Theme 3 Flashcards
Role of professional in acute care vs chronic care
Expert to select and conduct therapy vs teacher/coach/consultant/partner supporting patients
Role of patient in acute care vs chronic care
Passive and follows orders vs partner/daily manager/own caregiver
Two domains of CCM
Community (resources and policies)
Health system (health care organization)
Aspects of health system in CCM
Self-management support
Delivery system design
Decision support
Clinical information systems
Productive interactions in CCM between
The informed, activated patient en the prepared, proactive practice team
Self-management support
Empowering and preparing patients to manage their own health by:
- Emotional support
- Knowledge about the condition
- Sustaining healthy behaviours
Delivery system design
Assure the delivery of planned, effective and efficient care and self-management support
Goals of delivery system design
Defining roles and distributing task
Planned interactions to support EB-care
Provide case-management services
Regular follow-up
Give care that fits background & is understandable
Decision support
Promoting clinical care that is consistent with scientific evidence and patient preferences
Goals of decision support
Embedding EB-guidelines into practice
Integrating specialist expertise
Using proven provider methods
Share guidelines & information with patients
Clinical information systems
Organising patient and population data to facilitate efficient and effective care
Goals of clinical information systems
Providing timely reminders
Identifying relevant subpopulations for proactive care
Facilitating individual patient care planning
Sharing information to coordinate care
Monitoring performance of practice team and care system
Health system
Ensure practices within the organization have the motivation, support and resources needed to redesign their care systems
Community
Help patients access effective and useful services and resources in their surrounding community
