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. 2016 Oct 20;32(3):418–429. doi: 10.1093/heapol/czw143

Table 1.

Roles of health care organizations according to ICCC

Health care organization roles according to ICCC Description of the roles according to ICCC
Promote continuity and coordination
  • Availability of services at facility levela

  • Services coordinated across levels of care from primary to tertiary

  • Services coordinated across providers—i.e. providers should communicate

  • Care coordinator to serve as overseer and director of patient care

  • Care planned over the course of condition

  • Schedule follow-up visits for patients

  • Providers to be proactive in patient care

Encourage quality through leadership and incentives
  • Organization leaders support and sponsor care improvement

  • Establish rewards for patients and providers for effective clinical processes that affect management and prevention

  • On-going quality monitoring and quality improvement

  • Organization leaders create an environment that values quality

Organize and equip health care teams
  • Provide supplies, equipment, laboratory access and essential medications

  • Provide decision-making support, such as guidelines of care, and algorithms

  • Health care teams need special skills and knowledge: communication, behavioural intervention skills and skills to work cooperatively

Use information systems
  • Use information systems to improve planning and the standards of care

  • Keep a list of patients with chronic conditions (‘patient registry’)

  • Registry may serve as a reminder tool for follow-up services, may help health care teams to identify patients’ needs, plan care, monitor responses to treatment and assess health outcomes

  • Integrate a systematic strategy for collecting useful patient information that will result in effective management

Support self- management and prevention
  • Patients and their caregivers informed about self-management strategies and motivated to implement them daily over time

  • Health care workers are crucial in educating patients and families about self-management, and in helping then initiate and maintain lifestyle changes

a

An additional element that emerged from data.