Achieving collaboration between healthcare providers and chronically ill patients requires organisational changes in six related areas.
Organisation of care—Clinical leadership should encourage efforts to improve quality, including development of incentives for improved care and reorganisation of acute care to encourage self care.
Clinical information systems—A disease (or disorder) registry should be set up that identifies the population to be served and includes information on the performance of guideline based care, including self care tasks. The registry should permit identification of patients with specific needs, reminder systems, and tailored treatment planning.
Plan for collaborative self care
• Assess patient's self management beliefs, attitudes, and knowledge
• Identify personal barriers and supports
• Collaborate in setting goals
• Develop individually tailored strategies and problem solving
2 Goal setting and personal action plan
• List goals in behavioural terms
• Identify barriers to implementation
• Make plans that address barriers to progress
• Provide a follow up plan
• Share the plan with all members of the healthcare team
3 Active follow up to monitor progress and support patient
Levels of stepped care
1 Systematic routine assessment and preventive maintenance
2 Self care with low intensity support
3 Care management in primary care
4 Intensive care management with specialist advice
5 Specialist care
Assumptions of stepped care
• Different individuals require different levels of care
• The optimal level of care is determined by monitoring outcomes
• Moving from lower to higher levels of care based on patient outcomes can increases effectiveness and lower costs
Example of changes in organisation of care for patients with diabetes
Organisation of care
• Primary care clinic initiates year long effort to reorganise diabetes care
• Team is set up and meets regularly to make changes, monitor progress, and address obstacles
• Team develops a register of all patients with diabetes in the clinic, with records of HbA1C values, eye and foot examinations, and goals and key elements of patients' personal action plans
Delivery system design
• Clinic nurses assigned responsibility for diabetes case management
• Doctors agree to provide planned visits for all diabetic patients at least once a year, including preventive services (such as eye and foot examinations, ordering HbA1C tests, screening for depression)
• Clinic support staff maintain the register and print out a status report before each visit
• Team agrees on standard evidence based guidelines and adapts them to clinic and liaison with the specialist diabetic clinic
• Team agrees a standard form for planned visits
• Nurse case managers plan training in diabetes self management. The nurses are trained to co-lead the course at regular intervals
Self care support
• Nurse case managers decide that every diabetic patient will have a personal action plan developed within a year
• Each nurse sees one patient a week until this goal is accomplished
• Nurses telephone patients who have not been seen for six months and those who need extra support to achieve their goals
Delivery system design—Practice team roles should be changed in the organisation of visits and in follow up care. Useful innovations include group visits, planned visits, and telephone delivered care.
Decision support—Evidence based practice guidelines and protocols should be made effective by integrating information and reminders into visits. There should be collaborative support from relevant medical specialties.
Community resources—Links should be established with community resources, especially for vulnerable populations such as elderly, low income, and deprived populations.
Self care support—Tailored educational resources, skills training, and psychosocial support are effective. Successful self care programmes rely on collaboration; patient centred interventions for managing illness are especially beneficial.
Is this approach feasible for the large numbers of patients seen in busy primary and secondary care settings? There is growing experience with integrating support for self care to the delivery of routine medical care. Specific techniques such as cognitive behavioural interventions and the use of nurses and other staff as care managers have been found to be both feasible and effective. However, the full implementation of this approach in primary care requires substantial organisational changes. These enable medical and other expertise to be used more effectively and efficiently. They also enable doctors to obtain greater satisfaction in being responsible for higher quality care.
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