Table 2 The use of the Chronic Care Model gaps as an example to develop healthcare workforce in the United Arab Emirates—Abu Dhabi

Health system

Promote effective improvement strategies aimed at comprehensive system change

• Apply Plan-Do-Study-Act.

Visibly support coordination and improvement at all levels of the health system organization, beginning with the senior leadership team

• Provide some degree of independence to the healthcare team leaders (e.g., hospital/clinic directors).

Self-management support

Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving, and follow-up

• Increase the number of nurse health educators to empower all patients to self-manage their chronic diseases.

• Educate active community members to engage patients.

• Disseminate health education materials through multiple channels (e.g., printed, electronic, social media, community initiatives.

Community

Encourage patients to participate in effective community programs

• Foster the development of community-based health programs, such as walking clubs for diabetes patients.

Form partnerships with community organizations to support and develop interventions that fill gaps in needed services

• Harmonize the different entities dealing with chronic diseases to work together to promote patient well-being with their own disease, for example Emirates Diabetes Foundation, Imperial College of Diabetes, Universities.

Advocate for policies to improve patient care

• Create healthcare worker stakeholder teams to ensure policy makers understand the opportunities and barriers at the implementation level.

Delivery system design

Define roles and distribute tasks among team members

• Improve leadership among the hierarchy chain within all the team members.

Use planned interactions to support evidence-based care

• Create online scheduling reminders.

Provide clinical case management services for complex patients

• Invest in clinical case managers who focus on communicating with the patient’s family and support services.

Ensure regular follow-up by the care team

• Employ the family medicine doctor concept whereby they act as the gatekeeper to specialist services.

• Allocate one primary healthcare, doctor or nurse, to each patient with regular appointments.

• Develop a secure messaging communication system between patients and physicians/nurses.

Decision support

Embed evidence-based guidelines into daily clinical practice

• Promote the discussion of clinical guidelines among healthcare workers by allocating specific times/events for this purpose (e.g., bi-monthly journal club/seminar).

Share evidence-based guidelines and information with patients to encourage their participation

• Foster teams to translate clinical guidelines into interactive materials for patients in their native language according to their level of health literacy.

• Train health professionals to use information systems that fully integrate shared decision-making into the patient flow.

Clinical information system

Identify relevant subpopulations for proactive care

• Train clinical staff with digital knowledge and skills to be able to target high risk groups through electronic health records.

• Train staff to extend their reach to patients with care gaps.

• Incorporate the reach-out for patients with care gaps into the clinical information system.

Provide timely reminders for providers and patients

• Design the clinical information systems to send reminder messages to patients for their appointments.

• Develop and implement clinical information systems to notify doctors with patients that have examinations that are overdue or with guidelines according to the diagnosis.

Share information with patients and providers to coordinate care

• Encourage people to use and connect with the health system through Mallafi—the Electronic Health Register brand.

Monitor performance of practice team and care system.

• Develop live dashboard systems by individual and practice performances.