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
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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
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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
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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
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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
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