Delivery system design
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Regular comprehensive assessment |
1. … one of my care providers assesses my whole situation regularly (for instance, every six months); and not only my medical situation, but also explores how I feel, what my daily life looks like and whether I can manage at home and in daily life. |
12 |
Individual care plan |
2. … one of my care providers develops a personal care plan with me, based on my needs and preferences; which not only focuses on the management of my chronic conditions, but also addresses my broader needs and way of living, including my social contacts and living environment |
3 |
Care coordinator |
3. … one of my care providers is the link between me, my important others/carers and all other care providers of which I receive care or support; thus, one person who will liaise and manages all information about my care |
6 |
Decision support
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Consultation system |
4. … my care providers consult experts (for instance, medical specialists, psychologists, etc), if they lack knowledge or experience to decide about the best care or treatment for me |
2 |
Self‐management support
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Provide options for self‐management |
5. … my care providers support me in retaining control and taking care of myself |
8 |
Shared decision making |
6. … my care providers encourage me to actively consider my options for care and treatment and engage in shared decision‐making about my care |
5 |
Information systems and technology
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Patient‐operated technology |
7. … my care provider considers eHealth technology as an option for me; for instance whether I could use an app or website to send health monitoring information to the health center or hospital, so that less face‐to‐face visits will be needed |
3 |
Shared electronic health records |
8. … my care providers register my health and care data in one electronic file, so that they have quick access to all relevant information |
15 |
Social and community resources
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Assessment of support needs |
9. … my care provider asks about my needs for support, for example my need for domestic help, transport facilities, exercise programmes or peer support |
4 |
Access to community and social resources |
10. … my care provider informs me about community resources for support and activities in my neighbourhood, and helps me getting in touch |
2 |