of vitamin B12 levels in metformin-treated
individuals, especially in those with anemia or peripheral neuropathy.
Prevention of Vascular Disease and Mortality
Statin therapy.
Person-Centered Care Goals
A follow-up visit should include most components of the initial comprehensive
medical evaluation.
SARS-COV-2 VACCINES AND OTHER IMMUNIZATIONS
FACILITATING POSITIVE HEALTH BEHAVIORS AND WELL-BEING TO
IMPROVE HEALTH OUTCOMES
PSYCHOSOCIAL CARE
GLYCEMIC CONTROL
DATA AT HAND SALIENT FEATURES DIAGNOSIS MANAGEMENT/INTERVENTION

Initially, Cecilia had a Celia is aware that she needs treatment so that Salient Clinical Features and Psycho-educational approach (Catharsis-Education-Action)
single parent family she can function well as their provider. Psychosocial, Bioethical Issues: “How does that make you feel?”
but when she moved Patient presented with symptoms “Can you tell me more about that feeling?”
in with her children in Family-Life Cycle Stage: Family with young consistent with Diabetes Mellitus, “What is it that makes you feel that way the most?”
her parent’s home, children Type II: weight loss, polyuria,
her family now Celia has a dysfunctional relationship with a rigid polyphagia Motivational and behavioral counseling:
became extended. boundary with her husband, Lino. They are Laboratory findings consistent Counsel the patient that she should prioritize her health so that she could
legally separated. She has a functional with DM, Type II: FBS 150mg/dl; optimally function for her kids.
She is a single mother relationship with clear boundary with Gina, and HBAIC of 7% Provide assurance that complications are preventable.
and a breadwinner. an enmeshed or overinvolved relationship with She has no idea how to take care Assess psychosocial issues and family stresses that could impact diabetes
Thus, she considers diffuse boundary with Ralph. She is worried of her health because she management and provide appropriate referrals to trained mental health
her health as her last about her younger brother’s situation. Gina and considers it her last priority. professionals.
priority. Ralph have a functional relationship with a clear She is a single parent with 2 kids Assess for the presence of social support providers (e.g., family, peer support, lay
boundary. They have a coalition against Gina. and is currently living with her diabetes educators/caretakers) who may facilitate self-management behaviors,
Family APGAR of 8, parents. reduce burden of illness, and improve diabetes and general quality of life.
highly functional Her enmeshed relationship with Ralph, her Screen for anxiety or worries regarding diabetes complications and medications.
family younger brother, can be a stressor and should Medical Diagnosis (ICD Code): Recognize if the patient expresses fear, dread, or irrational thoughts or if she
be resolved. ICD-10: E11.9 Type 2 diabetes shows anxiety symptoms such as avoidance behaviors, excessive repetitive
She thinks she can mellitus without complications behaviors, or social withdrawal
rely on her family. Sibling Relational Problem V61.8 (Z62.891)
They can extend help secondary to migration (Z60.3). Psychosocial Diagnosis (ICD Family discussion on the role of family relationships in the development and
and are very Code): treatment of the condition as well as the general well-being of the client.
supportive. SCREEM- The family map shows that there is a ICD-10: V60.2 Inadequate
RES score of 25. dysfunctional relationship between Celia and her material resources Encourage to elucidate clearly to each other the nature of the Illness: Maintains
husband. However, her extended family is openness and allow sharing and support
adequately capable of resolving their problems;
has the capacity to adapt, to care for one Assess the likely effect of the illness on the family, predict problems likely to arise;
another, and to meet responsibilities. develop plans for realistically coping with them
 MODULE 3
COMMUNITY ORIENTED CARE
SECTION 2

[Activities]
Assess the issues for social determinants of health
and building blocks of health through;
- SCREEM
- ECOMAP
 SCREEM

She thinks she can rely on her family. They can extend help
and are very supportive. SCREEM-RES score of 25.

S – 5 Adequate
C - 5 - Adequate
R - 6 - Adequate
E - 2 - Severely Inadequate
E - 3 - Moderately Inadequate
M - 4 - Moderately Inadequate
TOTAL - 25 - Adequate Family Resources
 ECOMAP

MEDICAL

EDUCATION
70 65

40

RELATIVES BUSINESS

9 7

NEIGHBORS CHURCH
FAMILY MAP

Celia, our client has a dysfunctional or

disengage relationship with her husband Lino
as they were legally separated This also
signifies that they are emotionally distant to
each other. Celia and Gina has a functional
relationship with clear delineation of roles or
boundaries. Gina’s relationship with Ralph
and Celia is also functional with clear
boundaries. However, Celia’s relationship
with Ralph is somewhat overinvolved or
enmeshed with diffused or not clearly defined
boundaries. They had a coalition against Gina.
Using your active listening skills, you wanted to ask on the behavior of the community members and if they
can be helpful to her treatment journey.
Which active communication skills will enable you to do this? Justify your answer Your answer
a) Leading
b) Bracketing
c) Reflecting BRACKETING
d) Attending
Justification of the choice:
We want to bracket as to what is the behavior of the community members and if they can be helpful to her
treatment journey. This focuses specific topics we would want to know or extract.

