1. Interprofessional clinical protocol |
Case-management nurse |
All primary care nurses should do cardiovascular disease case management |
Motivational interviewing is relevant to nurse-led cardiovascular disease case management |
Evaluation of the family support is relevant to cardiovascular disease case management |
Pharmacist |
The in-clinic pharmacist should be included in the program |
2. Enhanced access to other health professionals |
Clinical judgment |
The clinical judgment of the case-management nurse plays an important role in orienting patient towards relevant and useful resources |
Lists of health resources |
Lists of public and private resources could be used to better coordinate the existing resources in the region |
3. Collective prescriptions |
Feasibility |
Training may be needed to apply collective prescriptions |
4. Patient health booklet |
Communication |
The health booklet facilitates communicating with the patient and between clinicians |
Patient and family needs |
Patients and family need the nurse’s help to fill it in |
5. Motivational interviewing |
Motivational section in the health booklet |
The health booklet may facilitate changing attitudes and creating awareness regarding the adoption of healthy lifestyle |
The health booklet enables priority setting in collaboration with patient respecting his or her objectives |
Role of the patient |
Patient engagement in treatment as described in the program is realist, as far as patient limits and priorities are taken in consideration, including patient’s motivation |
6. Directory of community and health resources |
Awareness |
The respondent was unaware of the existing computerized directory of resources |
Relevance |
The computerized directory of resources could be useful to the case-management nurse |
Role of the administrative support staff |
The clinic staff may provide information on health resources and the patient should take the responsibility to schedule appointment |