Table 1.

Components of a personalized care management model for people with Parkinson’s disease

COMPONENT	DEFINITION	KEY POINTS	EXAMPLE	QUALITY IMPROVEMENT INDICATORS INDINDICATORS
Care coordination	Team-based activity of involved health care providers to ensure sharing of relevant health information across all healthcare layers, creation of a common understanding of care needs of each patient, alignment of treatment plans to prevent contradictory disease management, and assurance of certainty about responsibilities of each discipline in the management process.	•Development of individualized care plans covering individuals’ unique needs and preferences •Sharing of the individualized care plans among all involved health care providers	Use of individualized care plans in people with gastrointestinal cancer led to significant improvement in patient reported quality of life outcomes, a significant decrease in feelings of anxiety, fewer depressive symptoms, and a reported higher satisfaction compared to the usual care group [29].	•Improved patients and carers care experience and satisfaction with received care •Lower caregiver burden
Patient navigation	Proactively guidance and support for patients to find their way through the complex health care system, referring them timely to the appropriate health care provider.	•Mapping of care team network of each patient •Building relationships between primary, secondary and tertiary care, and community resources	Patient navigation programs in cancer care have revealed improvement in continuity of care through timely receipt of disease treatment and follow-up care [52]	•People with PD and their carers report to receive the right care at the right place and time.
Information provision	Providing PD-related information in oral, written or other form.	•Establishment of an information delivery system •Availability of a single point of access	Education programme in combination with home visits and tele-consulting showed that cancer patients benefit from websites offering information on disease management [12]. The results supported earlier findings that education increases acceptance of disease, symptom control and also improves the quality of life.	•Level of shared decision making in disease treatment and care •Improved self-management skills•Patients are more ‘in control.
Proactive monitoring for early detection of signs and symptoms	The timely detection of the first changes in signs or symptoms, allowing for preemptive interventions to prevent further worsening of problems and to avoid complications that might lead to emergency department visits, hospital admission and use of unnecessary resources.	•Monitoring adherence to treatment plans •Supported by home-based monitoring, i.e., wearable motion sensors	Proactive monitoring of falls with wearable sensors in people with PD allow identification of patients with a high risk of falling, which In turn, allows for timely referral to fall prevention programs, which impacts activity of daily living [53].	•Less emergency department admissions •Less unneeded hospital admissions •Lower prevalence of preventable motor and non-motor complications •Improved functional status •Improved Work status •Treatment according to pre-defined care goals
Process monitoring	Routine review and evaluation of the care management process regarding adherence to care plans.	•Recognizing facilitators and barriers in the care management process •Evaluation that all involved health care providers work on the same pre-defined care goals.	Telemedicine based disease management programs including monitoring of adherence to care plans, improved health outcomes in veterans with poor diabetes by improving diabetes self-care [54].