CCM elements | CCM gaps in primary health care services | Health workforce patient interaction issues |
---|---|---|
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. |