Transcript Document

Principles of Family Medicine
Chronic Disease Management
Saudi Diploma in Family Medicine
Center of Post Graduate Studies in Family Medicine
Dr. Zekeriya Aktürk
[email protected]
www.aile.net
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Top 10 cause of Death in KSA
30 %
1-Al Balla SR,. J Trop Med Hyg 1993;96:157-62
2-Bamgboye EA, Saudi Med J 1993;13(1):8-13.
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Hypertension
Journal of Hypertension 2005, Vol 23 No 6
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Dyslipidemia
•The overall prevalence of hypercholesterolemia
TC > 200 mg/ dL: 35.4% .
•The overall prevalence of hypertriglyceridemia
TG > 150 mg/ dL) : 49.6%.
•HDL Values in men and women
Men <40mg/dL: 74.8 %
Women <50mg/dL: 81.8
Al-Nozha MM.et al. Metabolic syndrome in Saudi Arabia. Saudi Med J 2005; 26 (12): 1918-1925
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Obesity
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Smoking
Journal of Hypertension 2005, Vol 23 No 6
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Usual Care
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Chronic Care Model
Community
Resources and
Policies
Health System
Health Care Organization
SelfManagement Delivery
System
Support
Design
Informed,
Activated
Patient
Productive
Interactions
Clinical
Information
Decision
Systems
Support
Prepared,
Proactive
Practice Team
Improved Outcomes
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Essential Element of Good Chronic Illness
Care
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
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What characterizes an “informed,
activated patient”?
Informed,
Activated
Patient
They have the motivation, information, skills,
and confidence necessary to
effectively make decisions about
their health and manage it.
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What characterizes a “prepared”
practice team?
Prepared
Practice
Team
At the time of the interaction they have
the patient information, decision support, and
resources necessary to deliver
high-quality care.
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Self-Management Support
• Emphasize the patient's central role.
• Use effective self-management support strategies
that include assessment, goal-setting, action
planning, problem-solving, and follow-up.
• Organize resources to provide support.
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Delivery System Design
• Define roles and distribute tasks among team
members.
• Use planned interactions to support evidencebased care.
• Provide clinical case management services for
high risk patients.
• Ensure regular follow-up.
• Give care that patients understand and that fits
their culture.
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Features of Case Management
•
•
•
•
•
Regularly assess disease control, adherence, and
self-management status.
Either adjust treatment or communicate need to
primary care immediately.
Provide self-management support.
Provide more intense follow-up.
Provide navigation through the health care process.
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Decision Support
• Embed evidence-based guidelines into daily
clinical practice.
• Integrate specialist expertise and primary care.
• Use proven provider education methods.
• Share guidelines and information with patients.
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Clinical Information Systems
• Provide reminders for providers and patients.
• Identify relevant patient subpopulations for
proactive care.
• Facilitate individual patient care planning.
• Share information with providers and patients.
• Monitor performance of team and system.
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Community Resources and Policies
• Encourage patients to participate in effective
programs.
• Form partnerships with community organizations
to support or develop programs.
• Advocate for policies to improve care.
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Health Care Organization
• Visibly support improvement at all levels, starting
with senior leaders.
• Promote effective improvement strategies aimed at
comprehensive system change.
• Encourage open and systematic handling of
problems.
• Provide incentives based on quality of care.
• Develop agreements for care coordination.
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Chronic Care Model
Community
Resources and
Policies
Health System
Health Care Organization
SelfManagement Delivery
System
Support
Design
Informed,
Activated
Patient
Productive
Interactions
Clinical
Information
Decision
Systems
Support
Prepared,
Proactive
Practice Team
Improved Outcomes
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