But,

Bracketing is not so much a verbal or nonverbal skill as it is a mental skill. Frequently, when we listen to
someone speaking to us about his problem, we automatically want to ask for more information, we make
hypotheses in our minds as to what the problem might be, and we start thinking of what we want to say to
the patient once he stops talking. Sometimes, our view of the problem is colored by our biases and
prejudices, our pre-conceived notions about the patient or about the situation that he is describing.
Sometimes, our perceptions are colored by our own experiences in dealing with situations similar to what
our patient is describing especially when such experiences elicit in us much emotion. All of these
responses, while normal, detract from our empathy because, instead of really paying attention to what the
patient is saying and feeling, we are paying attention to our own. Bracketing means setting aside these
feelings and thoughts and judgments temporarily so that there will be space in our minds and in our hearts
for what the patient is really saying
 ACTIVITY
Fill the SCREEM table with data obtained from the narrative of our patient.
Assessing factors for SCREEM
Resources Pathologies

SOCIAL Social interaction between the Client and her Mother is strong and Has had a broken family. Socially feels unsafe from her neighbors
evident. In Addition, the Client’s mother family side has also hear say. The client identified the community as not safe to open
communication and serves as a support group. up her feelings.

CULTURAL Close family ties runs with the Filipino Culture as evident by her “MARITES” Culture is an emerging term that depicts a practice
relationship with her mother and mothers family. among Filipinos.

RELIGION Still attends church. It is safe to presume that She is still believing Is not regularly attending to avoid people that is sole root of her
into higher power. stress.

ECONOMIC None The client is economically deficient. This leads the family a difficulty
to meet monetary demands for crisis or illness.
Decrease political-economic
EDUCATION None The family has low level of educational attainment as evidence by
the clients decreased level of selfcare and health-seeking behavior
due to decreased level of knowledge in recognizing early signs of
illness.

MEDICAL Presence of available medical practitioner Not an ideal place/set up for quality health care service/delivery
 ECOMAP

MEDICAL

EDUCATION
70 65

40

RELATIVES BUSINESS

9 7

NEIGHBORS CHURCH
 MODULE 3
COMMUNITY ORIENTED CARE
SECTION 3

[Activities]
❑ Differentiate the identified issues whether it is a problem
on social determinants of health or for building blocks of
health systems
❑ Suggest an intervention plan for the case
 ACTIVITY
List down the problems identified; differentiate them as to which aspect of community-oriented problem each belongs.

LISTS OF IDENTIFIED
Differentiation
RESOURCE?of the identified problems TYPE OF PROBLEM
PATHOLOGY? (Highlight your choice)
PROBLEMS

No available funds for Not an ideal place/set up for quality health Social determinants of health: Socio-economic/Networks
care service/delivery Health systems financing.
Health Building blocks:

No manpower for Not an ideal place/set up for quality health Socio-economic/

Social determinants of health:
care service/delivery Networks/Health System
Health
Building blocks: Health workforce.
Poor Leadership on Decrease political-economic Social determinants of health: Socio-economic/
Not an ideal place/set up for quality health Networks/Health system
Health
care service/delivery
Building blocks: Leadership and governance
Decrease Activities for Not an ideal place/set up for quality health Social determinants of health: Socio-economic/
care service/delivery Networks/Health system
Health
Building blocks: Health service delivery
Poor Social Support on Has had a broken family. Socially feels unsafe Social determinants of health: Socio-economic/
from her neighbors hear say. The client Networks/Environmental/Cultural
Health
identified the community as not safe to open Building blocks: Health information systems.
up her feelings. Health service delivery.
 ACTIVITY
If this patient consulted in your real life community, what possible interventions can you suggest based on currently available
Suggest intervention
resources in your community? for the identified problems

LISTS OF RESOURCE? TYPE OF PROBLEM SUGGESTION

PATHOLOGY? (Highlight your choice)
IDENTIFIED INTERVENTION
PROBLEMS
No available funds for Not an ideal place/set up for quality Social determinants of health: Socio- Strengthening policies and
health care service/delivery economic/Networks
Health regulation of health
Building blocks: Health systems financing.

No manpower for Not an ideal place/set up for quality Social determinants of health: Socio-economic/ Increasing number of LGU hired/HRH
health care service/delivery Networks/Health System augmentation
Health
Building blocks: Health workforce.

Poor Leadership on Decrease political-economic
Not an ideal place/set up for quality
Health health care service/delivery
Social determinants of health: Socio-economic/ Enrollment of LCE in MLGP
Networks/Health system
Building blocks: Leadership and governance Strengthening policies and regulation of
health

Decrease Activities for Not an ideal place/set up for quality Social determinants of health: Socio-economic/ Strengthening policies and
health care service/delivery Networks/Health system
Health regulation of health
Building blocks: Health service delivery

Poor Social Support on Has had a broken family. Socially feels
unsafe from her neighbors hear say.
Health The client identified the community as
not safe to open up her feelings.
Social determinants of health: Socio-economic/ Strengthening policies and regulation of
Networks/Environmental/Cultural health
Building blocks: Health information systems. Information education Campaigns
Health service delivery. Strengthening health promotion
 MODULE 3
COMMUNITY ORIENTED CARE

END OF WEEK 1

Content created by:

Alfonso Syoei R. Yoshida, M.D., FPAFP – shomed992001@yahooo.com
For PAFP Subcommittee for PBRTP