Table 1 Chronic care model and health TAPESTRY

Healthcare organization and leadership

Strong leadership, readiness for change, and effective incentives to systematically promote successful quality improvement interventions.

Health TAPESTRY creates time and space for clinic huddles to take place to discuss clients individually in an organically defined, interprofessional process through support from clinic leadership.

Clinic leadership supports integration of volunteers into the team and the adoption and use of e-health technologies

Linkage to community resources

Efficient use of community resources such as peer-support groups, community programs, and counselling to improve the quality of care and support offered to patients and improve cost-effectiveness in the system.

Health TAPESTRY offers linkages to community organizations through support of volunteers and directed healthcare provider referral or connection based on goals and needs oriented action plans.

Support of patient self-management

Patient empowerment, activation, and support of self-management skills to effectively sustain management of chronic conditions.

Health TAPESTRY volunteers serve as advocates for clients and encourage self-management through follow-up and discussion of client-identified health goals. Healthcare providers encourage self-management activities through education and actions based on goals and needs oriented action plans.

Coordinated delivery system design

Disconnected care across multiple providers and caregivers is a point of inefficiency in the health system; therefore, addressing lack of coordination to significantly improve patient experience.

The KindredPHR seeks to allow clients to better connect to all their providers in a more coordinated way. The Health TAPESTRY specific applications generate information in the home that is shared electronically with the clinic.

Clinical decision support

Facilitating the use of evidence-based guidelines and patient assessment tools to enhance effectiveness.

The Health TAPESTRY App contains modules (surveys, risk algorithms) that have been supported by evidence and expert opinion.

Clinical information systems

Improving patient-provider and provider-provider communication, using reminder systems, documenting treatment plans and sending secure messages to enhance the delivery of proactive care.

The KindredPHR offers secure messaging between clients and providers and allows for establishment of reminders, tracking of health information and treatment plans, and recording data. Communication is also be facilitated by the clinic EMR.